Family planning science and practice lessons from the 2018 International Conference on Family Planning

Investing in family planning for a lifetime of returns

Measuring the returns on investments in FP is crucial for continued funding and support for FP programs. The business cases for FP presented at ICFP demonstrated the ways in which cost-effective FP programming may save money in the short-term and long-term at the individual, community, donor, and national levels. Willcox and colleagues developed a model based on 47 county referral hospitals in Kenya, which demonstrated that for every dollar invested in training and equipment for implant removal services, a future return of around USD $1.62 would be accrued from the economic benefits of continued implants uptake⁵. Costing data presented by Tumusiime and colleagues found that in Senegal and Uganda, the total costs—including direct medical costs (i.e. provider time, supplies, drugs), costs of self-injection training (based on a one-page instruction sheet scenario), and direct non-medical costs (i.e. client travel and time costs)—are significantly lower for the self-injection of depot medroxyprogesterone acetate administered subcutaneously (DMPA-SC) as opposed to provider-administered injectables⁶. In Nigeria, Adedeji and colleagues found that for every $1 invested in high-impact intervention-focused FP programs, an estimated $1.40 may be saved on maternal and newborn care, and another $4 could be saved on treating complications from unplanned pregnancies⁷. While self-administered DMPA-SC may provide a cost-effective approach to improving access to long-acting reversible contraceptive (LARC) methods, a study conducted in Rwanda identified LARCs to be more cost-effective than non-LARC methods post-partum, with a savings of $31.42 per pregnancy averted for two years following birth, and additional cost savings expected over longer time frames⁸.

FP may also be a catalyst for the demographic transition and an opportunity to realize the benefits produced through the demographic dividend. The demographic dividend describes the changes in the population age structure caused by reductions in population-level fertility and mortality rates. These structural population changes result in a large working-age population and a smaller number of dependents⁹. The demographic transition leads to numerous, subsequent population-level and societal benefits which may help countries achieve Sustainable Development Goal (SDGs) targets. Modeling has shown that investments in FP may positively affect SDGs across several sectors including health, governance, economic growth, agriculture, and education^10,11. Despite improvements in FP funding and financing, expanded financial investments are still needed throughout much of sub-Saharan Africa in order to successfully reach the FP targets necessary for countries to reap their demographic dividend potential^7,12,13.

Key strategies to sustain FP advances include long-term financing for FP, particularly the transition from donor-dependent financing to locally owned initiatives. Donor funding to support FP continues to fall short of the amount needed to address the unmet need of family planning globally and the extent of this gap varies significantly across countries and regions¹⁴. To mitigate the impact of this shortage in donor funding, it is critical for countries to plan for shifts in financing options, including procurement financing for subsidized commodities. Locally owned community-based health insurance (CBHI) schemes may be a promising option in order to sustain FP financing. Research on CBHI schemes in sub-Saharan Africa showed positive effects on healthcare utilization and FP uptake. In Ethiopia, Pathfinder International found that women who were enrolled in a CBHI scheme were 1.3 times more likely to practice modern FP than those who were not exposed¹⁵. Since 2014, the Ethiopian government has slowly shifted away from donor-dependence and has launched and expanded the number of community-based health insurance (CBHI) and social health insurance (SHI) programs in more than one-third of districts. Based on current projections, by 2025, the number of modern contraceptive users in Ethiopia will have doubled from 6 million to 12 million, and the private sector will account for 40% of them¹⁶.

