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We conduct a randomized controlled trial that provides pregnant and immediate postpartum women with improved access to family planning through counseling, free transportation to a clinic, and financial reimbursement for family planning services over two years. We study the effects of our intervention on child growth and development outcomes among 1,034 children born to participating women directly before the intervention rollout. We find that children born to mothers assigned to the family planning intervention arm were 0.28-0.34 standard deviations taller for their age and 10.7-12.0 percentage points less likely to be stunted within a year of exposure to the intervention. Children born to mothers assigned to the intervention arm also scored 0.17-0.20 standard deviations higher on a caregiver-reported measure of cognitive development after two years of intervention exposure. Although the nonmeasurement of children is a challenge in our study, our estimates are robust to multiple methods of correcting for potential attrition bias. Our results are consistent with models of fertility that link couples' fertility decisions to child health and human capital. Our results also suggest that improved access to family planning might have positive downstream effects on child health beyond contraceptive use and fertility outcomes., (Copyright © 2024 The Authors.)

Estimates of unwanted family planning (UFP), which are based on a desire to have a child in the next nine months among current contraceptive users, exclude women who are sterilized since these women are not asked about their fertility preferences; all sterilized women are assumed to have a "met need" for family planning. However, the India National Family Health Survey asks sterilized women if they regret being sterilized and whether they were told that the operation would result in their permanent inability to have children. We extend the concept of UFP by classifying sterilized women who express regret or who were not informed about the procedure's permanence, as having UFP. When limiting our analysis of UFP to nonsterilized contraceptive users, we find that 0.9 percent of Indian women had UFP in 2019-2021. In this period, 29.9 percent of Indian women were sterilized. We estimate that 4.9 percent of sterilized women express regret and 16.3 percent were not told of the procedure's permanence. Adding sterilized women who express regret raises our UFP estimate in India to 2.3 percent, while also including sterilized women who were not told about the procedure's permanence yields an overall UFP estimate of 6.9 percent in India., (© 2024 The Author(s). Studies in Family Planning published by Wiley Periodicals LLC on behalf of Population Council.)

Economists use micro-based and macro-based approaches to assess the macroeconomic return to population health. The macro-based approach tends to yield estimates that are either negative and close to zero or positive and an order of magnitude larger than the range of estimates derived from the micro-based approach. This presents a micro-macro puzzle regarding the macroeconomic return to health. We reconcile the two approaches by controlling for the indirect effects of health on income per capita, which macro-based approaches usually include but micro-based approaches deliberately omit when isolating the direct income effects of health. Our results show that the macroeconomic return to health lies in the range of plausible microeconomic estimates, demonstrating that both approaches are in fact consistent with one another., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Injectables are one of the most popular methods of contraception worldwide, particularly in sub-Saharan Africa. An advantage of injectables over shorter-acting methods is that they provide additional flexibility by not requiring re-supply as frequently. However, there is a risk that injectable users may delay their next injection and may therefore have reduced or no protection from pregnancy. In surveys, women may report that they are using contraception in the form of injectables when the time since they had their last injection (more than four months) would imply that they have reduced protection against the risk of pregnancy. We carried out two field studies in urban Malawi, and we record reported injectable contraceptive use while also asking the number of months since women received their last injection. We observe that 13.8 percent of women who report using injectables also report that they received their last injection more than four months ago, and 11 percent report that they received their last injection more than six months ago. Our analysis highlights the need for additional follow-up with women who report using injectables in surveys to confirm whether they are, in fact, using the method effectively., (© 2024 The Authors. Studies in Family Planning published by Wiley Periodicals LLC on behalf of Population Council.)

Purpose: We evaluate contraceptive use and pregnancy two years following an intervention in Tanzania, which provided antenatal post-partum family planning counselling and post-partum intrauterine device (PPIUD) services following delivery., Methods: We analyse data from five hospitals in Tanzania using a difference-in-difference cluster randomised design, with randomisation at the hospital level. We use women-level data collected at the index birth and a follow-up survey two years later among 6,410 women. Outcomes (overall modern contraceptive use, contraceptive type, pregnancy) are modelled with an intent-to-treat (ITT) approach using linear regression. We compare with the complier average causal effect (CACE) of the intervention among those counselled., Results: The intervention increased long-term PPIUD use by 5.8 percentage points (95% CI: 0.7-11.2%) through substitution away from other modern methods. There was no impact on overall modern contraceptive prevalence or pregnancy. Only 29% of women reported receiving PPIUD counselling. When accounting for this in the CACE analysis we saw a larger impact with 25.7% percentage point increase in PPIUD use (95% CI: 22.7-28.6%)., Conclusion: The intervention provided women an additional contraceptive choice, resulting in higher use of PPIUD over two years. Increase in PPIUD use was brought about by shifting methods, not creating new modern contraceptive users.

