Siân L. Curtis

Contraceptive discontinuation and unintended pregnancy: an imperfect relationship.

CONTEXT Contraceptive discontinuation is a common event that may be associated with low motivation to avoid pregnancy. If this is the case, a substantial proportion of pregnancies that follow discontinuation will be reported as intended. METHODS Demographic and Health Survey data from six countries (Bangladesh, the Dominican Republic, Kazakhstan, Kenya, the Philippines and Zimbabwe) over the period 1999-2003 were used to explore the proportions of pregnancies women reported as intended or unintended following various contraceptive behaviors. Multivariate logistic regression analysis was used to examine the characteristics of women who reported births as intended when they followed contraceptive failure or discontinuation for reasons other than a desire for pregnancy. RESULTS The proportion of births reported as intended following contraceptive failure ranged from 16% in Bangladesh to 54% in Kazakhstan, and the proportion reported as intended following discontinuation for reasons other than a desire for pregnancy ranged from 37% in Kenya to 51% in Kazakhstan. In at least half the countries, associations were found between selected womens characteristics and their reports that births following either contraceptive failure or discontinuation were intended: Factors that were positively associated were womens age and the time elapsed between contraceptive discontinuation and the index conception; factors that were negatively associated were increasing number of living children and reporting method failure as opposed to method discontinuation. CONCLUSION These findings suggest that underlying variation in the motivation to avoid pregnancy is an important factor in contraceptive discontinuation.BACKGROUND Sixty percent of new HIV infections in Uganda occur in stable relationships between HIV discordant couples. Given the importance of fertility in Uganda, we hypothesized that unsafe sexual practices may be used to found a family/replace a dead child. Thus, we explored sexual practices to understand to what extent these are influenced by the desire to have children and the implications for HIV transmission among discordant couples. METHODS A cross-sectional survey of 114 HIV discordant couples in Kampala, and in-depth interviews with 15 purposively selected couples. Quantitative data were analysed using STATA. Multivariate logistic regression analysis done to identify factors associated with consistent condom use. Thematic content analysis of qualitative data was done using NVIVO 2. RESULTS Participants wanting children and those with multiple sexual partners were less likely to use condoms (Adj OR 0.51, and 0.36 respectively). Three of the five types of sexual practices used by couples do not allow pregnancy to occur. Main reasons for wanting a child included: ensuring lineage continuity and posterity, securing relationships and pressure from relatives to reproduce. Challenges included: risk of HIV transmission to partner and child, lack of negotiating power for safer sex, failure of health systems to offer safe methods of reproduction CONCLUSIONS HIV sero-discordant couples with strong desire for childbearing have a dilemma of risking HIV infection or infecting their spouse. Some risk transmission of HIV infection to reproduce. We need to address gender issues, risky behaviour and reproductive health services for HIV sero-discordant couples.

An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women?

Maternal health services continue to favour the wealthiest in lower and middle income countries. Debate about the potential of performance-based financing (PBF) to address these disparities continues. As PBF is adopted by countries, it is critical to understand the equity effects for maternal services. The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population. In Rwanda, PBF was designed to increase health service use, which was universally low. Paired districts were randomly assigned to intervention and control for PBF implementation. Using Rwandas Demographic Health Survey data from 2005 (pre-intervention) and 2007-8 (post-intervention), a cluster-level panel dataset of 7899 women 15-49 years of age from intervention (4477) and control districts (3422) was created. The impact of PBF on reported use of facility deliveries, antenatal care (ANC) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects. Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women. The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts (P = 0.014), while no significant effects were noted for ANC visits or modern contraceptive use. Service use increased for intervention and control populations and across all wealth quintiles from 2005 to 2007, with no evidence that PBF was a pro-poor or a pro-rich strategy. Insurance remained a positive predictor of service use. This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services, such as facility deliveries, may improve service use overall. However, if the equity gap is extreme, then a PBF programme without equity targets will do little to alleviate disparities.

