Accepted Manuscript Family planning: Choices and challenges for developing countries Michael T. Mbizvo , Sharon J. Phillips

PII:

S1521-6934(14)00086-8

DOI:

10.1016/j.bpobgyn.2014.04.014

Reference:

YBEOG 1353

To appear in:

Best Practice & Research Clinical Obstetrics & Gynaecology

Received Date: 9 April 2014 Revised Date:

22 April 2014

Accepted Date: 25 April 2014

Please cite this article as: Mbizvo MT, Phillips SJ, Family planning: Choices and challenges for developing countries, Best Practice & Research Clinical Obstetrics & Gynaecology (2014), doi: 10.1016/ j.bpobgyn.2014.04.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Michael T. Mbizvo1

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Family planning: Choices and challenges for developing countries

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Sharon J. Phillips2

Corresponding Author

Professor, Department of Obstetrics and Gynaecology, University of Zimbabwe, College of Health Sciences, Ex-Director, Reproductive Health & Research, World Health Organization 2

Medical Officer, Department of Reproductive Health and Research, World Health Organization

Disclaimer: The views expressed are the authors’ alone and do not necessarily represent the views of the World Health Organization.

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Abstract

While slow and uneven progress has been made on maternal health, attaining the 1994 Cairo

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International Conference on Population and Development (ICPD) goal for achieving universal access to reproductive health remains elusive for many developing countries. Assuring access to sexual and reproductive health services, including integrated family planning services, remains a

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critical strategy for improving the health and wellbeing of women and alleviating poverty.

Family planning not only prevents maternal, infant, and child deaths, but also empowers women

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to engage fully in socio-economic development and provides them with reproductive choices. This paper will discuss the current landscape of contraception in developing countries, including options available to women and couples, as well as the challenges to its provision. Finally we review suggestions to improve access and promising strategies to ensure all people have

Key words:

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universal access to reproductive health options.

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Contraception, family planning, low-income countries, developing countries

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Introduction The 1994 Cairo ICPD Program of Action was visionary when, among others, it asserted: “Recognize that appropriate methods for couples and individuals vary according to their age,

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parity, family size preference and other factors (e.g. reproductive stage and intention), and thus policies and programs should ensure that women and men have information and access to the widest possible range of safe and effective family planning methods, in order to enable them to

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exercise free and informed choice.”[1] Twenty years later, although great strides have been made in access to reproductive health choices, adolescents, women and couples living in low and

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middle-income countries still often lack access to a full range of contraceptive options and to comprehensive reproductive and sexuality education. The Millenium Development Goals (MDGs) offered an aspirational vision for improved health for billions of people worldwide, but reproductive health services such as family planning were not included in the original MDGs due

[2].

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to political pressure from countries opposed to sexuality education for adolescents and abortion

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In the early 2000s, countries and donors focused on significant new health challenges, such as HIV, and on meeting the measurable goals specified in the MDGs; funding for contraceptive

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services dropped, even as the world's population grew larger and the benefits accrued from investing in family planning became increasingly evident.[3] In 2007, however, MDG 5b target was added, calling for universal access to reproductive health by 2015 (measured by contraceptive prevalence, adolescent birth rate, antenatal care coverage, and unmet need for family planning) [4]. In 2012, at a summit sponsored by the UK Department for International Development and the Bill and Melinda Gates Foundation, wealthy countries pledged over two billion US dollars for family planning programming in developing countries; additionally, over 3

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20 developing countries pledged to improve access to contraception through their domestic programs. [5] Contraception is now recognized worldwide as a critical requirement for the health of girls, women, and families. Increasing contraceptive use in developing countries has reduced

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the number of maternal deaths by 40% over the past 20 years, merely by reducing the number of unintended pregnancies.[6] By preventing high-risk pregnancies, in particular in women of high parity and those that would have ended in unsafe abortion, contraceptive use has reduced

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maternal mortality ratio by about 26% in just above a decade. However, many challenges

choice in low-income countries.