Background: There is limited evidence between contraceptive use, availability of commodities and distance to the facility in developing countries. Distance to the facility is an essential determinant of contraceptive use. Still, women may not seek family planning services from the nearest facility and may be prepared to travel the farthest distance to receive quality family planning services., Methods: We analyzed women's survey data linked to health facility data and applied an alternate specific conditional logit model to examine the distance a woman is prepared to travel and the quality of services offered by facilities in urban areas in Karachi, Pakistan., Results: This study analyzed data from 336 women and 28 facilities and identified that the mean distance to the nearest facility was 0.44 km; the chosen facility was, on average, 5 km away. Women preferred facilities that offered a range of contraceptive methods and additional services provided by female healthcare providers only. Furthermore, on average, women are willing to travel a further 1.7 km for a facility that offers more family planning methods, 1.4 km for a facility that offers additional health services and 11 km for a facility that offers services delivered by female healthcare providers., Conclusions: The findings highlight the quality measures women prioritize over distance and consider essential when choosing a family planning facility., (© The Author(s) 2022. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Increasing socioeconomic resources through cash transfer payments could help promote healthy longevity. However, research in this area is limited due to endogeneity in cash transfer exposures and limited geographic representation., Methods: We leveraged the HPTN 068 randomized cash transfer trial, conducted from 2011 to 2015 in a rural setting in South Africa. We assessed long-term mortality follow-up (until March 2022) on older adult members (n = 3568) of households enrolled in the trial from the complete Agincourt Health and socio-Demographic Surveillance System census of the underlying source population. The trial intervention was a monthly cash payment of 300 Rand conditional on school enrollment of index young women. The payments were split between the young woman (1/3) and their caregiver (2/3). Young women and their households were randomized 1:1 to intervention vs. control. We used Cox PH models to compare mortality rates in older adults living in intervention vs. control households., Findings: The cash transfer intervention did not significantly impact mortality in the full sample [HR (95% CI): 0.94 (0.80, 1.10)]. However, we observed strong protective effects of the cash transfer intervention among those with above-median household assets [HR (95% CI): 0.66 (0.50, 0.86)] and higher educational attainment [HR (95% CI): 0.37 (0.15, 0.93)]., Interpretation: Our findings indicate that short-term cash transfers can lead to reduced mortality in certain subgroups of older adults with higher baseline socioeconomic status. Future work should focus on understanding the optimal timing, structure, and targets to maximize the benefits of cash transfer programs in promoting healthy aging and longevity., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Two-thirds of people living with Alzheimer's disease and related dementias (ADRD) live in low- and middle-income countries, and this figure is expected to rise as these populations are rapidly aging. Since evidence demonstrates links between socioeconomic status and slower rates of cognitive decline, protecting older adults' cognitive function in resource-limited countries that lack the infrastructure to cope with ADRD is crucial to reduce the burden it places on these populations and their health systems. While cash transfers are a promising intervention to promote healthy cognitive aging, factors such as household wealth and level of education often confound the ability to make causal inferences on the impact of cash transfers and cognitive function. This study uses a quasi-experimental design, leveraging an exogenous expansion to the Old Age Pension for men in South Africa, to approximate causal associations with cognitive function. We found evidence that there is a potential benefit of cash transfers at an earlier age for older individuals. As such, transfers such as pensions or other forms of direct basic income transfers may hold promise as potential interventions to promote healthy cognitive aging.

While there is a large literature on the prevalence of unmet need for family planning, there is no matching quantitative evidence on the prevalence of unwanted family planning; all contraceptive use is assumed to represent a "met need." This lack of evidence raises concerns that some observed contraceptive use may be undesired and coercive. We provide estimates of unwanted family planning using Demographic and Health Survey data collected from 1,546,987 women in 56 low- and middle-income countries between 2011 and 2019. We estimate the prevalence of unwanted family planning, defined as the proportion of women who report wanting a child in the next nine months but who are using contraception. We find that 12.2 percent of women have an unmet need for family planning, while 2.1 percent have unwanted family planning, with estimated prevalence rates ranging from 0.4 percent in Gambia to 7.1 percent in Jordan. About half of unwanted family planning use can be attributed to condoms, withdrawal, and abstinence. Estimating the prevalence of unwanted family planning is difficult given current data collection efforts, which are not designed for this purpose. We recommend that future surveys probe the reasons for the use of family planning., (© 2023 The Authors. Studies in Family Planning published by Wiley Periodicals LLC on behalf of Population Council.)