Multi-centred mixed-methods PEPFAR HIV care & support public health evaluation: study protocol

BackgroundA public health response is essential to meet the multidimensional needs of patients and families affected by HIV disease in sub-Saharan Africa. In order to appraise curret provision of HIV care and support in East Africa, and to provide evidence-based direction to future care programming, and Public Health Evaluation was commissioned by the PEPFAR programme of the US Government.Methods/DesignThis paper described the 2-Phase international mixed methods study protocol utilising longitudinal outcome measurement, surveys, patient and family qualitative interviews and focus groups, staff qualitative interviews, health economics and document analysis.Aim 1) To describe the nature and scope of HIV care and support in two African countries, including the types of facilities available, clients seen, and availability of specific components of care [Study Phase 1]. Aim 2) To determine patient health outcomes over time and principle cost drivers [Study Phase 2].The study objectives are as follows. 1) To undertake a cross-sectional survey of service configuration and activity by sampling 10% of the facilities being funded by PEPFAR to provide HIV care and support in Kenya and Uganda (Phase 1) in order to describe care currently provided, including pharmacy drug reviews to determine availability and supply of essential drugs in HIV management. 2) To conduct patient focus group discussions at each of these (Phase 1) to determine care received. 3) To undertake a longitudinal prospective study of 1200 patients who are newly diagnosed with HIV or patients with HIV who present with a new problem attending PEPFAR care and support services. Data collection includes self-reported quality of life, core palliative outcomes and components of care received (Phase 2). 4) To conduct qualitative interviews with staff, patients and carers in order to explore and understand service issues and care provision in more depth (Phase 2). 5) To undertake document analysis to appraise the clinical care procedures at each facility (Phase 2). 6) To determine principle cost drivers including staff, overhead and laboratory costs (Phase 2).DiscussionThis novel mixed methods protocol will permit transparent presentation of subsequent dataset results publication, and offers a substantive model of protocol design to measure and integrate key activities and outcomes that underpin a public health approach to disease management in a low-income setting.

Accuracy of Standard Measures of Family Planning Service Quality: Findings from the Simulated Client Method

In the field of international family planning, quality of care as a reproductive right is widely endorsed, yet we lack validated data-collection instruments that can accurately assess quality in terms of its public health importance. This study, conducted within 19 public and private facilities in Kisumu, Kenya, used the simulated client method to test the validity of three standard data-collection instruments used in large-scale facility surveys: provider interviews, client interviews, and observation of client-provider interactions. Results found low specificity and low positive predictive values in each of the three instruments for a number of quality indicators, suggesting that the quality of care provided may be overestimated by traditional methods of measurement. Revised approaches to measuring family planning service quality may be needed to ensure accurate assessment of programs and to better inform quality-improvement interventions.

Geographically linking population and facility surveys: methodological considerations

BackgroundThe relationship between health services and population outcomes is an important area of public health research that requires bringing together data on outcomes and the relevant service environment. Linking independent, existing datasets geographically is potentially an efficient approach; however, it raises a number of methodological issues which have not been extensively explored. This sensitivity analysis explores the potential misclassification error introduced when a sample rather than a census of health facilities is used and when household survey clusters are geographically displaced for confidentiality.MethodsUsing the 2007 Rwanda Service Provision Assessment (RSPA) of all public health facilities and the 2007–2008 Rwanda Interim Demographic and Health Survey (RIDHS), five health facility samples and five household cluster displacements were created to simulate typical SPA samples and household cluster datasets. Facility datasets were matched with cluster datasets to create 36 paired datasets. Four geographic techniques were employed to link clusters with facilities in each paired dataset. The links between clusters and facilities were operationalized by creating health service variables from the RSPA and attaching them to linked RIDHS clusters. Comparisons between the original facility census and undisplaced clusters dataset with the multiple samples and displaced clusters datasets enabled measurement of error due to sampling and displacement.ResultsFacility sampling produced larger misclassification errors than cluster displacement, underestimating access to services. Distance to the nearest facility was misclassified for over 50% of the clusters when directly linked, while linking to all facilities within an administrative boundary produced the lowest misclassification error. Measuring relative service environment produced equally poor results with over half of the clusters assigned to the incorrect quintile when linked with a sample of facilities and more than one-third misclassified due to displacement.ConclusionsAt low levels of geographic disaggregation, linking independent facility samples and household clusters is not recommended. Linking facility census data with population data at the cluster level is possible, but misclassification errors associated with geographic displacement of clusters will bias estimates of relationships between service environment and health outcomes. The potential need to link facility and population-based data requires consideration when designing a facility survey.

