Asymmetry in contraceptive information at two sites in Burkina Faso.

Background: Family planning programs are foundationally important to public health, but like any medical intervention, contraception has drawbacks in addition to its benefits. Knowledge of these drawbacks in addition to benefits is essential for informed choice. Despite a general consensus among family planning researchers and providers that contraceptive counseling should be unbiased, little quantitative research has assessed the extent of bias in contraceptive counseling, and in people's contraceptive knowledge more broadly.

Perceptions of access to long-acting reversible contraception removal among women in Burkina Faso.

Objectives: Long-acting reversible contraception (LARC) initiation has been well-studied and intervened upon. Because LARC requires provider intervention for initiation and removal, it is critical to measure informed choice at the time of desired discontinuation as well. We examined perceptions of access to LARC discontinuation among women at two sites in Burkina Faso, where LARC is the dominant method in the contraceptive mix.

Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study.

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.

Exploring Upward and Downward Provider Biases in Family Planning: The Case of Parity.

Introduction: 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.

"She told me no, that you cannot change": Understanding provider refusal to remove contraceptive implants.

Enthusiasm for long-acting reversible contraception (LARC) is growing among donors and NGOs throughout the global reproductive health field. There is an emerging concern, however, that the push to insert these methods has not been accompanied by a commensurate push for access to method removal. We use data from 17 focus group discussions with women of reproductive age in an anonymized African setting to understand how users approach providers to request method removal, and how they understand whether or not such a request will be granted.

Health care provider bias in the Appalachian region: The frequency and impact of contraceptive coercion.

Objective: To investigate the frequency and impact of contraceptive coercion in the Appalachian region of the United States.

Data Sources And Study Setting: In fall 2019, we collected primary survey data with participants in the Appalachian region.

Study Design: We conducted an online survey including patient-centered measures of contraceptive care and behavior.

Assessing the Suitability of Unmet Need as a Proxy for Access to Contraception and Desire to Use It.

Unmet 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.

Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator.

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.

Contraceptive stockouts in Western Kenya: a mixed-methods mystery client study.

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.

Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs.

Despite its central importance to global family planning, the "unmet need for contraception" metric is frequently misinterpreted. Often conflated with a lack of access, misinterpretation of what unmet need means and how it is measured has important implications for family planning programs. We review previous examinations of unmet need, with a focus on the roles of access and demand for contraception, as well as the role of population control in shaping the indicator's priorities.

Provider verbal disrespect in the provision of family planning in public-sector facilities in Western Kenya.

Public-sector healthcare providers in low- and middle-income countries are a primary source of family planning but their disrespectful (i.e., demeaning or insulting) treatment of family planning clients may impede free contraceptive choice.

Facility readiness to remove subdermal contraceptive implants in 6 sub-Saharan African countries.

Objective: This study aimed to estimate the proportion of health facilities without the capability to remove contraceptive implants and those that have the capability to insert them and to understand facility-level barriers to implant removal across 6 countries in sub-Saharan Africa.

Study Design: Using facility data from the Performance Monitoring for Action in Burkina Faso, the Democratic Republic of Congo, Ethiopia, Kenya, Nigeria, and Uganda from 2020, we examined the extent to which implant-providing facilities (1) lacked necessary supplies to remove implants, (2) did not have a provider trained to remove implants onsite, (3) could not remove deeply placed implants onsite, and (4) reported any of the above barriers to implant removal. We calculated the proportion of facilities that report each barrier, stratifying by facility type.

Do users of long-acting reversible contraceptives receive the same counseling content as other modern method users? A cross-sectional, multi-country analysis of women's experiences with the Method Information Index in six sub-Saharan African countries.

Objective: There has been a growing focus on informed choice in contraceptive research. Because removal of long-acting reversible contraception (LARC), including implants and IUDs, requires a trained provider, ensuring informed choice in the adoption of these methods is imperative. We sought to understand whether information received during contraceptive counseling differed among women using LARC and those using other modern methods of contraception.

The effect of a postpartum intrauterine device programme on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial.

Vertical global health programmes often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum intrauterine device (PPIUD) intervention on outcomes related to contraceptive method choice.

Evaluating the feasibility of the Community Score Card and subsequent contraceptive behavior in Kisumu, Kenya.

Background: Women seeking family planning services from public-sector facilities in low- and middle-income countries sometimes face provider-imposed barriers to care. Social accountability is an approach that could address provider-imposed barriers by empowering communities to hold their service providers to account for service quality. Yet little is known about the feasibility and potential impact of such efforts in the context of contraceptive care.