Purpose: Study findings suggest association between anemia and postpartum depression, but available evidence is scant and inconsistent. We investigate whether anemia is related to postpartum depression among women who have recently given birth in Malawi, where anemia prevalence is high., Methods: We use cross-sectional data from 829 women who were 18-36 years old, married, lived in Lilongwe, Malawi, and gave birth between August 2017 and February 2019. The primary outcome is postpartum depression in the year after birth, defined by the Patient Health Questionnaire-9 (PHQ-9). Anemia status was assessed using hemoglobin levels that were measured at the time of the interview. Multivariate logistic regression analyses were used to investigate the relationship between postpartum depression and anemia status., Results: Our analysis sample consists of 565 women who completed the PHQ-9, tested for anemia, and had no missing values for covariates. Of these women, 37.5% had anemia (hemoglobin levels ≤ 110 g/L), and 2.7% were classified as showing symptoms of a major depressive disorder (MDD). After adjusting for potential confounders, anemia was significantly associated with increased risk of MDD (OR: 3.48, 95% CI: 1.15-10.57, p -value: 0.03). No significant associations were found between other covariates and postpartum depression., Conclusions: Our findings suggest a potential association between anemia and postpartum depression among women in Malawi. Policies that aim to improve nutrition and health outcomes for pregnant and postpartum women could generate a "double benefit" by both preventing anemia and reducing the risk of postpartum depression.

Social protection schemes have been expanding around the world with the objective of protecting older persons during retirement. While theoretically they have been seen as tools to improve individual wellbeing, there are few studies that evaluate whether social pensions can improve health. In this study, we exploit the change in eligibility criteria for the South African Old Age grant to estimate the association between pension exposure eligibility and health of older persons. For this, we use data from the Health and Aging in Africa: A longitudinal Study of an INDEPTH Community in South Africa (HAALSI) and model pension exposure in terms of its cumulative effect. Our results show that pension exposure is associated with better health as measured by a set of health indices. Disentangling these effects, we find that pension exposure is most likely to improve health through the delayed onset of physical disabilities in the elderly population. Our study highlights the relevance of social protection schemes as a mechanism to protect older persons physical health., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Carlos RiumalloHerl, Chodziwadziwa Kabudula, Kathleen Kahn, Stephen Tollman, and David Canning report no conflicts of interest, (© 2022 The Author(s).)

An intervention aimed at institutionalizing postpartum intrauterine device (PPIUD) services was introduced in Nepal between 2015 and 2019. The intervention was evaluated using a cluster-randomized stepped-wedge trial, with data on women being collected immediately after delivery and at one- and two-year postpartum follow-ups. The sample consists of 19,155 women. We used intention-to-treat (ITT) analysis and structural equation model (SEM) to investigate how the intervention affected the occurrence of a new pregnancy (incident pregnancy). The ITT analysis showed that women in the intervention group had a reduced probability, -0.7 percentage points (95 percent CI: -3.0, 1.4), of having an incident pregnancy compared to women in the control group. The SEM analysis showed that the intervention increased the probability of receiving antenatal family planning counseling and PPIUD-specific counseling by 22.2 percentage points (95 percent CI: 20.0, 24.4) and 26.5 percentage points (95 percent CI: 24.8, 28.3), respectively. The intervention had an unintended spillover effect, increasing the probability of receiving postnatal family planning counseling by 11.4 percentage points (95 percent CI: 7.3, 15.5). In the SEM, we find the expected impact of the intervention on increased counseling and induced effects on contraceptive method initiation, lowering the probability of an incident pregnancy by 0.3 percentage points (95 percent CI: -0.5, -0.1)., (© 2022 The Population Council, Inc.)

Studies have suggested that improving access to family planning (FP) may improve contraceptive use and reduce fertility. However, high-quality evidence, particularly from randomized implementation trials, of the effect of FP programs and interventions on longer-term fertility and birth spacing is lacking. We conduct a nonblinded, randomized, controlled trial to assess the causal impact of improved access to FP on contraceptive use and pregnancy spacing in Lilongwe, Malawi. A total of 2,143 married women aged 18 to 35 who were either pregnant or had recently given birth were recruited through home visits between September 2016 and January 2017 and were randomly assigned to an intervention arm or a control arm. The intervention arm received four services over a 2-y period: 1) up to six FP counseling sessions; 2) free transportation to an FP clinic; 3) free FP services at the clinic or financial reimbursement for FP services obtained elsewhere; and 4) treatment for contraceptive-related side effects. Contraceptive use after 2 y of intervention exposure increased by 5.9 percentage points, mainly through an increased use of contraceptive implants. The intervention group’s hazard of pregnancy was 43.5% lower 24 mo after the index birth. Our results highlight the positive impact of increased access to FP on a woman’s contraceptive use. In addition, we show that exposure to the FP intervention led to a prolongation of birth intervals among intervention women relative to control women and increased her control over birth spacing and postpartum fertility, which, in turn, may contribute to her longer-term health and well-being.