Data gleaned from nationally representative datasets showed a similar global pattern in factors associated with FP utilization. The Ethiopia (2016), Kenya (2014), Nigeria (2013), Philippines (2013) Demographic Health Surveys (DHS) and Indonesia’s 2015 Susenas survey revealed trends in the number of insured women and the modern contraceptive prevalence rate (mCPR); specifically, the ratio of mCPR between insured versus uninsured individuals was greatest among women of the lowest socioeconomic status (SES) in the Philippines, Kenya, Indonesia, and Ethiopia^17–20. Insurance coverage was shown to be directly associated with FP utilization. These findings signify the importance of comprehensive health insurance for FP access amongst marginalized groups²¹. Another important finding related to FP access and insurance showed how national health priorities supersede individual FP access. While FP is often included under universal health coverage (UHC) schemes, the inclusion of FP is often not operationalized or realized²². Findings from 22 priority FP2020 countries on the limitations of UHC and barriers to universal access revealed that the challenges to comprehensive UHC are many, including government prioritization of less cost-effective, yet urgent, curative services, instead of preventive care or primary services²³.

Additionally, innovative research on health financing highlighted opportunities for new financing models and insurance schemes. In Tanzania, the United Nations Fund for Population Activities (UNFPA) and DKT International implemented an innovative micro-insurance scheme for urban youth and adolescents, which demonstrated high uptake in just one year of initiation. This program, “iPlan”, required a nominal annual fee of $10, after which an individual received comprehensive sexual and reproductive health (SRH) services including contraceptive counseling and commodities for one year²⁴. Similarly, researchers found that the Public-Private Partnership (PPP) Health Posts model in Rwanda was a cost-effective and viable solution for individuals living more than 60 minutes away from health facilities²⁵. The social franchising model created by the Family Health Guidance Association of Ethiopia (FGAE) was also shown to be a cost-effective model compared to the FGAE-owned static clinics. The cost per Couple Years of Protection (CYP) provided through the FGAE social franchise model was estimated to be between USD $0.73–$1.77, compared to USD $25.61–37.35 per CYP provided at the FGAE-owned static clinics²⁶.

Addressing inequities in family planning for adolescents, youth, and key populations

Inequities in access to FP exist across women from different socio-economic groups, age cohorts, health statuses, and physical abilities. Compared to other women of reproductive age, adolescent girls and young women (AGYW) have specific FP and sexual and reproductive health needs, including low contraceptive uptake, high risk of unintended pregnancies and unsafe abortions, high risk of sexually transmitted infections, and a greater risk of acquiring HIV^27,28.

Involving youth in advocacy and programming efforts was shown to be critical in order to ensure that unique, population-specific FP needs are met. Reproductive Health Uganda (RHU) developed an innovative program to support young people in realizing their right to hold state-actors accountable for improving access to youth-friendly health services. The initiative led to the successful allocation of county-level funds for youth-friendly services in all sectors and created a network of youth advocates for FP programming²⁹. In Kenya, the Network for Adolescents and Youth of Africa developed a holistic advocacy network in Kisii County that led to the allocation of KES 7,000,000 (USD 68,000) to contraceptive procurement and FP services in the financial year 2016/2017, the first time a line item for FP was included in the county budget³⁰.

FP programs for youth with hearing and speech impairments included a sexual health education program for adolescents in Vietnam and a social media literacy program integrating sexual and reproductive health and rights (SRHR) and FP information exchange in Burkina Faso^31,32. In Egypt, Love Matters Arabic Project was launched to engage young people on SRH issues, dispel myths and taboos, and improve access to accurate and reliable SRH and FP information³³. Some researchers maintain that to attract youth and gain their trust, programming must include a pleasure component and tie this information to healthy sexual behaviors and practices^29,34. This hypothesis needs further exploration in future research and programming.

Other key populations highlighted included youth living in conflict zones, people living with HIV, women with disabilities, female sex workers, people who use drugs, individuals with a low socioeconomic status, and individuals who do not identify as heterosexual^35,36. A nationally-representative survey from Ethiopia found that more than 95% of women living with a mental, physical, or visual disability faces obstacles in physically accessing health facilities and are less likely to have access to FP information³⁷. Furthermore, this sub-population may be more likely to face discrimination by healthcare providers. These barriers to FP services and knowledge may have direct consequences on health outcomes. For example, among women with disabilities who had ever had a pregnancy, more than 85% reported that the pregnancies were unintended³⁸.