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remain to ensure that its benefits are available in an equitable manner and with fully informed

Choices and availability of contraception within countries in the developing world A key determinant for achieving universal access to sexual and reproductive health is ensuring

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access to and availability and affordability of good quality methods of contraception. For all persons to exercise a choice among contraceptive options, a range of methods must be readily available.[7] Contraceptive prevalence rate is highest in countries where access to more choices,

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e.g. female sterilization, the IUD, the pill, injectables and the condom is uniformly high. Absence of full choice restricts personal access to each method as well as the use of all methods

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in a population.[7] To the extent that the ability to choose satisfactory contraceptive protection depends on ready access to multiple methods, there is a clear need for greater policy and programmatic attention to the provision of a full range of methods.

The reality in most developing countries is that only a limited choice of contraceptive methods is offered, particularly within the public sector, and women cannot easily or readily choose the method that best suits their reproductive needs. Although all modern contraceptives are highly 4

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effective, for some women long-acting, reversible contraceptive (LARC) methods, such as the IUD and contraceptive implants, are more effective with actual use, as they do not require women to remember to use them with each sex act as with condoms, or daily or tri-monthly as

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with oral contraceptive pills or injectables. For instance, while oral contraceptive pills are 99.7% effective with perfect use, with typical use 9% of women using the method will become pregnant in a year of use.[8] While some women are able to use oral contraceptives perfectly, or are

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willing to run the risk of increased chance of pregnancy with imperfect use, other women will prefer a method that is less user-dependent. Because LARC methods require no routine action to

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maintain their high efficacy, they are equally effective with both perfect use and typical use. Easy accessibility to such methods is, therefore, critical to ensuring women's contraceptive needs are met.

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Other methods must also be available, as every woman has unique needs, which may change throughout her life course. For women with certain medical conditions, combined oral contraceptives can serve simultaneously as an effective family planning method and as treatment

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for various medical conditions, such as pre-menstrual syndrome or menorrhagia.[9] For women and men who have completed their childbearing, surgical sterilization is an excellent option that

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does not require use of hormones, which are contra-indicated for women with certain medical or other conditions, and has no side effects. Additionally, vasectomy is the only highly-effective method for men, although it is particularly under-utilized in developing countries and by men of lower socio-economic status in those countries.[10]

Multiple barriers exist to providing surgical sterilization in developing countries. Often resources are inadequate to provide any surgical services. Factors impeding access to surgery in 5

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low-income countries include poor roads, lack of resources and surgical expertise, and the high costs of surgical care.[11] In general, permanent contraceptive methods have higher up-front costs than do shorter-acting or LARC methods, and as with LARC methods the materials

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necessary to perform the procedures often fail to be included in essential medication and medical supply lists. They also are often left out of programmatic strategies that focus heavily on

provision of commodities rather than services. However, family planning programs that do not

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families for whom such options would be best.[12]

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include permanent methods fail to offer complete and full choice, and are thus short-changing

Many women rely on traditional methods of contraception, particularly in developing countries. These methods range in effectiveness. Some are backed by evidence, such as fertility awareness methods, which range from 0.4-5% failure rates with one year of perfect use and approximately

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24% with typical use.[8] Withdrawal can also be fairly effective with perfect use, although with typical use 22% of couples using this method will become pregnant in one year.[8] Similarly, lactational amenorrhoea, when practiced correctly, is highly effective temporarily, for a

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maximum of six months post-partum.[13] However, many women and couples who are using 'traditional' methods either do not use these methods in such a manner as to be able to rely on

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high efficacy, or use other traditional methods that are less effective, such as the rhythm method, periodic abstinence, or other traditional methods such as herbs or other practices that may vary significantly depending on the country and region. The appeal of these methods for some women is significant; they may seem more natural and less likely to cause side effects, may be more acceptable to male partners, and are accessible without having to visit a health provider for initiation or continuation, allowing for better accessibility and privacy.[14] Unfortunately, many people using these methods are likely unaware of their limited efficacy when used typically (for 6