Contraceptive use dynamics research needs post fertility transition

Brazil, like many countries in the world today, has very low fertility and high contraceptive use. The TFR is now 1.8, below replacement level, and over 97% of sexually active women age 15-49 have used contraception at some time in their lives (BRASIL, 2008a). Despite the near universality of contraceptive use in Brazil today, 29.7% of births in the five years before the 2006 PNDS were reported as mistimed (wanted later) and 17.8% were reported as unwanted (BRASIL, 2008a). Similar patterns are observed in other low fertility, high contracepting populations; for example, in the United States 99% of women who have ever had sex have used contraception, yet one half of births in the US are unintended (MOSHER; JONES, 2010). In these contexts, a large proportion of unintended pregnancy is the result of contraceptive failure and inconsistent contraceptive use (BLANC; CURTIS; CROFT, 2002; BRADLEY; CROFT; RUTSTEIN, 2011). A large proportion of induced abortions are also preceded by contraceptive use in Brazil (BRASIL, 2008b). Contraceptive discontinuation rates are high for most reversible methods. In Brazil in 1996, the most recent year for which data are available, 12 month discontinuation rates ranged from 42.3% among pill users to 62.8% among injectable users (BLANC; CURTIS; CROFT, 2002). In the same study, 12 month discontinuation rates for all reversible methods in Latin America ranged from 42.8% in Bolivia to 62.9% in the Dominican Republic, and in the United States, 46.3% of women who had ever used a contraceptive method reported having discontinued a method because they were dissatisfied with it (MOREAU; CLELAND; TRUSSELL, 2007). Side effects and health concerns are a major reason for discontinuing modern contraceptive methods; 11.8% of pill users and 27.4% of injectable users in Brazil in 1996 discontinued within 12 months due to side effects and health concerns, (LEITE; GUPTA, 2007) making them the largest single reason for discontinuing these methods. In the US, 64.6% of women who discontinued the pill and 72.3% of women who discontinued the injectable did so because of side effects (MOREAU; CLELAND; TRUSSELL, 2007). The picture is a little different for condoms; the main reasons for discontinuation of condoms relate to characteristics of the method such as inconvenience of use, dislike of the method by partners, interference with sexual pleasure, and concerns over the effectiveness of the method (MOREAU; CLELAND; TRUSSELL, 2007). The s t reng th o f mot i va t ion to avoid pregnancy is another important factor. Analyses of the determinants of d iscont inuat ion cons is tent ly show demographic factors such as whether a woman is spacing or limiting births or her age to be more consistent determinants of discontinuation than socio-economic factors such as education or wealth status (CURTIS; BLANC, 1997; BRADLEY; SCHWANDT; KHAN, 2009). Women do not necessarily report births following discontinuation (for reasons other than desire to get pregnant) or failure as unintended (TRUSSELL, 1999; CURTIS; EVENS; SAMBISA, 2011) suggesting that ambivalence about pregnancy intentions plays a contributing role in discontinuation even when women do not explicitly state they are discontinuing contraceptive use in order to get pregnant. In the US, the National Survey of Family Growth has experimented with alternative methods of measuring fertility preferences and Santelli and colleagues have shown that

HIV status and postpartum contraceptive use in an antenatal population in Durban, South Africa.

OBJECTIVE We examined contraceptive use and dual protection in the postpartum period in a Prevention of Mother to Child Transmission population and whether it varied by HIV status. STUDY DESIGN Data are from a prospective study, the South Africa HIV Antenatal Post-test Support Study. Pregnant participants were recruited from a government clinic in an urban township, and the analytic sample was 821. Following enrollment, participants were tested for HIV and administered a questionnaire at baseline and 14 weeks postpartum. We used generalized linear regression models to examine HIV status and use of modern contraceptives at 14 weeks. RESULTS The risk ratio of condom use at 14 weeks postpartum was 1.66 [95% confidence interval (CI): 1.36-2.02] for HIV-positive compared to HIV-negative women. The risk ratio for dual protection (use of a condom and a hormonal method) was 1.96 (95% CI: 1.39-2.79) at 14 weeks for HIV-positive compared to HIV-negative women. CONCLUSIONS HIV positive status may be a motivating factor for women to use condoms and dual protection. In this setting where HIV is highly prevalent, it is ever more important that women control the timing and limiting of births so as to preserve the health of the mother and child. IMPLICATION HIV status may be an important motivating behavioral factor for women to use contraceptives and dual protection in the postpartum period.