Studies from conflict zones in Afghanistan, Cameroon, Liberia, Sierra Leone, and Yemen showed that girls who marry before the age of 18 have lower rates of FP use, less intention to use in the future, and a significantly higher risk of unintended pregnancy, compared to married women 18 years of age and older³⁷. Among Somali refugee girls, aged 10–19 and living in Ethiopia, nearly 75% of girls were aware of how to become pregnant, but fewer were aware of the risks associated with inadequate birth spacing. Despite nearly one in five girls having already given birth, 40% of participants remained unaware of methods to avoid pregnancy³⁹.

People living with HIV may also have trouble accessing comprehensive FP services. A study from Uganda found that unmarried women with an HIV-positive status and women of high parity were significantly less likely to use FP post-partum⁴⁰. Women on anti-retroviral therapy (ART) have desires to bear children as well as learn about contraception and methods to prevent mother-to-child transmission of HIV (PMTCT)⁴¹. To this end, a program in London demonstrated the promise of service integration to improve access to FP for women living with HIV; Mabonga and colleagues found a 50% increase in LARC use after the integration of FP and HIV services in a postnatal contraception clinic in London⁴². Due to the overlap of FP and HIV, integrating services into one convenient location helps promote healthy SRH while also easing client burden associated with traveling between different clinics.

Reproductive justice: Abortion care, family planning, and women’s wellbeing

Unsafe abortions have emerged as one of the key neglected public health problems, accounting for more than 1 in 10 maternal-related deaths worldwide⁴³. Accordingly, abstracts discussing safe abortion access and FP were cross-cutting through the conference’s tracks. Research on unsafe abortion services underscored determinants of abortion practices as well as inequities in the accessibility of safe abortion services. For example, in both Nigeria and Rwanda, younger, uneducated women in rural areas are more likely to seek out and use abortion services. However, due to restrictive abortion laws, these abortions are often unsafe, which pose not only health challenges but legal challenges as well^44,45. In 2012, 24% of all incarcerated women in Rwanda were convicted for participating in clandestine abortions⁴⁶. Access to safe abortion services is a critical component of comprehensive SRHR yet continues to be heavily restricted in many parts of the world. Several authors called for targeted advocacy for legal provisions to ensure the availability of safe abortion services^47,48. Amendments to national laws, increased and expanded training of providers, and improved access to medical methods of abortion were highlighted as priorities for high-level policymakers^24,49. Furthermore, emphasis was placed on the recognition of social disparities and inequities in abortion prevalence and access⁴⁵.

Analysis of a post-abortion care (PAC) program for women in humanitarian settings in DRC and Yemen proved that providers may effectively shift from unsafe practices of dilation and curettage (D&C) to manual vacuum aspiration and medical treatment with misoprostol. Over a period of 5 years, the percentage of PAC clients requiring evacuation who received D&C as treatment was reduced from of 18.6% to 2.0% in DRC and from 25% to 2.8% in Yemen⁵⁰.

Expanding access to safe abortion services can also directly increase women’s access to FP methods. Research from Kenya found that regardless of pregnancy intentions, over 70% of women who attended PAC initiated contraceptive use during the PAC visit⁵¹. Analyses of post-abortion FP (PAFP) service delivery across two states in India also revealed that 28% of women adopted a contraceptive method within two months after their abortion⁵². Another study from Kenya found that women’s choice of PAFP method varied based on the type of abortion the woman experienced. While women who had undergone surgical abortions were more likely to choose intrauterine devices (IUDs) or other long-acting or permanent methods, women who had medical abortions were more likely to choose implants. While this may be due to the fact that IUDs can be inserted following a surgical abortion but not following a medical abortion, further client-centered research is necessary to ensure women receive the FP method that best suits their needs, preferences, and fertility desires⁵³. Insights into context-specific ideals of family size as well as abortion care-seeking behaviors are important in understanding how to improve future PAFP service delivery and increase contraceptive use⁵¹.

