Pay ATTENTION to Reproductive INTENTION: Lynn M. Van

Pay ATTENTION to Reproductive INTENTION: Lynn M. Van Lith JHUCCP Photo by E. Uphoff / EngenderHealth Limiters Have Needs Too Photo by B. Jones / EngenderHealth Roses Story Photo by B. Jones / EngenderHealth Graces Story Secondary DHS Analysis 15 African countries with DHS surveys after 2000 Part of larger global secondary analysis of 37 countries Countries excluded if LA or PM method use was >25 Aggregated into linguistic groups: Anglophone Francophone

All women 15-49 includedanalysis done using STATA & SPSS Anglophone Africa Francophone Africa Ghana Benin Kenya Cameroon Lesotho Madagascar Malawi Senegal Namibia Rwanda Swaziland Tanzania Uganda

Zambia Zimbabwe Rationale: Women want to limit in Africa CPR increasing across Africa Trend of declining fertility Rise in proportion of women in Africa who want no more children Fertility intention predictor of behavior & contraceptive intentions even better predictorparticularly among women who want to limit Increases in CPR reduces high parity births which impacts MMR Key to concentrate on women who want to limit, in addition to those with spacing needs limiting has greater impact on TFR proportion of women who want no more children a strong predictor of CPR & TFR 20% 0% Unmet need to space Unmet need to limit Zimbabwe 200506 Zambia 2007 Uganda 2006 Tanzania 2004-05 Swaziland 200607

Senegal 2005 Rwanda 2005 Namibia 2006-07 Malawi 2004 Madagas car 2008-09 Lesotho 2004 Kenya 2003 Ghana 2008 Cameroon 2004 Benin 2006 Married women of reproductive age with unmet need Unmet need for limiting versus spacing Unmet need for limiting versus spacing

100% 80% 60% 40% Demand for Limiting Many assume Africa has low demand for limitingdata suggest otherwise 20.4% women in Anglophone Africa wanted no more children at the time of their last birth Photo by W. Betemariam / EngenderHealth Demand for limiting has remained strong or increased in nearly all analysis countries over past 20 years Increasing Trends in Demand for Limiting Changes in desire to limit births Benin 80 Cameroon Ghana

MWRA 60 Kenya Madagascar 40 Malaw i 20 Rw anda 0 Tanzania 1 6 98 Namibia Senegal Uganda 8 8

0 2 4 6 8 0 2 4 6 9 9 0 8 9 9 9 0 0 0 0 19 19 19 19 19 19 20 20 20 20

20 Zambia Zimbabw e Younger African Women Want to Limit As age increases, demand to limit begins to exceed demand to space Demand to limit crossover begins at: 31.3 years in Anglophone Africa 34.3 in Francophone Africa Demand for limiting often associated with older women, however, demand to limit exists among younger women Namibia: 31.7% of MWRA 15-29 have a demand for limiting Lesotho: 26.37% Kenya: 14.43% Malawi: 12.77% Pattern not limited to Southern Africa Evidence shows that not only older high-parity MWRA have demand for limiting How are FP programs preparing to meet this growing need? Photo by N. Rajani / EngenderHealth

Younger & Younger Women Want to Limit Age at which demand for limiting meets or exceeds demand for spacing 40 Age 30 20 10 0 0 20 40 Modern CPR 60 African Women Exceeding Desired Parity 8

8 6 6 4 4 2 2 0 0 n ni e B m Ca o er on

na a Gh a ny e K t so e L ho ar sc a ag ad M i l a a da nd ga

ni bi aw n i a l a e l a i a z n m az M an Rw Se Na T w S Mean parity Mean ideal parity

a nd a Ug m Za a bi bw ba m Zi e Mean ideal parity Mean parity Mean and ideal parity among permanent method users Method Effectiveness Even when demand for FP is satisfied by use, not all methods created equal TM and SAM have lower rates of effectiveness than LA/PMs Differences in effectiveness result in: Higher # of unintended pregnancies among users of SAM/TMs Adverse reproductive outcomes, such as maternal morbidity and mortality, from

unintended pregnancies If 20% of women who use pills and injectables in Africa switched to implants, would avert, over 5 yrs: 1.8 million unintended pregnancies 576,000 abortions (many of them unsafe) 10,000 maternal deaths 300,000 cases of serious maternal morbidity (e.g., obstetric fistula) Hubacher D, Mavranezouli I, McGinn E. Contraception 2008 Comparing effectiveness of contraceptive methods # of unintended pregnancies among 1,000 women in 1st year of (typical) use Method No method 850 Withdrawal 270 Male condom

150 Pill 80 Injectable 30 IUD 8 to 2 Female sterilization 5 Vasectomy 1.5 Implant 0.5 Source: Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York NY: Ardent Media, 2007.