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science-based fertility awareness methods), the limited amount of time they are effective (for lactational amenorrhea), or the lack of evidence suggesting that they are effective at all (for many other traditional methods). Even couples using fertility awareness based methods that are based

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on good evidence who participated in trials, in which there was a higher degree of support to continue the method than would be expected in typical practice, had very high method

discontinuation rates.[15] Many couples choosing such methods may be therefore expected to

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use them incorrectly or to discontinue their use quickly. As a result, people may be using

methods they think will be more effective than they are, and are thus at risk for unintended

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pregnancy and its attendant potential harms.

Although emergency contraception is not a regular, long-term contraceptive method, it can play a key role in preventing unintended pregnancy when other methods were forgotten, failed, or in a

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situation where a woman was unable to negotiate contraceptive use. Emergency contraception has failed to show a net pregnancy prevention benefit on a population level,[16] and is usually less effective at preventing pregnancy than regular contraceptive methods, but remains a critical

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option for preventing pregnancy in certain situations.[17] Emergency contraceptive pills, such as levonorgestrel, are widely available and are included in the WHO Essential Medicines List, but

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accessibility remains limited due to the lack of their inclusion in national healthcare programs, family planning social marketing efforts, and educational programs. [18] A newer emergency contraceptive pill, ulipristal acetate, may be more effective at preventing pregnancy that levonorgestrel, especially when more than 72 hours have passed since intercourse or the woman weighs more than 70 kg,[17] but is more expensive than levonorgestrel and is not yet widely available in many developing countries,[19] nor is it on the WHO Essential Medicines List.[20] Another option for post-coital contraception, the copper IUD, is highly effective regardless of 7

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weight, and is effective for up to seven days after unprotected intercourse, but is not widely available to many women on a scheduled, much less urgent, basis in many high-income countries,[21] let alone low-income countries. Quick availability of emergency contraceptive

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methods is particularly important in the context of post-rape care, gender-based violence, and in settings where women have limited opportunities to access and use regular contraceptive methods. All women accessing emergency contraceptive services should be offered the

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opportunity to initiate a more effective regular contraceptive method. The copper IUD is an ideal emergency contraceptive for women who wish to initiate regular contraception, as the

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method works as both an emergency contraceptive and is a highly effective LARC method as well.

Method mix and choice

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Although a wide range of contraceptive options is critical to ensuring women and couples can exercise their rights to reproductive options, many countries fail to offer a broad mix of methods. Additionally many people continue to rely heavily on less-effective or ineffective "traditional"

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contraceptive methods. An analysis by Sullivan et al reviewed comparative method mixes that were unbalanced, defining as skewed if a single method constituted 50% or more of all

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contraceptive use in a country.[22] Of 96 countries, 34 had a skewed method mix, sixteen in which traditional methods dominated, especially in sub-Saharan Africa; four in which female sterilization was predominant, in India and three Latin American countries; and fourteen that relied either on the pill, or IUD, or injectables, spread across various regions. Such a skewed method mix most likely is indicative of lack of true choice and options, given the stark contrast between the methods used by women in countries where women have ready access to multiple contraceptive methods and the methods used by women in countries with fewer choices. 8

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Women in the UK, for instance, use a wide variety of methods, including pills, LARC methods, permanent methods, and traditional methods. Meanwhile, in countries such as Indonesia and Kenya, many fewer women are using long-acting or permanent methods, and more are relying on

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shorter-acting methods such as oral contraceptive pills or injectables. Although Indonesia has a much higher rate of modern contraceptive use (61.9%) than Kenya (38.9%), similar percentages of women in both countries use less reliable methods for contraception. Finally, in Nigeria,

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where the rate of modern method use is quite low (8.8%), fewer than 10% of women using a method are using long-acting or permanent methods, while nearly half of those using a method

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are using less reliable traditional methods [23] (Figure 1) Although variability is to be expected from region to region in which methods are preferred, it is unlikely that the observed differences solely reflect women's preferences. Rather, women do not have access to a full range of options

Insert Figure 1 about here

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in some countries, and the methods they use (or do not use) reflect the lack of access.