Contraceptive method denial as downward contraceptive coercion: A mixed-methods mystery client study in Western Kenya.

Objective: This study uses mixed methods to quantify the frequency of method denial in Western Kenya and describe how this barrier impacts contraceptive access.

Study Design: We estimate the frequency of method denial using data from mystery clients deployed to 57 randomly selected public-sector facilities located in Western Kenya. These quantitative data are triangulated with data from 8 focus group discussions, 19 key informant interviews, and 2 journey mapping workshops with contraception clients and providers.

Sex, poverty, and public health: Connections between sexual wellbeing and economic resources among US reproductive health clients.

Objective: To document associations between socioeconomics and indicators of sexual wellbeing.

Methods: We obtained our data from the HER Salt Lake Initiative, a large, longitudinal cohort study of family planning clients in the United States who accessed free contraceptive services between March 2016 and March 2017. Baseline socioeconomic measures included Federal Poverty Level, receipt of public assistance, and difficulty paying for housing, food, and other necessities.

'I haven't heard much about other methods': quality of care and person-centredness in a programme to promote the postpartum intrauterine device in Tanzania.

Background: Programmes promoting the postpartum intrauterine device (PPIUD) have proliferated throughout South Asia and sub-Saharan Africa in recent years, with proponents touting this long-acting reversible contraceptive (LARC) method's high efficacy and potential to meet contraceptive unmet need. While critiques of LARC-first programming abound in the Global North, there have been few studies of the impact of LARC-centric programmes on patient-centred outcomes in the Global South.

Methods: Here, we explore the impact of a PPIUD intervention at five Tanzanian hospitals and their surrounding satellite clinics on quality of contraceptive counselling and person-centred care using 20 qualitative in-depth interviews with pregnant women seeking antenatal care at one of those clinics.

Reproductive Autonomy Is Nonnegotiable, Even in the Time of COVID-19.

The COVID-19 pandemic has swept across the world, altering nearly every facet of contemporary life and causing behavioral and socioeconomic changes that seemed unthinkable a few months ago. The increased risks for human health include not just the dangers posed by the virus itself, but also the upheaval to the broader health care and societal landscapes, which has threatened access to critical sexual and reproductive health services. In this viewpoint, we describe how the pandemic has already posed challenges to reproductive autonomy in both the United States and globally, and then offer insights on how it may do so in the future.

Evaluating the Implementation of an Intervention to Improve Postpartum Contraception in Tanzania: A Qualitative Study of Provider and Client Perspectives.

Background: This qualitative study assessed implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Tanzania, a country with high rates of unintended pregnancy and low contraceptive prevalence. The PPIUD Initiative was implemented to reduce unmet need for contraception among new mothers through postpartum family planning counseling delivered during antenatal care and offering PPIUD insertion immediately following birth.

Methods: We used the implementation outcomes framework and an ecological framework to analyze in-depth interviews with providers (N=15) and women (N=47) participating in the initiative.

Effect of a postpartum family planning intervention on postpartum intrauterine device counseling and choice: evidence from a cluster-randomized trial in Tanzania.

Background: The World Health Organization recommends postpartum family planning (PPFP) for healthy birth spacing. This study is an evaluation of an intervention that sought to improve women's access to PPFP in Tanzania. The intervention included counseling on PPFP during antenatal and delivery care and introducing postpartum intrauterine device (PPIUD) insertion as an integrated part of delivery services for women electing PPIUD in the immediate postpartum period.

Contraceptive Autonomy: Conceptions and Measurement of a Novel Family Planning Indicator.

Since the 1994 International Conference on Population and Development, there has been increased attention to high-quality and rights-based family planning, but these concepts have been difficult to measure. Perhaps due to an intellectual history intertwined with population control, contemporary family planning programs and researchers often use (modern) method use as a primary marker of success, with indicators focusing narrowly on contraceptive use and fertility. This results in a fundamental misalignment between existing metrics and the stated family planning goals of promoting reproductive health and rights.

"I wasn't ready": abortion decision-making pathways in Ouagadougou, Burkina Faso.

Objectives: This study explores abortion decision-making trajectories in Ouagadougou, Burkina Faso, examining the spaces for decision making that young people manage to create for themselves within restrictive policy, gender norms and other constraints.

Methods: The study presents data collected from observations in three referral health facilities in Ouagadougou and interviews (with 31 young women (aged 17-25) who had sought abortions and five men (aged 20-25) whose partners had done so). Using inductive content analysis, we capture the different streams, actors and rationales in the decision-making process, as well as the pattern of negotiation.