Measurement of Access to Family Planning in Demographic ... · 9/17/2014 · • Catalogue the DHS questions that map to elements of access • Pinpoint questions that elicit the

Measurement of Access to Family Planning in Demographic and Health Surveys:

Lessons and Challenges

Yoonjoung Choi, Madeleine Short Fabic, Jacob Adetunji

U.S. Agency for International Development

September 17, 2014 PFRH Seminar, JHSPH

Presentation • Background • Methods

– Data – Analysis

• Results • Discussion Audience Participation Thoughts? Questions? Suggestions?

Outline

• Driving paradigm in the programmatic and policy communities: – FP2020: “expanding access to family planning to an additional 120

million women and girls by 2020“ – Post-2015 agenda

• Widely studied over decades as a determinant of utilization, from observational studies to randomized controlled trials

• Complex concept

– Challenges in measurement in large-scale surveys (going back to World Fertility Surveys)

– Frameworks to define access to healthcare/FP • Five As: Penchansky and Thomas (1981) • Bertrand et. al. (1995) • AAAQ: UN Committee on Economic, Social, and Cultural Rights

(2000)

Background Access to Family Planning

Background Elements of Access to FP

Five As AAAQ Bertrand Geographic accessibility to SDP Economic accessibility Administrative accessibility to/at SDP Service quality at SDP Cognitive accessibility Psychosocial accessibility

SDP: Service Delivery Points

Background Elements of Access to FP

Five As AAAQ Bertrand Geographic accessibility to SDP

Accessibility Accessibility* Geographic/Physical accessibility

Economic accessibility

Affordability Accessibility* Economic accessibility

Administrative accessibility to/at SDP

Accommodation Administrative accessibility

Service quality at SDP

Availability Accountability

Availability Accessibility* Accountability Quality

Cognitive accessibility

Accessibility* Cognitive accessibility

Psychosocial accessibility

Psychosocial accessibility

Needed Data: Policy, Service Delivery, Community, Individual… • To understand bottle necks of achieving full access, data at each level

required Data from Population-Based Surveys: Individual-Level • Information on barriers at the individual-level or individual

understanding of barriers that originate from other levels • Large scale surveys have collected data on contraceptive use and

barriers to use • Demographic and Health Surveys (DHS): on-going & oldest global

survey program in low-income countries

Background Measurement of Access

Our Motivation 1) How is access to FP defined? 2) What is DHS’s contribution to our measurement of access to FP? Study Objective: To understand the elements of FP access captured by DHS, and document their strengths and limitations Our Approach • Catalogue the DHS questions that map to elements of access • Pinpoint questions that elicit the most information on access • Examine data derived from the questions:

– to document common barriers to access, – discuss limitations of the data collected, and – discuss potential improvements to the measurement of FP access

Background Study Objectives

• Nationally representative household surveys • Main scope: Reproductive Health/Family Planning, Maternal and Child

Health, Nutrition, HIV/AIDS, Malaria, etc • Household questionnaire, & Women’s questionnaire • Data collection by local implementing agency – usually National

Statistics Office – with technical assistance from the DHS Program • Sponsored by USAID, increasingly with other donors • 300+ surveys in 90+ countries since 1984 • Open data access

Methods – Data Demographic and Health Surveys (DHS)

Most directly related questions: Reasons for not using (1)

“Can you tell me why you are not using a method to prevent pregnancy?” Counseling about side effects and potential other methods to use (6)

“At that time*, were you told about side effects or problems you might have with the method?” “At that time*, were you told by a health or FP worker about other methods of family planning that you could use?”

Awareness of methods/ Knowledge on source (2) “Have you ever heard of [Method]?” “Do you know of a place where you can obtain a method of FP?”

FP outreach (4) “In the last 12 months, were you visited by a fieldworker who talked to you about family planning?”

Reasons for discontinuation (Contraceptive calendar)

Methods – Data Questions Related to FP Access in DHS

Most directly related questions: Reasons for not using (1)

“Can you tell me why you are not using a method to prevent pregnancy?” Counseling about side effects and potential other methods to use (6)

“At that time*, were you told about side effects or problems you might have with the method?” “At that time*, were you told by a health or FP worker about other methods of family planning that you could use?”

Awareness of methods/ Knowledge on source (2) “Have you ever heard of [Method]?” “Do you know of a place where you can obtain a method of FP?”

FP outreach (4) “In the last 12 months, were you visited by a fieldworker who talked to you about family planning?”