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Personal choice is critical to initiation and continuation of contraceptive use. In settings with access to more contraceptive methods, a greater mix of methods are used.[24] Women who are

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given a full range of choices, with full information, may be more likely to continue their method and to be more satisfied with their method, although evidence for this is limited.[25] Regardless, human rights principles dictate the need for full information and choice to the greatest extent possible.[26] This need for personal choice among contraceptive options presents the need for the availability of multiple methods. A recent review on trends in contraceptive use found that, although use of modern contraceptive methods has increased between 2003 and 2012, in regions and sub regions of developing countries, unmet need for contraceptives was still very high. In 9

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2012, 222 million women had an unmet need for contraception, especially in sub-Saharan Africa (60%), South Asia (34%), and Western Asia (50%).[27] To meet this unmet need, the authors concluded that countries need to increase resources, improve access to contraceptive services and

The role of choice and access in contraceptive use

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reduce barriers to contraceptive use.

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supplies, and provide high quality services and large-scale public education interventions to

Even though access and choice are limited in many countries, these are precisely what is required

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to ensure more women use contraceptive methods. Although there is a paucity of information regarding whether having multiple methods to choose from impacts contraceptive use on an individual level,[25] countries with a broader method mix have been noted to have higher contraceptive prevalence. In a review of survey data on contraceptive use from 80 countries, the

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prevalence of use for five modern contraceptive methods was correlated with a variety of access measures.[24] Greater access was accompanied by a better balance among methods for both access and use. In the same study, this trend was also seen in sub-Saharan Africa, though at

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lower levels. Studies during the early emergence of contraception showed that the addition of each new method raised contraceptive prevalence. In Thailand, when the contraceptive pill was

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added to the family planning program through the national network of auxiliary nurse midwives, its use was double that for the pre-existing methods.[28] In Egypt, regulatory constraints to IUD provision were removed and the new Copper-T IUD was introduced, leading to a doubling of contraceptive use.[29]

Improved contraceptive choice and access could reduce unmet need for family planning; however, even with improved availability, women's concerns about side effects, difficulties 10

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negotiating contraceptive use with partners, and a multitude of other barriers could all prevent effective use of contraceptive methods.[30] Some of these barriers could be overcome with improved contraceptive technology, as methods with fewer side effects and that are less

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dependent on perfect use by the woman and partner agreement are developed. If methods-

related reasons for non-use of modern contraception could be overcome, unintended pregnancies could be reduced by as much as 59% in sub-Saharan Africa and South-Central and South-East

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Asia.[30]

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Health workforce

In order to ensure unmet need for contraceptives is decreased, significant health workforce investments must be made. Fortunately, unlike many higher-level functions, most contraceptive provision can be performed by mid-level providers, such as nurses, and some can be performed

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in the community by trained lay health workers and pharmacists. The World Health Organization recommends that, in the context of monitoring and evaluation, lay health workers may provide initiation and continuation of injectable contraceptives. Additionally, nurses and

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nurse midwives may insert and remove contraceptive implants and IUDs, and advanced level associate clinicians may provide vasectomy and tubal ligation.[31] Emergency contraceptive

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pills are available without a prescription to women through community pharmacies in many countries, which has been shown to increase timely access to the method.[32] Pharmacists in some settings are taking active roles in provision of some contraceptive methods, such as injectables [33] and oral contraceptive pills,[34] and given the greater flexibility in the hours they are open and more convenient location may become key players in contraceptive provision in the future.

