Special Issue: Family Planning

TL;DR

This paper analyzes global and regional progress toward meeting family planning goals by 2030, showing that most countries need to significantly accelerate their efforts.

Contribution

The study proposes a model to predict family planning coverage using contraceptive use prevalence, simplifying data collection in resource-limited settings.

Findings

To meet the 2030 benchmark, 63 countries need a 2.2 percentage point annual increase in modern contraceptive use, more than double current projections.

A predictive model using contraceptive use prevalence explains 95% of the variability in family planning coverage with high precision.

Low modern contraceptive use in Burkina Faso is linked to higher birth risks and child mortality, particularly in the Sahel, Est, and Sud-Ouest regions.

Abstract

In order to track progress towards the target of universal access to sexual and reproductive health care services of the post-2015 Sustainable Development Goals (SDGs), a measure (demand for family planning satisfied with modern contraceptive methods) and a benchmark (at least 75% by 2030 in all countries) have been recommended.

The goal of this study was to assess the prospects of reaching the benchmark at the country level. Such information can facilitate strategic planning, including resource allocation at global and country levels.

We selected 63 countries based on their status as least developed according to the United Nations or as a priority country in global family planning initiatives. Using United Nations estimates and projections of family planning indicators between 1970 and 2030, we calculated percent demand for family planning satisfied with modern contraceptive methods for each year and country. We then calculated the annual percentage point changes between 2014 and 2030 required to meet the benchmark. The required rates of change were compared to current projections as well as estimates between 1970 and 2010.

To reach the benchmark on average across the 63 countries, demand satisfied with modern methods must increase by 2.2 percentage points per year between 2014 and 2030 – more than double current projections. Between 1970 and 2010, such rapid progress was observed in 24 study countries but typically spanning 5–10 years. At currently projected rates, only 9 of the 63 study countries will reach the benchmark. Meanwhile, the gap between projected and required changes is largest in the Central and West African regions, 0.9 and 3.0 percentage points per year, respectively. If the benchmark is achieved, 334 million women across the study countries will use a modern contraceptive method in 2030, compared to 226 million women in 2014.

In order to achieve the component of the SDGs calling for universal access to sexual and reproductive health services, substantial effort is needed to accelerate rates of progress by a factor of 2 in most study countries and by a factor of 3 in Central and West African countries.

Contraception is one of the most important health interventions currently available and yet, many women and couples still do not have reliable access to modern contraceptives. The best indicator for monitoring family planning is the proportion of women using contraception among those who need it. This indicator is frequently called demand for family planning satisfied and we argue that it should be called family planning coverage (FPC). This indicator is complex to calculate and requires a considerable number of questions to be included in a household survey.

We propose a model that can predict FPC from a much simpler indicator – contraceptive use prevalence – for situations where it cannot be derived directly.

Using 197 Multiple Indicator Cluster Surveys and Demographic and Health Surveys from 82 countries, we explored least-squares regression models that could be used to predict FPC. Non-linearity was expected in this situation and we used a fractional polynomial approach to find the best fitting model. We also explored the effect of calendar time and of wealth on the models explored.

Given the high correlation between the variables involved in FPC, we managed to derive a relatively simple model that depends only on contraceptive use prevalence but explains 95% of the variability of the outcome, with high precision for the estimated regression line. We also show that the relationship between the two variables has not changed with time. A concordance analysis showed agreement between observed and fitted results within a range of ±9 percentage points.

We show that it is possible to obtain fairly good estimates of FPC using only contraceptive prevalence as a predictor, a strategy that is useful in situations where it is not possible to estimate FPC directly.

In sub-Saharan Africa, few studies have stressed the importance of spatial heterogeneity analysis in modern contraceptive use and the relationships with high-risk births.

This paper aims to analyse the association between modern contraceptive use, distribution of birth risk, and under-five child mortality at both national and regional levels in Burkina Faso.

The last three Demographic and Health Surveys – conducted in Burkina Faso in 1998, 2003, and 2010 – enabled descriptions of differentials, trends, and associations between modern contraceptive use, total fertility rates (TFR), and factors associated with high-risk births and under-five child mortality. Multivariate models, adjusted by covariates of cultural and socio-economic background and contact with health system, were used to investigate the relationship between birth risk factors and modern contraceptive prevalence rates (mCPR).

