Saumya RamaRao

Improving Quality of Care and Use of Contraceptives in Senegal

In the 1990s, the government of Senegal implemented a series of policy changes for the provision of family planning services through the public sector. A strategy to provide high quality services through reference centres was adopted. This paper presents findings from a longitudinal survey of 1,320 Senegalese women who had sought family planning services at ten public sector facilities--five reference centres and five health centres. Information was collected on the quality of care they received at the time they adopted family planning. One thousand one hundred and ten of the respondents were followed up sixteen months later to ascertain their contraceptive status. The first principal finding was that attendees at reference centres reported receiving relative better care than those who attended health centres. On average, clients at reference centres received 4.3 out of five units of care, compared to 3.8 units as reported by health centre clients. Second, multivariate analyses indicated that quality of care received at the time of adopting a contraceptive has a significant influence on subsequent contraceptive use. Those who received good care were 1.3 times more likely to be using a method than others.

Reducing Unmet Need by Supporting Women with Met Need

CONTEXT The 2012 London Summit on family planning set a goal of providing modern contraceptives to 120 million women with unmet need by 2020. Reducing the high rate of contraceptive discontinuation by facilitating switching among methods will play a critical role in meeting that goal. METHODS Data collected from married women in Demographic and Health Surveys conducted in 34 countries between 2005 and 2010 were used to estimate the potential contribution of contraceptive discontinuation to current and future unmet need. An indicator of relevant discontinuation was created by calculating the proportion of past users with an unmet need for modern methods among ever-users. Regression analyses identified associations between this indicator and access to and composition of methods. RESULTS Women who had discontinued method use and subsequently had unmet need at the survey accounted for 38% of the total estimated unmet need. These past users represented 19% of women who had ever used modern methods. Both the access to and composition of available methods were associated with a reduction in the relevant discontinuation rate. The level of discontinuation in Sub-Saharan Africa was significantly higher than in other regions, in part due to differences in method availability. CONCLUSIONS High contraceptive discontinuation in the past has contributed tens of millions of cases of unmet need, and discontinuation among current users will contribute even more cases in the future. Enabling past users with unmet need to resume use and encouraging current users to continue use of the same or another method could be an effective strategy to reduce future unmet need.

Motivations for entry into sex work and HIV risk among mobile female sex workers in India.

This paper assesses the reasons for entry into sex work and its association with HIV risk behaviours among mobile female sex workers (FSWs) in India. Data were collected from a cross-sectional survey conducted in 22 districts across four high HIV prevalence states in India during 2007-2008. Analyses were limited to 5498 eligible mobile FSWs. The reasons given by FSWs for entering sex work and associations with socio-demographic characteristics were assessed. Reported reasons for entering sex work include poor or deprived economic conditions; negative social circumstances in life; own choice; force by an external person; and family tradition. The results from multivariate analyses indicate that those FSWs who entered sex work due to poor economic conditions or negative social circumstances in life or force demonstrated elevated levels of current inconsistent condom use as well as in the past in comparison with those FSWs who reported entering sex work by choice or family tradition. This finding indicates the need for a careful assessment of the pre-entry contexts among HIV prevention interventions since these factors may continue to hinder the effectiveness of efforts to reduce the spread of HIV/AIDS in India and elsewhere.

Assessing the validity of indicators of the quality of maternal and newborn health care in Kenya

Background The measurement of progress in maternal and newborn health often relies on data provided by women in surveys on the quality of care they received. The majority of these indicators, however, including the widely tracked “skilled attendance at birth” indicator, have not been validated. We assess the validity of a large set of maternal and newborn health indicators that are included or have the potential to be included in population–based surveys. Methods We compare women’s reports of care received during labor and delivery in two Kenyan hospitals prior to discharge against a reference standard of direct observations by a trained third party (n = 662). We assessed individual–level reporting accuracy by quantifying the area under the receiver operating curve (AUC) and estimated population–level accuracy using the inflation factor (IF) for each indicator with sufficient numbers for analysis. Findings Four of 41 indicators performed well on both validation criteria (AUC>0.70 and 0.75<IF<1.25). These were: main provider during delivery was a nurse/midwife, a support companion was present at birth, cesarean operation, and low birthweight infant (<2500 g). Twenty–one indicators met acceptable levels for one criterion only (11 for AUC; 9 for IF). The skilled birth attendance indicator met the IF criterion only. Interpretation Few indicators met both validation criteria, partly because many routine care interventions almost always occurred, and there was insufficient variation for robust analysis. Validity is influenced by whether the woman had a cesarean section, and by question wording. Low validity is associated with indicators related to the timing or sequence of events. The validity of maternal and newborn quality of care indicators should be assessed in a range of settings to refine these findings.

Progesterone vaginal ring: introducing a contraceptive to meet the needs of breastfeeding women

BACKGROUND The 2012 London Summit on Family Planning called for innovative solutions for increasing contraceptive access for 120 million women and girls by 2020. One way of contributing to this goal is to address the contraceptive needs of postpartum women, who have considerable unmet need especially during lactation. The progesterone vaginal ring (PVR) has been shown to be effective and safe for breastfeeding women and has the potential to enhance contraceptive choice. This user-controlled method reduces dependence on health care providers and has the potential to reduce some access-related barriers that users face. Postpartum women who have used the method have found it easy to use and find it acceptable. A well-designed introductory approach is important to ensure that the PVR is integrated into health systems. CONCLUSION The PVR is a new technology that increases contraceptive options for breastfeeding women and has the potential to improve the health of women and their infants. Careful planning with attention paid to numerous factors can result in its successful introduction.