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Contraception and equity Contraceptive use has increased markedly worldwide in the past half-century. Unfortunately, these gains belie the uneven progress that has been made. While women living in wealthy

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countries increasingly use contraception, and use a wide range of methods, there remain

significant gaps in use between the rich and the poor, and substantial regional variations in

contraceptive use. A study of 55 developing countries with DHS data available showed that

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modern contraceptive prevalence is substantially lower regardless of income group in sub-

Saharan Africa, and to some degree in Latin America and the Caribbean, when compared to

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Asian countries.[35] The study also found that countries with the greatest income inequality similarly had the greatest inequality in contraceptive use, with the poor less likely to use modern contraceptives, and that this inequality has increased over time. Another study of DHS data from 54 developing countries found that family planning was among the most inequitably distributed

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interventions in maternal, newborn, and child health, with 67% of people in the top economic quintile reporting their needs were satisfied, compared with 41.4% of people in the bottom economic quintile.[36] The poorest women are also the least likely to be exposed to educational

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messages about the benefits of family planning.[37]

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There is evidence that, where significant public investment is made into family planning programs, these gaps are less prominent. For instance, in Bangladesh, where equity and health has been a subject of concerted effort and contraceptive programs have been a focus of investment for years,[38] married women in the richest and poorest quintile are equally likely to be using a modern contraceptive method. On the other hand, significant differences by wealth quintile are evident in both Malawi, where great efforts to increase contraceptive use have been made, [39, 40] and in the Democratic Republic of the Congo, where contraceptive prevalence is 12

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very low for all wealth quintiles at less than 6%. In Malawi, 34.9% of women in the poorest households use a modern method, compared with 48.4% of those in the richest households. In DRC, less than 3% of the poorest women use modern methods, compared with 14.9% of women

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in the highest income quintile.[41] (Figure 2) Access to contraceptive methods, and the creation of conditions enabling their use, must be considered through a lens of equity. Promising

potential service delivery mechanisms that may improve equity of access include voucher

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Insert Figure 2 about here

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programs targeting poor populations.[42]

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Challenges, barriers and cultural restraints to use of modern contraception

Although the benefits of modern contraception to women’s health outweigh the risks (real or perceived), barriers and challenges remain. Limited access to and choice of contraceptive

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methods are among the critical challenges. Unmet need remains high among the most vulnerable groups, such as the poor and young people. The barriers to serving the most vulnerable have not,

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however, been well elucidated in developing countries. Potential challenges include negative user attitudes towards contraception, provider beliefs, and those arising from the culture and health systems. Users who only infrequently engage in sexual activity may not believe they need contraceptives; additionally, many people are familiar with only a limited number of methods, or may subscribe to traditional and/or religious belief systems that preclude contraceptive use.[43]

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In a systematic review of 12 studies (six from sub-Saharan Africa, one from South East Asia) assessing the barriers to use of contraceptives in developing countries, hormonal method use was limited by lack of knowledge, obstacles to access and concern over side effects especially fear of

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infertility.[14] Although condoms were often more accessible, their use for contraception was limited by association with disease and promiscuity, together with greater male control. The review concluded that increasing modern contraceptive method use requires a community-wide,

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multifaceted intervention and the combined provision of information, life skills, support and access to youth friendly services. Interventions should aim to counter negative perceptions of

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modern contraceptive methods and the dual role of condoms for contraception and STI/HIV prevention should be underscored continuously.

A review of research evidence and programmatic experience on needs, barriers and approaches

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to access and use of contraception by adolescents in low and middle income countries concluded that all adolescents, especially unmarried ones, face a number of barriers in obtaining and using contraception.[44) The authors recommended enacting and implementing laws and policies on

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provision of sexuality education and adolescent-friendly health services, providing contraception

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through a variety of outlets and building community support for adolescent services.