Reasons for discontinuation (Contraceptive calendar)



Element of access

Denominator Among all women Among users Among non-users

Geographic Reasons for not using

Administrative Service quality Counseling “ Economic “ Cognitive Method awareness,

source knowledge, FP outreach

“

Psychosocial “

Study Question

Open-ended question response coding categories:

Eligible respondants

Methods – Data Eligibility for “Reasons for

Non-Use” Question

Open-ended question response coding categories:

Eligible respondants

Methods – Data Eligibility for “Reasons for

Non-Use” Question

Pre-structured coding categories Multiple reasons allowed

Methods – Data Reasons for Non-Use: Categories

Pre-structured coding categories Multiple reasons allowed

• not married* • not having sex • infrequent sex • menopausal/hysterectomy • Sub-fecund/infecund • postpartum amenorrhea • breastfeeding*

• respondent opposed • husband/partner opposed • others opposed • religious prohibition

Methods – Data Reasons for Non-Use: Categories

• knows no method • knows no source

• lack of access/too far • costs too much • fear of side effects/health

concerns* • inconvenient to use • interferes with body's processes • preferred method not available • no method available • fatalistic • other • don't know

• In-depth descriptive analyses around/of “reasons for non-use” question, using 4 selected surveys

• We examined: 1. Distribution across eligibility criteria 2. Background characteristics of women by eligibility 3. Among ineligible women, use of any contraception 4. Among eligible women, response pattern (number and type) 5. Among women who gave particular reasons, related data

consistency

• Analysis for each country/survey separately, adjusted for sampling

weight

Methods - Data Analysis

• Selected four surveys for illustrative purposes

Methods - Data Analysis Data

Zimbabwe Rwanda Ethiopia Senegal 2010-11 2010 2011 2010

MCPR (%) 57.3 45.1 27.3 12.1 Unmet need (%) 14.6 20.8 26.3 30.1 Demand for FP satisfied with modern methods (%)

78.4 62.3 49.7 28.0

Survey sample size (women 15-49 years)

15,688 13,671 9,171 16,515

Results

Results 1 Distribution of Women by Eligibility (%)

Zimbabwe Rwanda Ethiopia Senegal 2010-11 2010 2011 2010 Total (All women 15-49 yrs) 100.0 100.0 100.0 100.0 Ineligible because:

She never had sex 18.1 30.0 25.2 26.1 She or her partner is sterilized 0.9 0.5 0.4 0.2 She is currently pregnant 8.3 7.0 7.3 7.7 When asked about future fertility intention, she:

is undecided or does not know 4.3 1.1 2.2 1.3 declares she cannot get pregnant 1.1 0.7 1.8 2.1 wants a/another child in the next 24 mo. 13.0 5.0 11.5 18.3 wants a/another child after marriage 1.2 4.2 1.0 5.8 wants a/another child but does not know when 0.9 0.7 1.6 3.1

She uses a contraceptive method 32.4 26.2 16.0 6.7

Eligible for the question 19.9 24.7 33.0 28.8

Results 1 Distribution of Women by Eligibility (%)

Zimbabwe Rwanda Ethiopia Senegal 2010-11 2010 2011 2010 Total (All women 15-49 yrs) 100.0 100.0 100.0 100.0 Ineligible because:





Results 2 Modern Contraceptive Use by Eligibility Criterion (%)

Zimbabwe Rwanda Ethiopia Senegal 2010-11 2010 2011 2010 Ineligible because:






Ineligible Eligible Ineligible Eligible Ineligible Eligible Ineligible Eligible Residential area

rural 60 66 84 87 72 85 46 62 urban 40 34 16 13 28 15 54 38

Education, highest level attended no education 2 5 11 28 42 69 51 75 some primary 26 35 70 63 44 26 24 17 some secondary 67 55 17 8 9 3 23 7 > secondary 5 4 2 1 6 2 3 1

Union/Sexual activity status in union 65 49 48 58 55 77 54 95 single, SA, <1month 3 3 2 2 1 1 1 0 single, SA, ≥1month 9 48 11 40 6 22 9 5

single, never had sex 23 0 40 0 38 0 35 0

Eligible women tend to be less educated & rural. In terms of union/sexual activity status…

Results 3 Who answers the question? Distribution of Background Characteristics by Eligibility (%)

Results 3 Who answers the question? Distribution of Background Characteristics by Eligibility (%)


Ineligible Eligible Ineligible Eligible Ineligible Eligible Ineligible Eligible Residential area

rural 60 66 84 87 72 85 46 62 urban 40 34 16 13 28 15 54 38

Education, highest level attended no education 2 5 11 28 42 69 51 75 some primary 26 35 70 63 44 26 24 17 some secondary 67 55 17 8 9 3 23 7 higher than secondary 5 4 2 1 6 2 3 1

Union/Sexual activity status in union 65 49 48 58 55 77 54 95 single, SA, <1month 3 3 2 2 1 1 1 0 single, SA, ≥1month 9 48 11 40 6 22 9 5

single, never had sex 23 0 40 0 38 0 35 0

Eligible women tend to be less educated & rural. In terms of union/sexual activity status…

Results 4 Reasons for Not Using (%)

