Tumlinson K, Senderowicz L, Bullington B, et al. Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study.
BMJ Open. 2023;13 ::e071775.
Publisher's VersionAbstract
Objectives Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal.
Methods We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred.
Findings The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day.
Conclusion Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals.
Full text Bullington B, Sawadogo N, Tumlinson K, et al. Prevalence of non-preferred family planning methods among reproductive-aged women in Burkina Faso: results from a cross-sectional, population-based study.
Sexual and Reproductive Health Matters . 2023;31 (1) : 2174244.
Publisher's VersionAbstractFamily planning researchers have traditionally focused efforts on understanding contraceptive non-use and promoting contraceptive uptake. Recently, however, more scholars have been exploring method dissatisfaction, questioning the assumption that contraceptive users necessarily have their needs met. Here, we introduce the concept of “non-preferred method use”, which we define as the use of one contraceptive method while having the desire to use a different method. Non-preferred method use reflects barriers to contraceptive autonomy and may contribute to method discontinuation. We use survey data collected from 2017 to 2018 to better understand non-preferred contraceptive method use among 1210 reproductive-aged family planning users in Burkina Faso. We operationalise non-preferred method use as both (1) use of a method that was not the user’s original preference and (2) use of a method while reporting preference for another method. Using these two approaches, we describe the prevalence of non-preferred method use, reasons for using non-preferred methods, and patterns in non-preferred method use by current and preferred methods. We find that 7% of respondents reported using a method they did not desire at the time of adoption, 33% would use a different method if they could and 37% report at least one form of non-preferred method use. Many women cite facility-level barriers, such as providers refusing to give them their preferred method, as reasons for non-preferred method use. The high prevalence of non-preferred method use reflects the obstacles that women face when attempting to fulfil their contraceptive desires. Further research on reasons for use of non-preferred methods is necessary to promote contraceptive autonomy.
Full text Swan L, Senderowicz L, Lefman T, Ely G.
Health care provider bias in the Appalachian region: The frequency and impact of contraceptive coercion.
Health Services Research. 2023.
Publisher's VersionAbstractObjective:To investigate the frequency and impact of contraceptive coercion in theAppalachian region of the United States.Data Sources and Study Setting:In fall 2019, we collected primary survey data withparticipants in the Appalachian region.Study Design:We conducted an online survey including patient-centered measuresof contraceptive care and behavior.Data Collection/Extraction Methods:We used social media advertisements torecruit Appalachians of reproductive age who were assigned female at birth(N=622). After exploring the frequency of upward coercion (pressure to usecontraception) and downward coercion (pressure not to use contraception), we ranchi-square and logistic regression analyses to explore the relationships betweencontraceptive coercion and preferred contraceptive use.Principal Findings:Approximately one in four (23%,n=143) participants reportedthat they were not using their preferred contraceptive method. More than one-thirdof participants (37.0%,n=230) reported ever experiencing coercion in their contra-ceptive care, with 15.8% reporting downward coercion and 29.6% reporting upwardcoercion. Chi-square tests indicated that downward (χ2(1)=23.337,p< 0.001) andupward coercion (χ2(1)=24.481,p< 0.001) were both associated with a decreasedlikelihood of using the preferred contraceptive method. These relationships remainedsignificant when controlling for sociodemographic factors in a logistic regressionmodel (downward coercion: Marginal effect=0.169,p=0.001; upward coercion:Marginal effect=0.121,p=0.002).Conclusions:This study utilized novel person-centered measures to investigate con-traceptive coercion in the Appalachian region. Findings highlight the negative impactof contraceptive coercion on patients' reproductive autonomy. Promoting contracep-tive access, in Appalachia and beyond, requires comprehensive and unbiasedcontraceptive care.
Full text Bullington B, Sawadogo N, Tumlinson K, et al. Exploring Upward and Downward Provider Biases in Family Planning: The Case of Parity.
Global Health: Science and Practice. 2023;11 (3).
Publisher's VersionAbstractIntroduction: Provider bias has become an important topic of family planning research over the past several decades. Much existing research on provider bias has focused on the ways providers restrict access to contraception. Here, we propose a distinction between the classical “downward” provider bias that discourages contraceptive use and a new conception of “upward” provider bias that occurs when providers pressure or encourage clients to adopt contraception. Methods: Using cross-sectional data from reproductive-aged women in Burkina Faso, we describe lifetime prevalence of experiencing provider encouragement to use contraception due to provider perceptions of high parity (a type of upward provider bias) and provider discouragement from using contraception due to provider perceptions of low parity (a type of downward provider bias). We also examine associations between sociodemographic characteristics and experiences of provider encouragement to use contraception due to perceptions of high parity. Results: Sixteen percent of participants reported that a provider had encouraged them to use contraception due to provider perceptions of high parity, and 1% of participants reported that a provider had discouraged them from using contraception because of provider perceptions of low parity. Being married, being from the rural site, having higher parity, and having attended the 45th-day postpartum check-up were associated with increased odds of being encouraged to use contraception due to provider perceptions of high parity. Conclusion: We find that experiences of upward provider bias linked to provider perceptions of high parity were considerably more common in this setting than downward provider bias linked to perceptions of low parity. Research into the mechanisms through which upward provider bias operates and how it may be mitigated is imperative to promote contraceptive autonomy.