A study among women in Nigeria proffered the most commonly perceived barriers accounting for low contraceptive use as perceived side effects (44%), ignorance (32.6%), misinformation (25.1%), superstition (22.0%) and cultural (20.3%). [45] Predictors of use of modern contraceptives included the awareness of a place of family planning service provision, respondents' approval of the use of contraceptives, higher education status and being married. The authors proposed to address the low point prevalence of contraceptive use through: 14

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community-based behavioral change communication programs that bridge the knowledge gap to address deep-seated negative belief systems. In a review on family planning in sub-Saharan Africa, attitudinal resistance was posited to be the cause of slow progress towards adoption of

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family planning in Western Africa. [46]

The cost of family planning programs and methods may be a barrier to their wide availability in

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some developing countries. Some methods, particularly long-acting and permanent methods, are associated with significant initial costs, although their yearly costs tend to be less than yearly

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costs for injectables, pills or condoms (notably, contraceptive implants cost a similar amount per year of use as other hormonal methods). It is estimated that providing improved, modern contraceptive services to all women with an unmet need for family planning would cost $8.1 billion ($3 billion more than current expenditures), and these increased costs would

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predominantly be borne by low- and middle-income countries.[47] However, these costs lead to net benefits for those countries that invest in contraception; each $1 spent saves approximately $1.40 in maternal and child health services.[48] Additional economic and non-economic benefits

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from the fertility decline enjoyed by countries that invest in family planning include increased per capita income, improved social and economic standing for women, and healthier, better-

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educated children in future generations.[49]

Increasing access to, and utilization of, family planning services With all the benefits that accrue to women, families, and society in general when family planning services are used, increasing access to them, and their use, is clearly important. FP2020 has laid out a clear mandate to increase the number of contraceptive users to 120 million by 2020, in order to rally global support with a measurable outcome.[50] While this goal is admirable, it is 15

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critical that women's rights be maintained in the quest to achieve it, and that contraceptive use is truly voluntary. For human rights to be upheld, contraceptive services must be offered without coercion, with attention to adequate supplies, removal of barriers to access, and high quality

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services.[51] A framework has been proposed to ensure that family planning programs maintain human rights standards,[52] and the World Health Organization recently issued guidelines on

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human rights in family planning service provision.[26]

Despite the clear need, and decades of work on family planning programming, with a few

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exceptions it remains unclear which societal factors are most important to increased family planning uptake, and which programming strategies are most beneficial. Although improved economic conditions and effort put into programming are associated with increased contraceptive uptake,[53] understanding of the specific programmatic interventions that are most

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beneficial remains elusive. This may be at least in part due to the complex nature of decisions within families about when to have children. A systematic review found that the majority of both supply-side and demand-side interventions had a beneficial effect on increasing

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contraceptive use (found in 36 of 49 studies published between 1995 and 2009), although fewer studies were able to show an effect on fertility-related measures such as unintended pregnancy or

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abortions (found in 6 of 13 studies included). It is notable that relatively few of the studies (only 13 of 63 identified) reported on these fertility-related measures [54], although these are truly the outcome of interest for policy-makers. Additionally, little information is available on the population-level impact of male involvement, public-private partnerships, and voucher programs, as well as the comparative costs of various programmatic strategies.

Creation of a conducive policy and programmatic environment 16

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A conducive policy and programmatic environment is a major pre-requisite for the successful access and uptake of family planning service. Successful family planning programs have been

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noted to include the components indicated in Table 1.

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Quality of care

Quality of care in family planning programs follows from human rights principles and should be

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considered a vital component of any program in developing countries. One suggested framework includes six key elements: choice of method, information given to clients, technical competence, interpersonal relations, mechanisms for follow-up and continuity, and an appropriate constellation of services.[55] Additional important qualities include cost, proximity

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of services to where those in need of family planning live, and gender considerations.[51] Although the connection between quality of care and contraceptive prevalence is not fully understood, some studies have suggested that improved quality leads to increased use of family

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providers. [56, 57]

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planning methods and that a focus on quality of care is beneficial to both contraceptive users and

Comprehensive sexuality education All people, particularly adolescents, require and are entitled to sexuality education to protect themselves from factors associated with reproductive morbidity and mortality, such as reproductive tract infections, HIV, and unintended pregnancy.[26] Effective sexuality education can provide young people with age-appropriate, culturally relevant, and scientifically accurate information. School-based comprehensive sexuality education is a politically difficult topic in 17