Overall, Burkina Faso's modern contraception level remains low (15.4% in 2010), despite significant increases during the last decade. However, there are substantial variations in mCPR by region, and health facility contact was positively associated with mCPR increase. Women's fertility history and cultural and socio-economic background were also significant factors in predicting use of modern contraception. Low modern contraceptive use is associated with higher birth risks and increased child mortality. This association is stronger in the Sahel, Est, and Sud-Ouest regions. Even though all factors in high-risk births were associated with under-five mortality, it should be stressed that short birth spacing ranked as the highest risk in relation to mortality of children.

Programmes that target sub-national differentials and leverage women's health system contacts to inform women about family planning opportunities may be effective in improving coverage, quality, and equity of modern contraceptive use. Improving the demand satisfied for modern contraception may result in a reduction in the percentage of women experiencing high-risk births and may also reduce child mortality.

Evidence shows that family planning contributes to the decline in child mortality by decreasing the proportions of births that are considered high risk. The main objective of the present analysis was to examine the trends in use of modern contraceptives and their relationship with total fertility rate (TFR) and distribution of births by demographic risk factors as defined by mother's age, birth interval, and birth order at the sub-national level in Ethiopia.

Analyses used data from three Demographic and Health Surveys in Ethiopia (2000, 2005, and 2011), which are nationally representative data collected through questionnaire-based interviews from women 15–49 using a stratified, two-stage cluster sampling. First, we examined the trends of and relationship between TFR (in the 3 years before each survey) and modern contraceptive use among currently married women in all administrative regions over the time period 2000–2011 using linear regression analysis. We also examined the relationship between birth risks and under-five mortality using the no-risk group as a reference. Finally, multiple logistic regression analysis was performed to estimate the relationship between the effect of being a resident in one of the regions and having an avoidable birth risk (which includes births to mothers younger than 18 and older than 34 years, birth interval of less than 24 months and birth order higher than third) after adjusting for select covariates including wealth, educational status, residence, religion and exposure to family planning information.

Sub-national-level regression analysis showed an inverse relationship between modern contraceptive use among married women and the TFR, with an average decrease of TFR by one child per woman associated with a 13 percentage point increase in modern contraceptive use between 2000 and 2011. A high percentage of births in Ethiopia (62%) fall in one of the risk categories (excluding first births), with wide regional variation from 55% in Gambela to 72% in the Somali region. The multivariate analysis showed women living in the Somali, Afar and Benishangul-Gumuz regions had significantly higher odds of having avoidable birth risk compared to those in Addis Ababa after controlling for observed covariates. The trend analysis showed there was a significant drop in the proportion of births from women above 34 years between 2000 and 2011. There was no significant decline in births to women less than 18 years between 2000 and 2011.

A majority of births in Ethiopia fall in one of the risk categories, with substantial region-to-region variation in the percentage of births with avoidable risk factors, Somali and Afar having the highest burden. The analysis indicated that births in the three regions had significantly higher odds of having one of the avoidable risk factors compared to Addis Ababa, and we suggest family planning programmes need to identify differentials of modern contraceptive use at the sub-national level in order to better address coverage and equity issues.

Family planning expansion has been identified as an impetus to harnessing Nigeria's demographic dividend. However, there is a need for data to address pockets of inequality and to better understand cultural and social factors affecting contraceptive use and health benefits. This paper contributes to addressing these needs by providing evidence on the trends and sub-national patterns of modern contraceptive prevalence in Nigeria and the association between contraceptive use and high-risk births in Nigeria.

The study utilised women's data from the last three Demographic and Health Surveys (2003, 2008, and 2013) in Nigeria. The analysis involved descriptive, bivariate, and multivariate analyses. The multivariate analyses were performed to examine the relationship between high-risk births and contraceptive use. Associations were examined using Poisson regression.

Findings showed that respondents in avoidable high-risk birth categories were less likely to use contraceptives compared to those at no risk [rate ratio 0.82, confidence interval: 0.76–0.89, p<0.001]. Education and wealth index consistently predicted significant differences in contraceptive use across the models.