Do improvements in client–provider interaction increase contraceptive continuation? Unraveling the puzzle

OBJECTIVE Evidence on the association between client-provider interaction (CPI) and contraceptive continuation has been mixed. This paper attempts to unravel the puzzle by examining various factors that may have contributed to the mixed results. METHODS This paper critically reviews key studies that examined the association between CPI and contraceptive continuation. A scan of peer reviewed publications and project reports was undertaken with a focus on CPI and contraceptive continuation. In addition, a review of key studies that examined the impact of interventions to improve CPI in compliance with medical regimens was carried out. RESULTS The inconsistency of results may be attributed to methodological factors, characteristics of interventions to improve CPI, or conceptual factors related to the complexity of the issue of contraceptive continuation. CONCLUSION More rigorous research is needed to understand the role played by CPI in contraceptive continuation as well as socio-demographic, behavioral and contextual factors that moderate the relationship between CPI and contraceptive continuation. PRACTICE IMPLICATIONS Counseling services should be expanded to address physical, social and emotional needs of continuing clients. Moreover, interventions to improve CPI should also address contextual and health system factors that prevent clients from using family planning consistently and effectively.

Postabortion Care: Going to Scale

This commentary discusses the complementary efforts required to ensure that research findings associated with designing and delivering postabortion care services are utilized and scaled up. It describes the complementary efforts as ranging from identifying champions and advocates for postabortion care to providing technical assistance for replication and scale-up. It draws on specific country program experiences in sub-Saharan Africa Latin America and Asia where postabortion care services have been or have the potential to be scaled up.

Aligning Goals, Intents, and Performance Indicators in Family Planning Service Delivery

A flurry of policy initiatives in the fields of both population and development and reproductive health, many addressing the provision of family planning services, are currently underway: FP2020, the ICPD Beyond 2014, and the post-2015 development agenda, among others. This is an opportune time, therefore, to reflect upon and take into consideration what five decades of family planning programs can teach us about ensuring that policies and programs integrate their underlying intents, concrete goals, and performance indicators. The family planning field has encountered instances in its history when inconsistencies between goals, intents, and indicators arose and adversely affected the delivery of services. This commentary presents our observations concerning potential misalignments that may arise within the many promising initiatives underway. We examine the relationship between the intent, goal, and indicators of FP2020 as a case study highlighting the need for ensuring a tight alignment. We offer suggestions for ensuring that this and other initiatives use carefully calibrated indicators to guide the achievement of explicit program goals without undermining their underlying intent--namely, promoting well-being and reproductive rights.

Emergency contraception in Senegal: challenges and opportunities.

Abstract Objectives This paper highlights lessons from introductory efforts and presents new data on community, provider and key opinion leader perspectives to support expanded use of emergency contraception (EC) in Senegal. Sources of information The paper draws on four data sources: (i) a literature review; (ii) a secondary analysis of a household survey conducted by the Urban Reproductive Health Initiative; (iii) in-depth interviews with key opinion leaders; and (iv) a quantitative survey of healthcare providers from a range of service delivery points. Analysis of data Knowledge of EC among women is low in urban areas, with only 20% of women having heard of the method and 4% having ever used it. There were serious gaps in providers’ technical knowledge about EC; only 57% knew its mode of action and 34% were aware of the need for timely use (within 120 h). Moreover, nearly half reported reluctance to provide EC to married women and even fewer were willing to provide it to youths, particularly to adolescent girls. Responses from key opinion leaders were mixed, demonstrating ambivalence about EC and how it could be offered. Conclusion In Senegal, the current positive political climate for family planning provides a good opportunity for strengthening EC programming to address knowledge and attitudinal barriers among providers, key opinion leaders and communities. Chinese Abstract 摘要 ：目的，这篇文章的亮点来自导言，尽力展示并且提供了社区、提供者及关键意见领袖支持紧急避孕药在塞内加尔的广泛使用的新数据。 资料来源 这篇文章的资料来源于四个数据：（1）文献综述；（2）一篇由城市生殖健康倡议进行的入户调查的二级分析。（3）一个和关键意见领袖的深度的采访。（4）很多医疗保健服务提供方从乡镇机构得到的量化调查结果。 数据分析 在城市地区的妇女对紧急避孕药的了解很少，仅有20%的女性听说过这种方法而只有4%的女性使用过。供应者提供的紧急避孕药的技术知识存在缺口，只有57%的人知道其作用方式，34%的人知道要在120小时内及时地使用。此外，据报道几乎有一半的情况愿意向已婚女性提供紧急避孕药，极少愿意提供给青年人尤其是青春期的女孩。关键意见领袖的反应是不确定的，对于紧急避孕药及该如何提供存在着矛盾。 结论 在塞内加尔，当前计划生育积极的政治气候对于加强紧急避孕药的规划、对药物的供应者，关键意见领袖和社区介绍药品的知识和态度上的障碍提供了很好的机会，。

New vistas in contraceptive technology

Population forecasts predict that by 2050, about 150 million women (and couples) of child-bearing age will need contraception, and many of them are likely to find their needs unmet, due to problems of access, availability, and acceptability of the contraceptive options for one or both partners. Current contraceptive options are largely intended for use by women (pills, intrauterine devices [IUDs], injectables, and implants), with condoms and vasectomy being the only two options for men. In many countries, contraceptive use tends to be in the womans domain, in part due to the nature of the contraceptive. This article discusses how womens health advocates have been able to raise important concerns regarding contraceptive technology and its development. It also reviews the range of new contraceptives that addresses issues of user autonomy and controllability, offers protection against pregnancy and STIs and HIV, and addresses male needs and concerns.