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many developing countries, largely due to concerns that such education will encourage adolescents to engage in sexual activity. However, when such education is undertaken appropriately, sexuality education programs can help people abstain from or delay sexual debut,

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reduce unprotected sexual activity, reduce the number of sexual partners they have, and increase the use of methods to prevent pregnancy and RTIs. Schools are a key educational arena for these programs, but programming can also occur in settings outside of formal education.[58] The cost

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of such programs varies significantly by country, but in general they have been shown to be cost-

and unintended pregnancies.[59]

Supply- and demand-side interventions

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effective and, in some settings, cost-saving in developing countries by averting HIV infections

Multiple interventions have been attempted and many are successful, although data on

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population-level outcomes are generally missing. One exception is the Matlab project in rural Bangladesh. A maternal and child health program that included a family planning component was introduced in 1977. Of 149 villages, half received more extensive programming

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interventions, primarily focusing on family planning but also including some other maternal/child health interventions; the other half received the usual services provided by the

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government. Contraceptive prevalence increased in both areas, but increased more in the intervention area. In 1990 (13 years after the intervention was initiated), 57.1% of women were using contraception in the intervention villages, compared with 27.2% in the comparison area. This increase appears to be directly related to the programmatic intervention and cannot be explained by other factors.[60] Population-level outcomes were also affected by the intervention; both abortion rates [61] and maternal mortality rates [62] declined more in the intervention area than in the control area. 18

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Demand-side interventions that have shown some promise include mass media campaigns, educational programs using peer educators, more formally trained instructors, or community-

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based programs. Other programs, such as conditional cash transfer programs, have failed to show a positive effect on fertility (and in one case, fertility increased due to unintended

consequences of incentives to have more children [63]), though some have shown increased

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contraceptive use.[54] Supply-side interventions that may be helpful (though thus far results have been mixed) include social franchising, improving quality of care, increasing male

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involvement, and vouchers for free services. [54]

Missed opportunities

Key moments when women have contact with the health system present critical opportunities to

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provide them with high quality family planning services. Such opportunities are often missed, however. Immediate post-partum provision of certain contraceptives, such as IUDs, is safe, effective, and highly acceptable by women, although the higher risk of expulsion when

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compared with interval placement may be problematic in countries with limited resources and where women have little access to follow-up services four to six weeks post-partum.[64] As

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increasing numbers of women opt for childbirth with skilled birth attendants and in facilities, [65] contraceptive information and voluntary family planning services should be made readily available to all of them. Most women immediately post-partum want to space their next pregnancy, but many do not use any family planning method during either the immediate or extended post-partum period.[66] Antenatal care presents an opportunity for education about contraceptive methods that are available post-partum. As post-partum visits are not as common in many developing countries, such women are unlikely to be offered a family planning method 19

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before they again enter a fertile period. However, as increasing numbers of programs are offering home-based post-partum care to both mother and infant, this may present an important opportunity to educate women about their contraceptive options, and in some cases directly to

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provide methods.

Another important missed opportunity is the post-abortion period. Women undergoing induced

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or spontaneous abortion, or being treated for complications of unsafe abortion, may have a

particularly high need for family planning, especially as they may be at risk of pregnancy as soon

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as three weeks post-abortion.[67] Most methods, including LARC, can be initiated immediately after a surgical abortion. Some methods can be initiated immediately after medical abortion, although IUDs cannot be inserted until the abortion is complete.[68] A recent systematic review found that data is currently insufficient to conclude that family planning counseling increases

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uptake of contraceptive services post-abortion.[69] This finding highlights the need to assess the impact of such programming further, as few studies addressing this topic were identified and most were not of high quality. All women accessing abortion or post-abortion care require

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perspective.[70]

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voluntary family planning information, counseling, and service provision from a human rights