The results of this study suggest that women in the high-risk birth categories were significantly less likely to use a modern method of contraception relative to those categorised as having no risk. However, there are huge sub-national variations at regional and state levels in contraceptive prevalence and subsequent high-risk births. These results further strengthen evidence-based justification for increased investments in family planning programmes at the state and regional levels, particularly regions and states with high unmet needs for family planning.

The benefits of universal access to voluntary contraception have been widely documented in terms of maternal and newborn survival, women's empowerment, and human capital. Given population dynamics, the choices and opportunities adolescents have in terms of access to sexual and reproductive health information and services could significantly affect the burden of diseases and nations’ human capital.

The objectives of this paper are to assess the patterns and trends of modern contraception use among sexually active adolescents by socio-economic characteristics and by birth spacing and parity; to explore predictors of use of modern contraception in relation to the health system; and to discuss implications of the findings for family planning policy and programmes.

Data are from the last three Demographic and Health Surveys of Ethiopia, Burkina Faso, and Nigeria. The descriptive analysis focused on sexually active adolescents (15- to 19-year age group), used modern contraception as the dependent variable, and a series of contact points with the health system (antenatal care, institutional delivery, postnatal care, immunisation) as covariates. The multivariate analysis used the same covariates, adjusting for socio-economic variables.

There are two different groups of sexually active adolescents: those married or in a union with very low use of modern contraception and lower socio-economic status, and those unmarried, among whom nearly 50% are using modern contraception. Younger adolescents have lower modern contraceptive prevalence. There are significant inequality issues in modern contraception use by education, residence, and wealth quintile. However, while there was no significant progress in Burkina Faso and Nigeria, the data in Ethiopia point to a significant and systematic reduction of inequalities. The narrowing of the equity gap was most notable for childbearing adolescents with no education or living in rural areas. In the three countries, after adjusting for socio-economic variables, the strongest factors affecting modern contraception use among childbearing adolescents were marriage and child immunisation.

Addressing child marriage and adopting effective policies and strategies to reach married adolescents are critical for improving empowerment and human capital of adolescent girls. The reduction of the equity gap in coverage in Ethiopia warrants further studies and documentation. The results suggest a missed opportunity for maternal and newborn and family planning integration.

The first 12 months following childbirth are a period when a subsequent pregnancy holds the greatest risk for mother and baby, but also when there are numerous contacts with the healthcare system for postnatal care for mother and baby (immunisation, nutrition, etc.). The benefits and importance of postpartum family planning are well documented. They include a reduction in risk of miscarriage, as well as mitigation of (or protection against) low birth weight, neonatal and maternal death, preterm birth, and anaemia.

The objectives of this paper are to assess patterns and trends in the use of postpartum family planning at the country level, to determine whether postpartum family planning is associated with birth interval and parity, and to identify the health services most closely associated with postpartum family planning after adjusting for socio-economic characteristics.

Data were used from Demographic and Health Surveys that contain a reproductive calendar, carried out within the last 10 years, from Ethiopia, Malawi, and Nigeria. All women for whom the calendar was completed and who gave birth between 57 and 60 months prior to data collection were included in the analysis. For each of the births, we merged the reproductive calendar with the birth record into a survey for each country reflecting the previous 60 months. The definition of the postpartum period in this paper is based on a period of 3 months postpartum. We used this definition to assess early adoption of postpartum family planning. We assessed variations in postpartum family planning according to demographic and socio-economic variables, as well as its association with various contact opportunities with the health system [antenatal care (ANC), childbirth in facilities, immunisation, etc.]. We did simple descriptive analysis with tabular, graphic, and ‘equiplot’ displays and a logistic regression controlling for important background characteristics.

Overall, variation in postpartum use of modern contraception was not affected over the years by age or marital status. One contrast to this is in Ethiopia, where the data show a significant increase in uptake of postpartum contraception among adolescents from 2005 to 2011. There are systematic and pervasive equity issues in the use of modern postpartum family planning by education level, place of residence, and wealth quintile, especially in Ethiopia where the gaps are very large. Disaggregation of data also point to significant sub-national variations. After adjusting for socio-economic variables, the most consistent health sector services associated with modern postpartum contraception are institutional childbirth and child immunisation. ANC is less likely to be associated with the use of modern postpartum family planning.

