Making sense of Tanzania's fertility: the role of contraceptive use

Contraceptive use has been identified as one of the primary factors contributing to fertility decline; however, the link between contraception use and fertility is weaker and less understood in sub-Saharan Africa. For example, despite a large increase in the contraceptive prevalence rate (CPR) in Tanzania since the early 1990s, its total fertility rate (TFR) has remained high. There has been little research on the impact of method mix in this relationship. An understanding of the dynamics of the relationship between contraceptive use, method mix and fertility would provide an important evidence to advocate and plan for future scale-up of and investment in family planning programs. Main question/hypothesis What role has changes in contraceptive use and method mix played in determining fertility trends and differentials in Tanzania? Methodology (location, study design, data source, time frame, sample size, analysis approach) The study analyzes secondary data from the last three Demographic and Health Surveys (DHS) in Tanzania (1991/2, 1996, 2004/5) and the 199 Reproductive and Child Health Survey. The sample size of women 15-49 ranged from 4,029 to 10,329. Analysis is conducted at the national level and by urban and rural residence. Trends and differentials in TFR and CPR are assessed through calculating absolute and percent changes between surveys and testing for statistical significant changes. Bongaarts’ Proximate Determinants Model is constructed based on three indices: contraception (Cc), postpartum infecundability (Ci), and marriage/cohabitation (Cm). Due to insufficient data, abortion (Ca) is not included. In addition, relationships between variables are assessed using non-parametric Spearman’s correlations. Results/Key Findings The TFR, given CPR, was higher than expected in rural areas; however, the opposite is true in urban areas. To explain possible reasons for these patterns, 12 iterations of Bongaarts’ model were created- national, urban, and rural residence for each survey. Aside from one instance (1999 urban), there was consistency between the predicted and observed TRF, with a slight overestimation of urban TFR and underestimation of rural TFR. This is attributable, in part, to not including unmarried women or abortion. Examining trends in the indices revealed that contraception, although not the largest inhibiting factor, varied the most both overtime and between urban and rural areas, suggesting contraceptive use has played a key role in determining fertility trends and differentials. In rural areas a surprising pattern was found; the proportion of in-union women increased over time. Traditionally the opposite is found due to increases in age of first marriage. Therefore much of the fertility inhibiting gain in rural contraceptive use went to cancelling out resulting increases in Cm. Across the four surveys, urban CPR was consistently double rural CPR. In both urban and rural areas the largest average annual CPR increase happened between the first two surveys (1991/2 to 1996); 18.4% and 16.7% respectively. Between 1999 and 2004/5, the average annual increase slowed to less that 2% in both areas. Changes in method mix mirror those of CPR; a large increase in the use of long-acting methods during the between the first two surveys, followed by relatively small changes to method mix thereafter. This resulted in little change in average use effectiveness post-1996. An attempt to account for the relationship between method mix and fertility produced inconclusive results. This is likely due to how duration and consistency of use are accounted for in measures of average effectiveness. For example, in 2004/5 approximately one-third of in-union women using contraception had used their method for less than six months, while the TFR is measured over a three-year period. Bongaarts’ model was applied to hypothetical future scenarios. Results suggest meeting the existing unmet need could result in TFRs as low as 2.5 in urban areas and 4.0 in rural areas, and meeting the Government’s target of 60% CPR would bring fertility near replacement levels. 5. Knowledge contribution The study has shown that national level measures of CPR and TRF mask important, policy-relevant differential patterns. Specifically, sub-national analysis reveals large and growing differences in these two measures between urban and rural areas, suggesting the importance of focusing programmes and resources to underserved rural communities. The study has also highlight the need for additional research to better understand how consistency and duration of use area factored into measures of method effectiveness. Unmet need remains high in Tanzania (22% in 2004/5), and despite large increases in contraceptive use in the early to mid-1990s, the rate of increase has slowed considerably. The study results provide additional support for efforts to revitalize FP efforts in Tanzania; such as the Government’s National Family Planning Costed Implementation Program (NFPCIP). This is not only vital to respecting individual women’s fertility preferences, but also at a national level will result in slowed population growth and improvements in the development prospects of the country

Impact of changes in Tanzania’s family planning policies could benefit other African countries

Based on a new paper, LSE’s Ernestina Coast and alumna Michelle Weinberger examine the lessons learned from trends in Tanzania’s family planning policy over the past 20 years

The maximum contraceptive prevalence ‘demand curve’: guiding discussions on programmatic investments [version 1; referees: 1 approved, 2 approved with reservations]