Limiters using TM/SAM more than LA/PMs Family planning use among women with a demand to limit births MWRA 60% 50% Unmet need for limiting 40% TM Users 30% SAM Users 20% LA Users 10% PM Users 0% i

l r in o n a na ny a tho ca law ib ia nd a g a and nia nda bia bw e n o Be e r Gh Ke e so gas Ma a m w a ene azil nza g a am ba m Z U a a L N R S m T Zi Ca Sw ad M Barriers to FP Use Social constructs & accepted norms about sex, family size, and composition impact decision making Pressures from extended family, community influences,

& gender dimensions Spousal communication (or lack thereof) Family, friends, & neighbors key in providing support & influencing contraceptive decision-making FP services distinct from many other health services > ignite judgmental attitudes > social disapproval > moralistic beliefs Knowledge & attitudinal factors pose significant constraints Photo by M. Tuschman / EngenderHealth Factors include: Reasons for Non-Use: Findings from 15 African Countries MWRA with unmet need for limiting cited: Fear of side effects as top reason for lack of intention to use FP in future [Anglophone (23.59%); Francophone Africa (17.29%)] Health concerns [13.65% in AA; 14.64% in FA ] Infrequent sex [14.51% AA; 14.40% FA] Opposed to FP [12.35% of married non-users in FA; 9.75% in AA] Spacers cite ambivalence, limiters rarely do* Driven by misinformation which inhibits use

resulting in unintended births *Bhushan I. Understanding unmet need. JHUCCP, 1997 (Working Paper No. 4) Photo by N. Rajani / EngenderHealth Pervasive fear of contraceptives and perceived side effects Knowledge of FP Methods Informed choice requires access to wide range of FP methods & one must understand complete, accurate, and up-to-date information Photo by C. Svingen / EngenderHealth Measuring knowledge is critical Knowledge of SAMs nearly universal; LA or PMs considerably lower Almost 1 in 2 non-users cannot name an LA or a PM (AA & FA) >1 in 4 TM users cannot name an LA or PM (AA & FA) True knowledge extends much deeper Understanding how methods work Associated side effects

Whether they best suit ones reproductive intentions (which vary over time) Effect of Poverty on Limiters Poorer women use contraception far less than wealthy Wealthier women more likely to use methods for limiting: AA: 30.5% of MWRA in wealthiest quintile and only 12.2% in poorest quintile FA: 17.5% of the wealthiest women and 4.4% of poorest use FP for limiting Wealthiest women more likely to use LA/PMs AA: wealthiest use LAs nearly 4 times more than poorest FA: wealthiest use LAs 2 times more than poorest Poorest women in AA use PMs considerably less than richest; opposite true in FA Photo by C. Svingen / EngenderHealth Poor women less likely to be exposed to accurate FP messages & to have access to quality services Conclusions: Profile of Limiters in Africa Unmet need for limiting exists in Africa Demand exists in Africa Large # exceed desired fertility Ambivalence may be less of an issue Expressed demand for LA/PMs exists

Many barriers to use Focusing on meeting limiting needs has greater effect than does spacing Photo by C. Svingen / EngenderHealth Younger cohorts desire to limit future childbearing Conclusions: Demand an essential element Exposure to BCC messages has positive effects Increases knowledge of methods Increases spousal communication Increases favorable attitudes on use & intention to use Increases use of FP Mass media, social mktg, IPC, mHealth, EE, community engagement & others are promising approaches Multiple channels reinforce & support dose effect = increased FP use Meets RH needs of limiters & a countrys health goals Recommendations Demand generation with limiters as

unique audience Address social norms through creative means Address key barriers: fears of side effects & health concerns Dont shy away from sensitivities Expand method choice to wide range of options Pay ATTENTION to Reproductive INTENTION Greater contraceptive choice = increasing CPR Context-specific responses needed Greater awareness raising of LA/PMs

Address policy & supply barriers Photo by B. Jones / EngenderHealth Photo by B. Jones / EngenderHealth Comments and Questions www.respond-project.org