Full text Senderowicz L, Bullington B, Sawadogo N, et al. Assessing the Suitability of Unmet Need as a Proxy for Access to Contraception and Desire to Use It.
Studies in Family Planning. 2023;54 (1) :231-250.
Publisher's VersionAbstractUnmet need for contraception is a widely used but frequently misunderstood indicator. Although calculated from measures of pregnancy intention and current contraceptive use, unmet need is commonly used as a proxy measure for (1) lack of access to contraception and (2) desire to use it. Using data from a survey in Burkina Faso, we examine the extent to which unmet need corresponds with and diverges from these two concepts, calculating sensitivity, specificity, and positive/negative predictive values. Among women assigned conventional unmet need, 67 percent report no desire to use contraception and 61 percent report access to a broad range of affordable contraceptives. Results show unmet need has low sensitivity and specificity in differentiating those who lack access and/or who desire to use a method from those who do not. These findings suggest that unmet need is of limited utility to inform family planning programs and may be leading stakeholders to overestimate the proportion of women in need of expanded family planning services. We conclude that more direct measures are feasible at the population level, rendering the proxy measure of unmet need unnecessary. Where access to and/or desire for contraception are the true outcomes of interest, more direct measures should be used.
Full text Senderowicz L, Bullington B, Sawadogo N, et al. Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator.
Studies in Family Planning. 2023;54 (1) :201-230.
Publisher's VersionAbstract
Abstract
There is growing consensus in the family planning community around the need for novel measures of autonomy. Existing literature highlights the tension between efforts to pursue contraceptive targets and maximize uptake on the one hand, and efforts to promote quality, person-centeredness, and contraceptive autonomy on the other hand. Here, we pilot a novel measure of contraceptive autonomy, measuring it at two Health and Demographic Surveillance System sites in Burkina Faso. We conducted a population-based survey with 3,929 women of reproductive age, testing an array of new survey items within the three subdomains of informed choice, full choice, and free choice. In addition to providing tentative estimates of the prevalence of contraceptive autonomy and its subdomains in our sample of Burkinabè women, we critically examine which parts of the proposed methodology worked well, what challenges/limitations we encountered, and what next steps might be for refining, improving, and validating the indicator. We demonstrate that contraceptive autonomy can be measured at the population level but a number of complex measurement challenges remain. Rather than a final validated tool, we consider this a step on a long road toward a more person-centered measurement agenda for the global family planning community.
Full text Tumlinson K, Britton L, Goland E, et al. Contraceptive stockouts in Western Kenya: a mixed-methods mystery client study.
BMC Health Services Research. 2023;23 (1) :74.
Publisher's VersionAbstract
Background
The prevalence of modern contraception use is higher in Kenya than in most countries in Sub-Saharan Africa. The uptake has however slowed down in recent years, which, among other factors, has been attributed to challenges in the supply chain and increasing stockouts of family planning commodities. Research on the frequency of contraceptive stockouts and its consequences for women in Kenya is still limited and mainly based on facility audits.
Methods
This study employs a set of methods that includes mystery clients, focus group discussions, key informant interviews, and journey mapping workshops. Using this multi-method approach, we aim to quantify the frequency of method denial resulting from contraceptive stockout and describe the impact of stockouts on the lived experiences of women seeking contraception in Western Kenya.
Results
Contraceptives were found to be out of stock in 19% of visits made to health facilities by mystery clients, with all contraceptive methods stocked out in 9% of visits. Women experienced stockouts as a sizeable barrier to accessing their preferred method of contraception and a reason for taking up non-preferred methods, which has dire consequences for heath, autonomy, and the ability to prevent unintended pregnancy. Reasons for contraceptive stockouts are many and complex, and often linked to challenges in the supply chain – including inefficient planning, procurement, and distribution of family planning commodities.
Conclusions
Contraceptive stockouts are frequent and negatively impact patients, providers, and communities. Based on the findings of this study, the authors identify areas where funding and sustained action have the potential to ameliorate the frequency and severity of contraceptive stockouts, including more regular deliveries, in-person data collection, and use of data for forecasting, and point to areas where further research is needed.
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