Couple dynamics and family planning decision-making

Research on women’s covert use of FP underscored the ethical tensions between supporting and validating women’s ability to exercise reproductive autonomy without disclosure to a partner while also striving to engage male partners in reproductive health decisions⁵⁴. Research revealed that a woman’s decision to covertly use FP may be linked to discordant partner views on childbearing and fertility desires⁵⁵. One study found that when men expressed beliefs that contraception is “women’s business”, women were more likely to engage in covert use and not disclose their FP decisions to their partner⁵³. However, women who use FP covertly often struggle with the cost of contraceptives and worry about concealing FP from their partner⁵³. Power dynamics continue to influence FP use, even when women choose to use FP methods covertly.

Couple power dynamics, including household decision-making power, also influence FP utilization. Easterlina and colleagues found that 75% of women in West Pokot, Kenya, identified their husband or partner as the biggest barrier to voluntary FP use⁵⁶. In the Afar region of Ethiopia, 58.8% of women reported not having the freedom to make independent fertility decisions⁵⁷. Researchers have found that the odds of using modern contraception increases significantly when couples make FP decisions together⁵⁸. Couples who reported shared decision-making on everyday life choices (e.g. financial decisions) in Ibadan, Nigeria, were more likely to report using FP than couples in which decisions were made solely by the husband⁵⁹. The educational status of couple dyads, couple’s knowledge of reproductive health and rights, women’s economic security and involvement in microcredit schemes, and gender equitable household dynamics have been found to be significantly associated with couple’s FP decision-making^60,61.

Male involvement in family planning programming

Considering men’s influence on FP decisions, involving male partners in FP programming is essential to meeting FP goals globally. Research revealed the potential of male champions and advocates in changing social norms, educating male networks, and creating a community culture receptive and open to family planning discussions. In Uttar Pradesh, India, a community-based information diffusion strategy was used to dispel FP myths and misconceptions and provide comprehensive information on non-scalpel vasectomy. To accommodate the diverse lives of men living in informal settlements, men were engaged by their peers at traditional male gathering points at convenient times, such as evening meetings for rickshaw pullers⁶². In Zamboanga City, Philippines, a packaged community-based learning program, EL HOMBRE, used a successful peer-to-peer technique for information dissemination related to FP within broader conversations around family matters and family plans⁶³. Similarly, a male champions program was rolled out successfully in Western Kenya, where 50 male champions held sensitization forums once a month to encourage discussions on healthy timing and spacing of pregnancies⁵⁵. In Benin, USAID/ANCRE implemented a “men as advocates” intervention that included counseling male spouses on FP when their partners left the maternity ward and creating groups of “committed men” to sensitize male peers. Over the course of a year, post-partum FP counseling for males increased by more than 100% across 47 health facilities⁶⁴.

Males have a desire to learn about FP and contraception, but often have limited or inaccurate information. In turn, this affects their decision to engage in FP programs and make informed decisions related to FP. In Uganda, when men were asked why they do not allow their wives to use modern FP methods, participants expressed fears that their wives were likely to become promiscuous if they began using contraception. However, the researchers found that male participants’ beliefs about FP were often inaccurate, inconsistent, or grounded in gendered stereotypes, and this fueled their fears about wives’ promiscuity⁶⁵. Similarly, Easterlina and colleagues found that 50% of men in West Pokot, Kenya, lack the information on the benefits of healthy timing and spacing⁵⁶. In Nepal, men’s limited understanding of contraceptives and prevalent misconceptions were shown also to impact their partner’s uptake of IUDs⁶⁶.

Couple-based approaches to behavioral change and FP uptake also show promise. Project Concern International implemented a social and behavioral change program that used couples as community change agents to address social norms, SRHR and myths, improve couple communication strategies, and aid couples in the development of their FP and fertility goals⁶⁷. The Emanzi program in Uganda also showed an improvement in the attitudes of men towards gender norms, a rise in shared decision-making, and a significant increase in FP uptake⁶⁸.