Zimbabwe Rwanda Ethiopia Senegal 2010-11 2010 2011 2010 not married 24.0 5.4 13.6 2.7 perceived no need 69.9 73.6 45.7 50.7

no/infrequent sex 52.8 43.3 15.6 17.1 sub/infecund 11.3 5.4 4.3 5.7 postpartum* 8.4 28.3 27.7 30.7

opposition 9.4 4.4 11.8 26.3 knows no method or source 0.3 0.4 5.2 4.1 method related 7.6 12.4 19.3 11.4

method, quality** 7.2 12.4 19.1 11.1 method, stock-out 0.5 0.0 0.3 0.3

lack of access/too far 0.7 0.0 1.7 0.8 costs too much 2.1 0.0 0.2 2.3 fatalistic 2.4 6.0 9.7 4.0 other 3.0 20.9 7.3 0.9 don't know 0.4 0.2 1.0 4.2 *breastfeeding, postpartum amenorrhea **fear of side effects/health concerns, inconvenient to use, interferes with body's processes

Results 4 Reasons for Not Using (%)

Zimbabwe Rwanda Ethiopia Senegal 2010-11 2010 2011 2010 not married 24.0 5.4 13.6 2.7 perceived no need 69.9 73.6 45.7 50.7

no/infrequent sex 52.8 43.3 15.6 17.1 sub/infecund 11.3 5.4 4.3 5.7 postpartum* 8.4 28.3 27.7 30.7

opposition 9.4 4.4 11.8 26.3 knows no method or source 0.3 0.4 5.2 4.1 method related 7.6 12.4 19.3 11.4

method, quality** 7.2 12.4 19.1 11.1 method, stock-out 0.5 0.0 0.3 0.3

lack of access/too far 0.7 0.0 1.7 0.8 costs too much 2.1 0.0 0.2 2.3 fatalistic 2.4 6.0 9.7 4.0 other 3.0 20.9 7.3 0.9 don't know 0.4 0.2 1.0 4.2 *breastfeeding, postpartum amenorrhea **fear of side effects/health concerns, inconvenient to use, interferes with body's processes

Results 5 Are responses valid? Internal Data Consistency for Selected Reasons

Zimbabwe Rwanda Ethiopia Senegal 2010-11 2010 2011 2010 Among women with ”perceived no need due to no/infrequent sex”

sexually active <1 month (%) 9 8 10 19 Among women with "perceived no need due to breastfeeding*/postpartum amenorrhea”

postpartum period (month) 15.8 9.9 16.3 11.0 < 6-month postpartum (%) 54 44 33 35

postpartum amenorrhea (%) 69 92 85 74

meet part of LAM definition* (%) 46 43 32 32

LAM: Lactation Amenorrhea Method. *6-month postpartum and amenorrhea, but without breastfeeding component

Discussion (Over to Madeleine)

Discussion DHS Data Challenges

Reasons for Non-Use in DHS

1) Ineligible women include those with potential unmet need—those who want a child after marriage, want a child but don’t know when, are undecided, or are currently pregnant with an unintended pregnancy, introducing selection bias.

2) Interpretation of responses is challenging, especially for many common responses (“not married”, “breastfeeding”, “side effects”…)

3) Interpretation of omissions is also challenging. Only a small percentage of reasons provided related to contraceptive cost or availability. Is this because they are not barriers or because the respondents haven’t yet experienced these barriers?

4) Reporting inconsistency in selected reasons



















Discussion Improving Measurement of Access

Need to: 1) Arrive at a shared definition of access

“The elimination of barriers to contraceptive uptake and continuation among all who desire to prevent pregnancy, to stop childbearing, or to space their next birth.” <for discussion>

2) Learn from our own history

3) Consider expanding DHS data on access

4) Better utilize household and facility-based data from non-DHS sources

5) Conduct qualitative research




o Leadership of the 1970s and 1980s o World Fertility Survey Questions o Previous DHS Questions (older modules, country-specific adds)








o Hone response categories to Q709 by adding additional probes following reasons that are vague

o Expand eligibility criteria to Q709 o Add questions to current contraceptive users to assess their

challenges experienced to uptake and continuation o Add questions to better assess “side effects”








o Service Provision Assessments o PMA2020








o Coordinated multi-site/multi-country qualitative research

Audience Participation

• Suggestions for taking our analysis further?

• Lessons from historic experience? (e.g., WFS, CPS, RHS) • Lessons from other fields or health areas? • Definition of access? • Other key data sources to measure access? • Suggestions for improvements to existing data sources?

Thank you very much!

Questions and comments: [email protected], [email protected]

Views and opinions expressed in this paper are the authors’. They do not necessarily represent the views and opinions of the US

Agency for International Development

mailto:[email protected]

mailto:[email protected]


Measuring Access among FP Users in DHS

Access barriers are not only experienced by non-users; they are also experienced by current contraceptive users. Soapbox: The FP community must also recognize that FP access is of concern to both FP users and non-users, and examine access-related data from both groups.

Documents

Measurement of Access to Family Planning in Demographic ... · 9/17/2014 · • Catalogue the DHS questions that map to elements of access • Pinpoint questions that elicit the