Most frameworks for family planning include both access and demand interventions. Understanding how these two are linked and when each should be prioritized is difficult. The maximum contraceptive prevalence ‘demand curve’ was created based on a relationship between the modern contraceptive prevalence rate (mCPR) and mean ideal number of children to allow for a quantitative assessment of the balance between access and demand interventions. The curve represents the maximum mCPR that is likely to be seen given fertility intentions and related norms and constructs that influence contraceptive use. The gap between a country’s mCPR and this maximum is referred to as the ‘potential use gap.’ This concept can be used by countries to prioritize access investments where the gap is large, and discuss implications for future contraceptive use where the gap is small. It is also used within the FP Goals model to ensure mCPR growth from access interventions does not exceed available demand

The business case for investing in social and behavior change for family planning

Although the development field generally considers social and behavior change interventions essential parts of quality health programs, lack of synthesized information on costs and effectiveness means that decision-makers under-appreciate and under-fund social and behavior change efforts. This business case uses evidence to answer questions about the effectiveness, cost, cost-effectiveness, and return on investment from social and behavior change efforts. To develop this family planning social and behavior change business case, nearly 200 studies were evaluated. All USAID strategic priorities for global health—preventing child and maternal deaths, controlling the HIV/AIDS epidemic, and combating infectious diseases—employ social and behavior change approaches to varying degrees. This is the first in a planned series of complementary, health area-specific business cases

The Platformed Money Ecosystem: Digital Financial Platforms, Datafication, and Reimagining Financial Well-being

Digital financial platforms have become an integral part of consumers\u27 lives–resulting in the datafication of everyday life and potential for uniquely impacting financial well-being. Extending previous transformative consumer research, we suggest financial well-being must center the ways digital financial platforms and their resulting data are increasingly enmeshed with financial decision making and consumption. Drawing on a theoretical lens of platformization, we propose the Platformed Money Ecosystem, which accounts for increased embeddedness of digital financial platforms within consumers\u27 lives and the subtlety of how everyday life is transformed into data: producing data at the micro-level, monetizing data at the meso-level, and regulating data at the macro-level. In conceptualizing the Platformed Money Ecosystem, we identify three data-informed considerations for scholars and policymakers to reimagine financial well-being: protecting consumer data, limiting data biases, and supporting data literacy

Challenges and opportunities in evaluating programmes incorporating human-centred design: lessons learnt from the evaluation of Adolescents 360.

Adolescents 360 (A360) is a four-year initiative (2016-2020) to increase 15-19-year-old girls' use of modern contraception in Nigeria, Ethiopia and Tanzania. The innovative A360 approach is led by human-centred design (HCD), combined with social marketing, developmental neuroscience, public health, sociocultural anthropology and youth engagement 'lenses', and aims to create context-specific, youth-driven solutions that respond to the needs of adolescent girls. The A360 external evaluation includes a process evaluation, quasi-experimental outcome evaluation, and a cost-effectiveness study. We reflect on evaluation opportunities and challenges associated with measuring the application and impact of this novel HCD-led design approach. For the process evaluation, participant observations were key to capturing the depth of the fast-paced, highly-iterative HCD process, and to understand decision-making within the design process. The evaluation team had to be flexible and align closely with the work plan of the implementers. The HCD process meant that key information such as intervention components, settings, and eligible populations were unclear and changed over outcome evaluation and cost-effectiveness protocol development. This resulted in a more time-consuming and resource-intensive study design process. As much time and resources went into the creation of a new design approach, separating one-off "creation" costs versus those costs associated with actually implementing the programme was challenging. Opportunities included the potential to inform programmatic decision-making in real-time to ensure that interventions adequately met the contextualized needs in targeted areas. Robust evaluation of interventions designed using HCD, a promising and increasingly popular approach, is warranted yet challenging. Future HCD-based initiatives should consider a phased evaluation, focusing initially on programme theory refinement and process evaluation, and then, when the intervention program details are clearer, following with outcome evaluation and cost-effectiveness analysis. A phased approach would delay the availability of evaluation findings but would allow for a more appropriate and tailored evaluation design

Outcomes in patients with gunshot wounds to the brain.

Introduction:Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. Methods:We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. Results:825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. Conclusion:We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. Level of evidence:Level II

Novel genetic loci associated with hippocampal volume

The hippocampal formation is a brain structure integrally involved in episodic memory, spatial navigation, cognition and stress responsiveness. Structural abnormalities in hippocampal volume and shape are found in several common neuropsychiatric disorders. To identify the genetic underpinnings of hippocampal structure here we perform a genome-wide association study (GWAS) of 33,536 individuals and discover six independent loci significantly associated with hippocampal volume, four of them novel. Of the novel loci, three lie within genes (ASTN2, DPP4 and MAST4) and one is found 200 kb upstream of SHH. A hippocampal subfield analysis shows that a locus within the MSRB3 gene shows evidence of a localized effect along the dentate gyrus, subiculum, CA1 and fissure. Further, we show that genetic variants associated with decreased hippocampal volume are also associated with increased risk for Alzheimer's disease (rg =-0.155). Our findings suggest novel biological pathways through which human genetic variation influences hippocampal volume and risk for neuropsychiatric illness