Finally, although the feasibility and efficacy of integrating family planning programming with routine child health care services such as immunizations is largely unclear and may present significant challenges, this time point is often also an important contact with the health system where women may be able to be reached for family planning services.[71] Few studies have assessed the impact of integrating family planning services with child health services, and have generally found that combining time-intensive services such as family planning counseling with 20

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quick services such as vaccine delivery can be problematic.[72] One RCT failed to find an effect on contraceptive uptake of an intervention integrating family planning messages and referrals into facility-based child immunization services.[73] However, many approaches are possible,

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such as having a dedicated family planning provider present at immunization campaign days or including group educational sessions at facilities while women wait for their children to be

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immunized.[71]

Other opportunities where women have contact with the health sector but often are not offered

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contraceptive services include when they seek care for other medical reasons. For instance, family planning can be integrated within programs and services for HIV treatment, and voluntary counseling and testing. Additionally, contraceptive services can be offered within the context of

Conclusions

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STI prevention and treatment, as well as at the primary care level.

Although great strides have been made in improving contraceptive access and use in developing

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countries, many women and couples still do not use any modern method. For those who wish to prevent or space pregnancies, or limit family size, failure to use a modern contraceptive method

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puts these women at risk of maternal morbidity and mortality, and increases the likelihood their children will die or suffer illness. Failure to access voluntary family planning also perpetuates poverty, as women get trapped in a vicious cycle that inhibits their full participation in gainful socio-economic development activities. It is therefore imperative that voluntary family planning services reach all women in developing countries. Barriers to increasing the use of modern contraceptive include multiple cultural, financial, policy and programmatic considerations, many of which still need further research. Many successful interventions have, however, been 21

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employed in countries worldwide, and many others show promise. The renewed global attention to family planning may create an environment in which interventions can be more carefully evaluated and greater attention can be paid to ensuring access for all women to this life-saving

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intervention. In this discourse, interventions will also need to reach the most vulnerable, including young people and the poor.

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Conflict of interest statement

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The authors report no conflicts of interest.

Practice points

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1. Use of modern contraceptive methods in developing countries remains low, contributing to maternal and infant morbidity and mortality. 2. When contraceptives are made available in many developing countries, method mix is

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often skewed and affected by misconceptions. 3. Although the impact of expanding contraceptive choice is not entirely clear, countries

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with more options tend to have higher use of modern contraceptives, and human rights principles dictate that full information and choice be offered to all women and couples.

4. Adolescents and the poor continue to be vulnerable populations requiring extra attention in contraceptive provision.

Research priorities

22

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1. What is the impact of making a wide variety of contraceptive options accessible and available to women and couples on contraceptive uptake, unintended pregnancy, and maternal and infant morbidity and mortality in developing countries?

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2. What are the most important and effective components of family planning programs in low- and middle-income countries?

contraceptive uptake?

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3. Which supply- and demand-side interventions are most effective at increasing voluntary

4. How should the barriers to use of contraceptives, from the perspectives of both users and

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providers, in developing countries, be addressed?

*1.

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Table 1

Characteristics of successful family planning programmes

Evidence-based programming Strong leadership and good management Effective communication strategies

High-performing staff Client-centered care Easy access to services Affordable services

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Appropriate integration of services

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Ensuring contraceptive security and logistics management

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Supportive and gender sensitive policies

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Adapted from Richey and Salem, 2008 (75)

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Figure 1 100%

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90% 80% 70% 60%

Traditional

50%

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Pill

40% 30%

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20% 10% 0%

Injectable LARC Sterilization

United Kingdom - Indonesia Kenya - Modern Nigeria - Modern method use method use Modern method Modern method use 84% use 61.9% 38.9% (2008/09) 14.1% (2011) (2008/09) (2012)

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Among women using a contraceptive method, percent using each indicated method (Source: United Nations, Department of Economic and Social Affairs, Population

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Division. World Contraceptive Patterns 2013)(23)

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Figure 2

Percent distribution of currently married women using any modern contraceptive

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method, by household wealth index (quintile) (Source: ICF International, 2012, The

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DHS Program STATcompiler) (41)

1