Gender-transformative programming is grounded in the notion that changes in gendered norms, beliefs, and attitudes can influence behaviors and thus positive health outcomes. The gender-transformative Bandebereho intervention in Rwanda included 15-week group education meetings for more than 4,000 young adult men and women and 1,700 expectant and new fathers and couples. When compared to the control group, findings showed an increase in the proportion of young people who had sought SRH services, as well as changes in positive gender norms and increases in the decision-making⁶⁹. The GroupUp Smart education curriculum in Rwanda targeted prepubescent male and female adolescents and their parents. The program found that adolescent boys’ awareness of prevention pregnancy strategies increased from 65% to 81% and their knowledge of female and male reproductive health significantly increased. When comparing pre- and post-test results, adolescent boys experienced significant changes in gender equity scores, pointing to the notion that SRH education that includes gender equity components may be more beneficial than SRH education alone, particularly when introduced earlier in life⁷⁰.

Breakthroughs in novel contraceptives and systems improvement in family planning

Research advances in contraceptive technology highlighted the importance of beginning with the end-user in mind. In Nigeria and India, initial acceptability research of a microneedle contraceptive patch (MNP) explored client perceptions of the method and quantified desired MNP attributes. Across both contexts, prospective users liked the potential for self-application and both providers and clients found the method to be easily used. Researchers also wanted to identify user preferences for other attributes, including the method’s effect on menstruation, duration of effectiveness, placement location, pain, and the potential for skin reactions at the application site⁷¹. These findings underscored high overall acceptability of microneedles as a novel delivery method, yet also emphasized the importance of reducing side effects associated with existing contraceptive methods.

Use of the levonorgestrel intrauterine system (LNG-IUS) has risen rapidly in high-income countries and is one of the most effective forms of contraception available. However, the cost of the method is typically a barrier to clients in low-income countries. Research by Marie Stopes International Nigeria piloted the introduction of an affordable version of the LNG-IUS at multiple service delivery points and found that users, providers, and key opinion leaders expressed enthusiasm for the method. Many clients also reported reduced menstrual bleeding as a key non-contraceptive benefit of the method. This research also suggested that a multi-stakeholder approach, including coordinated demand-generation activities, may be important in order to advance the scale-up of LNG-IUS in Nigeria and in other similar contexts.

Improved access to subdermal implants and other long-acting methods like IUDs have raised concerns on whether women can access timely removal services on-demand. Data from pilot studies examining the subdermal implant removal tool, RemovAid, suggested that this novel device is safe to proceed to larger studies, and with it, physicians can safely remove one-rod implants and minimize the removal time to just under seven minutes⁷². Furthermore, initial acceptability research revealed that a novel postpartum IUD inserter would be attractive in India due to high unmet need and a lack of trained providers⁷³. These products would not require additional supplies, aside from what it’s packaged with, and demonstrated high client and provider satisfaction.

Novel approaches to service delivery and contraceptive commodity procurement included the development of an “informed push” model, which would change the public health sector’s reporting system to allow for consolidated transport routes and combined supply delivery. Rather than following a typical model where an individual health facility is responsible for FP commodity reporting, product requisition, and pick-up, this model relied on health “zone staff” to optimize transport routes and report on stockouts and product consumption. By consolidating FP commodities alongside other health products and optimizing transit routes, the study demonstrated a substantial reduction in the incidence of stockouts and a decline in transit costs⁷⁴. In India, an application developed by the Ministry of Health and Family Welfare also seeks to collect consumption data, forecast demand, and track commodity distribution. While still in the formative stage, individual states have demonstrated an interest in customization of the app per state to allow the government to improve commodity distribution and transfers by tracking “live” data⁷⁵.

Lastly, algorithm-based fertility apps, such as the Dynamic Optimal Timing application (DOT) demonstrated a typical-use failure rate that was comparable or better to other user-initiated methods, including fertility-awareness based methods. This method delivered consistently correct information to women about their daily fertility status, which suggests that the app could allow women to self-manage fertile days to avoid pregnancy⁷⁶.