Postpartum use of modern family planning has remained very low over the years, including for childbearing adolescents. Our results indicate that improving postpartum family planning requires policies and strategies to address the inequalities caused by socio-economic factors and the integration of family planning with maternal and newborn health services, particularly with childbirth in facilities and child immunisation. Scaling up systematic screening, training of providers, and generation of demand are some possible ways forward.

Recent steep declines in child mortality have been attributed in part to increased use of contraceptives and the resulting change in fertility behaviour, including an increase in the time between births. Previous observational studies have documented strong associations between short birth spacing and an increase in the risk of neonatal, infant, and under-five mortality, compared to births with longer preceding birth intervals. In this analysis, we compare two methods to estimate the association between short birth intervals and mortality risk to better inform modelling efforts linking family planning and mortality in children.

Our goal was to estimate the mortality risk for neonates, infants, and young children by preceding birth space using household survey data, controlling for mother-level factors and to compare the results to those from previous analyses with survey data.

We assessed the potential for confounding when estimating the relative mortality risk by preceding birth interval and estimated mortality risk by birth interval in four categories: less than 18 months, 18–23 months, 24–35 months, and 36 months or longer. We estimated the relative risks among women who were 35 and older at the time of the survey with two methods: in a Cox proportional hazards regression adjusting for potential confounders and also by stratifying Cox regression by mother, to control for all factors that remain constant over a woman's childbearing years. We estimated the overall effects for birth spacing in a meta-analysis with random survey effects.

We identified several factors known for their associations with neonatal, infant, and child mortality that are also associated with preceding birth interval. When estimating the effect of birth spacing on mortality, we found that regression adjustment for these factors does not substantially change the risk ratio for short birth intervals compared to an unadjusted mortality ratio. For birth intervals less than 18 months, standard regression adjustment for confounding factors estimated a risk ratio for neonatal mortality of 2.28 (95% confidence interval: 2.18–2.37). This same effect estimated within mother is 1.57 (95% confidence interval: 1.52–1.63), a decline of almost one-third in the effect on neonatal mortality.

Neonatal, infant, and child mortality are strongly and significantly related to preceding birth interval, where births within a short interval of time after the previous birth have increased mortality. Previous analyses have demonstrated this relationship on average across all births; however, women who have short spaces between births are different from women with long spaces. Among women 35 years and older where a comparison of birth spaces within mother is possible, we find a much reduced although still significant effect of short birth spaces on child mortality.

Figures

Full text

In September 2015, under the leadership of United Nations Secretary-General Ban Ki-Moon, the international community took a huge step forward for people, the planet, and prosperity with the adoption of the 2030 Agenda for Sustainable Development. The 17 Sustainable Development Goals (SDGs) pave a brave path towards a world of equity and inclusion, health, including sexual and reproductive health and reproductive rights, education, and greater equality (1).

Over the 1990–2015 timeframe of the Millennium Development Goals and, particularly since the 1994 International Conference on Population and Development, considerable progress has been made in women's sexual and reproductive health, including increases in contraceptive use globally, expanded access to skilled maternity care, and the reduction of new HIV infections and maternal and newborn deaths. The secretary-general's ‘Every Woman Every Child’ strategy (2) has catalysed increased leadership and commitment from governments and strong support from all partners, including United Nations agencies, non-governmental organisations, foundations, academia and professional associations.

Behind the positive global trends, however, lie significant differences among and within countries. For example, around 225 million women in low- and middle-income countries (LMICs) who do not want to become pregnant are not using modern contraception. It is estimated that 30 million unplanned births and 40 million abortions, half of them illegal and unsafe, occur annually. An estimated 499 million new sexually transmitted infections (excluding HIV) occur annually, approximately half among girls and women (2, 3).

