Many developing countries have created public-sector family planning programs to reduce unintended pregnancies and improve sexual and reproductive health. However, determining the effectiveness of such programs is difficult, because common indicators designed to measure contraceptive behavior—including modern contraceptive prevalence (mCPR), unmet need for contraception, demand for contraception and demand satisfied—cannot isolate the impact of a government program from that of nongovernmental and private providers. In the lead article of this issue of International Perspectives on Sexual and Reproductive Health, John Bongaarts and Karen Hardee analyze trends in these measures in 26 Sub-Saharan African countries over time and discuss the cases of four of those countries in depth. On the basis of these analyses, they propose a new indicator—the public-sector family planning program impact score (PFPI), which captures the proportion of demand for contraception that is satisfied specifically by government programs.
In Nigeria, private providers are an important source of contraceptive services, but have limited access to clinical, counseling and business training. Using a combination of mystery client surveys, facility surveys and proprietor surveys, Jorge Ugaz and colleagues evaluate a package of trainings designed to increase the quality and scope of family planning services and improve business practices in private health care facilities in Lagos State. The evaluation measured the impact of these trainings on the number of modern contraceptive methods offered, the quality of family planning counseling, recordkeeping practices, the number and success of loan applications, and facility revenue. Noting that the training package had a positive effect on all measures of success except overall facility revenue, the authors conclude that such interventions could be an effective means of improving the provision of contraceptive services by private facilities in Sub-Saharan Africa.
Provision of contraceptives after uterine evacuation appears poor in Bangladesh overall and varies widely between the public and private sectors and by type of treatment. To understand service delivery barriers women face in obtaining contraceptives the same day they receive a menstrual regulation procedure or postabortion care, Erin Pearson and colleagues collected data on adoption of short-acting methods from 479 women who received uterine evacuation services at a health care facility in Bangladesh and did not intend to become pregnant within four months. According to their analyses, both the likelihood that a woman would begin using a contraceptive method, and the type of method she would choose, varied according to service delivery characteristics, including the type of uterine evacuation, the facility level and the governmental or nongovernmental entity that managed the facility. The authors suggest that improved provider training and interventions at the health system level could help to ensure that personal preferences—rather than service delivery factors—drive a woman's choice of and access to an effective, short-acting contraceptive method.
Although contraceptive use rose and fertility declined in Kenya between the late 1970s and the late 1990s, momentum stalled in the following decade. The Tupange program, which aimed to increase contraceptive use and family planning education through training of community health workers, media outreach activities and improvements to the supply environment, was implemented in five Kenyan cities from 2010 to 2014. According to an evaluation by Ilene Speizer and colleagues, the program had a positive impact on the adoption of modern family planning methods over the study period. Among the 5,217 women interviewed at both baseline and endline, modern contraceptive use increased from 45% to 52% by the end of the study, and the proportion of modern method users relying on long-acting or permanent methods rose from 6% to 19%. A fixed-effects model found that modern method use was associated with having heard Tupange-related local radio programming, which was the most cost-effective program activity. According to the authors, the experience of the Tupange program provides valuable information for design of interventions to increase contraceptive use in urban areas in Sub-Saharan Africa.
Abortion is permitted under a broad range of circumstances in Zambia, yet many women die or suffer serious complications from unsafe abortions. Given men's social and economic power over women's decisions about and access to health care, Emily Freeman and colleagues conducted in-depth interviews with 112 women at Zambia's largest abortion services provider to explore the roles men (typically family members or sexual partners) played in their pathway to safe or unsafe abortion. Of the women who were interviewed, 63% had received a safe abortion and 37% had received treatment for complications following an unsafe abortion. Overall, 49% of the participants reported that men had been actively involved in their abortion trajectories. Of women who reported that men had been actively involved, 72% had received a safe abortion; according to the authors, this reflects both men's provision of financial assistance and their ability to obtain information about where to obtain safe abortion services. However, in many cases, men reduced a woman's access to safe abortion by causing her to delay care or seek abortion in secrecy. Because of the significance of men's influence, whether positive or negative, the authors recommend that interventions to prevent unsafe abortion include men.