Measuring Maternal Mortality: Three Case Studies Using Verbal Autopsy with Different Platforms.

Background Accurate measurement of maternal mortality is needed to develop a greater understanding of the scale of the problem, to increase effectiveness of program planning and targeting, and to track progress. In the absence of good quality vital statistics, interim methods are used to measure maternal mortality. The purpose of this study is to document experience with three community-based interim methods that measure maternal mortality using verbal autopsy. Methods This study uses a post-census mortality survey, a sample vital registration with verbal autopsy, and a large-scale household survey to summarize the measures of maternal mortality obtained from these three platforms, compares and contrasts the different methodologies employed, and evaluates strengths and weaknesses of each approach. Included is also a discussion of issues related to death identification and classification, estimating maternal mortality ratios and rates, sample sizes and periodicity of estimates, data quality, and cost. Results The sample sizes vary considerably between the three data sources and the number of maternal deaths identified through each platform was small. The proportion of deaths to women of reproductive age that are maternal deaths ranged from 8.8% to 17.3%. The maternal mortality rate was estimable using two of the platforms while obtaining an estimate of the maternal mortality ratio was only possible using one of the platforms. The percentage of maternal deaths due to direct obstetric causes ranged from 45.2% to 80.4%. Conclusions This study documents experiences applying standard verbal autopsy methods to estimate maternal mortality and confirms that verbal autopsy is a feasible method for collecting maternal mortality data. None of these interim methods are likely to be suitable for detecting short term changes in mortality due to prohibitive sample size requirements, and thus, comprehensive and continuous civil registration systems to provide high quality vital statistics are essential in the long-term.

Postpartum Family Planning Service Provision in Durban, South Africa: Client and Provider Perspectives

Researchers in Sub-Saharan Africa have found that health facility factors influence client contraceptive use. We sought to understand how client-provider interactions, discussions of side effects, and HIV status influence womens contraceptive use postpartum. We conducted in-depth interviews with eight HIV negative clients and six HIV positive clients in Zulu, and with five nurses in English. Interviews were translated and transcribed into English. We created a codebook and coded all transcripts. Nurses and clients reported limited time to discuss contraception, side effects, and HIV. Nurses did not comply with national contraceptive policies and created unnecessary barriers to contraceptive use.

Evaluating the impact of social support services on tuberculosis treatment default in Ukraine

Ukraine is among the top 20 highest drug-resistant tuberculosis burden countries in the world. Driving the high drug-resistant tuberculosis rates is an unchecked treatment default rate. This evaluation measures the effect of social support provided to tuberculosis patients at risk of defaulting on treatment during outpatient treatment. Five tuberculosis patient cohorts, served in three oblasts from 2011 and 2012, were constructed from medical records to compare risk factors for default, receipt of social services, and treatment outcome. Regression analyses were used to identify risk factors predictive of treatment default and to estimate the impact of the social support program on treatment default, controlling for risk, disease status, and demographics. In 2012, tuberculosis patients receiving social support in Ukraine reduced their probability of defaulting on continuation treatment by 10 percentage points compared to high-risk patients who did not receive social support in 2012 or 2011. Treatment success rates for the high-risk patients receiving social support were comparable to the low-risk cohorts and significantly improved over the high-risk comparison cohorts. Further research is recommended to quantify the costs and benefits for scaling-up social support services, evaluate social support program fidelity, identify which populations respond best to select services, and what barriers might still exist to achieve better adherence. With that information, tailoring programs to most effectively reach and serve clients in a patient-centered approach may reap substantial rewards for Ukraine.