The papers in this Special Issue reinforce the centrality of universal access to modern contraception within the SDGs and targets set for 2030 (1). Indeed the research and findings presented here point to an ecological correlation between satisfying demand for family planning using modern contraceptives and economic development (4). To reach the proposed benchmark of 75%, demand satisfied with modern methods of contraception would need to increase by 2.2 percentage points annually between 2014 and 2030 – more than double the current projections on average across the 63 countries analysed. Such rapid progress would require significant effort, particularly to meet needs among adolescent girls. If the 75% benchmark were achieved, 334 million women across the LMICs studied would use a modern contraceptive method by 2030, compared to 226 million women in 2014.

Strategies to increase family planning coverage (FPC) have to be backed up by effective metrics for assessing progress. For this purpose, a new FPC indicator has been developed by the authors in this special issue, based on the prevalence of contraceptive use (5).

Although coverage is an important indicator, meeting unmet needs and ensuring universal access to human rights-based family planning will not be achieved without addressing equity and quality issues. In this Special Issue, some authors have taken a detailed look at differences in access and use at the subnational level and over time in three countries: Burkina Faso, Ethiopia, and Nigeria (6–8). In all three cases they discovered substantial variations in modern contraceptive use between rural and urban areas and by other socio-economic factors. Consistently across all three countries the results confirm an association between fertility history and modern contraceptive use, as well as between low modern contraceptive use and higher birth risks, leading to increased child mortality. Moreover, women living in rural areas have significantly higher odds of avoidable birth risks (and hence child mortality) compared to their counterparts living in urban areas. In Burkina Faso short birth spacing ranked as the highest risk in relation to child deaths (6).

As the world aspires to a situation in which every adolescent girl and woman has easy access to comprehensive sexuality education and contraceptive services, studies here on contraceptive use among sexually active adolescents in Burkina Faso, Ethiopia, and Nigeria (9) and postpartum family planning uptake in Ethiopia, Malawi, and Nigeria (10) also highlighted equity and quality issues. Health systems must address these issues as the global community moves towards universal access. Marriage at very young ages is not only a human rights issue in itself, but also a barrier to modern contraceptive use, and it thus disempowers girls. Adolescent girls experience significant inequality in access to modern contraception by education, residence, and wealth quintile. The results from Ethiopia, however, show that leadership and commitment at the country level can bring change. The authors reported a significant and systematic reduction of inequalities, but also a narrowing of the equity gap, most notably for childbearing adolescents with no education or living in rural areas.

Mortality risks associated with low birth spacing have been further studied to assess potential confounding in the association between short-birth intervals and increased neonatal, infant, and child mortality in order to better inform attributable effects (11). After adjusting for confounding, the authors reported that neonatal, infant, and child mortality remained strongly and significantly related to short birth intervals, albeit with a one third reduction in the attributable risk ratio.

Any resilient health system must take into account the provision of reproductive, maternal, newborn, and adolescent health services across the life cycle, including easy access to family planning. The findings in these papers point to missed opportunities for integrating maternal and newborn health, including failure to combine child immunisation with family planning, as the factor most associated with the non-uptake of modern contraception in the postpartum period (10).

As we celebrate the historic adoption of the SDGs and look ahead to their implementation, access to family planning represents an important entry point and a marker for universal access to reproductive health and rights. Access to modern contraception reduces the risks of maternal and newborn deaths (11) as well as reducing lifetime parity, and thus it affects health, life expectancy, and the dependency ratio. The availability of family planning affects education prospects and human capital among adolescent girls by preventing teenage pregnancies and enabling girls to stay in school. It could also improve access to food and reduce hunger by reducing the dependency ratio. Urbanisation and population dynamics are intrinsically linked, particularly internal and external migration, which have poverty as a root cause. Access to modern contraception can spur the economy, protect the environment, and contribute to overall poverty reduction.

The research findings in this Special Issue, which come from distinguished scientists in United Nations agencies, non-governmental organisations, and universities, present a range of global and local policy and programmatic priorities to address measurement, coverage, impact, quality and equity issues in family planning services, which are integral to the global sustainable development agenda. This is particularly important for countries in sub-Saharan Africa. We thus call on world leaders and financiers to join forces and work towards the future we want, a future in which every pregnancy is wanted, every birth is safe, and every young person's potential is fulfilled.