Cross-national studies of the linkage of health-care spending with population health have found surprisingly limited evidence of benefits. In this study, we investigated associations between national health spending and key health resources (numbers of hospital beds, physicians, and nurses) and utilization of cost-effective health services (antenatal care, attendance of trained staff at childbirth, and measles vaccination), sometimes in ways that curtail the benefits of that expenditure. Using annual panel data from 1990-2014 covering 140 countries, we show that variation in health spending as a share of gross domestic product is not associated with decreased mortality rates. It is also very weakly associated with increased health-care resources and health service utilization (elasticity smaller than 0.08), with the association being close to 0 in low-income countries. In addition, countries with a higher share of out-of-pocket spending have a significantly lower level of health resources and service utilization. These findings, rather than the ineffectiveness of health care, could explain the lack of impact of health spending. In contrast, gross domestic product per capita is significantly associated with increased health resources, a higher rate of service utilization, and lower mortality rates, suggesting that income is an important determinant of public health., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The aim of this study was to investigate nurse and allied health professional experiences and attitudes toward critical care research in Wales., Methods: Data were collected related to demographic characteristics, involvement in and understanding of research, perceived influences and attitudes towards research. We calculated means (ranges) for continuous variable and frequencies (proportions) for discrete variables and performed an exploratory factor analysis., Results: Response rate was 55% ( n  = 575). Most respondents (84%) had participated in research less than five times in the previous 12 months, yet 91% believed research led to improved care patients. Only 32% respondents felt they were encouraged by managers to participate in research. Only 25% respondents had undertaken research training. Few respondents (29%) reported receiving adequate information regarding study progress or results (25%). Linear regression models indicate that a higher level of formal education was associated with a more positive view of research across all attitude factors. Promotion of research by colleagues and recognition/ opportunities for involvement in critical care research, were positively associated with the acceptability and experience of research., Discussion: A number of factors have been identified that could be targeted to improve recruitment to critical care research, including identification of staff to promote research, improved communication of study progress and findings and management encouragement to attend research training. Staff attitudes were positive towards the benefit of research on patient care in Wales., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2020.)

We studied the relationship of prenatal and post-birth exposure to particulate matter < 2.5 μm in diameter (PM 2.5 ) with infant mortality for all births between 2011 and 2013 in the conterminous United States. Prenatal exposure was defined separately for each trimester, post-birth exposure was defined in the 12 months following the prenatal period, and infant mortality was defined as death in the first year of life. For the analysis, we merged over 10 million cohort-linked live birth-infant death records with daily, county-level PM 2.5 concentration data and then fit a Structural Equation Model controlling for several individual- and county-level confounders. We estimated direct paths from the two exposures to infant death as well as indirect paths from the prenatal exposure to the outcome through preterm birth and low birth weight. Prenatal PM 2.5 exposure was positively associated with infant death across all trimesters, although the relationship was strongest in the third trimester. The direct pathway from the prenatal exposure to the outcome accounted for most of this association. Estimates for the post-birth PM 2.5 -infant death relationship were less precise. The results from our study add to a growing literature that provides evidence in favor of the potential harmful effects on human health of low levels of air pollution.

Objective: The primary aim of the study was to examine the relationship between self-reported ethnic identity, region of birth and contraceptive use, in Istanbul, Turkey., Methods: Cross-sectional data from a random sample of 3038 married women of reproductive age living in two urban districts of Istanbul were used in a series of logistic regression models to assess key relationships., Results: Kurdish ethnic minority women were less likely than Turkish ethnic majority women to use traditional contraceptive methods over no method (relative risk ratio [RRR] 0.69; 95% confidence interval [CI] 0.50, 0.96). However, there were no significant differences between ethnicities (i.e., Turkish, Kurdish and other) and modern method use. Among Turkish women, those born in regions farther away from the western region were more likely to use traditional methods (RRR northern 2.06; 95% CI 1.31, 3.22)., Conclusion: While Kurdish ethnic minority women were less likely to use traditional methods, compared with Turkish ethnic majority women, the difference might have been due to the length of time living in a neighbourhood. Regional variations in contraceptive use were concentrated only among Turkish ethnic majority women and for traditional methods. Regional norms of traditional method use may be a barrier to modern contraceptive use in Turkey.

Background: Adolescent pregnancy in Uganda declined from 31% in 2000-01 to 25% in 2006 but thereafter stalled at 25% from 2006 to 2016. This paper investigates the factors associated with the recent stall in the rate of decline of adolescent pregnancy in Uganda., Methods: We used logistic regression models for 4 years (2000-01, 2006, 2011 and 2016) of data from the Uganda Demographic Health Survey to explore proximate and distal factors of adolescent pregnancy in Uganda. We carried out Blinder-Oaxaca decomposition models to explore the contributions of different factors in explaining the observed decline in adolescent pregnancy between 2001 and 2006, and the subsequent stall between 2006 and 2016., Results: We found that marriage among women aged 15-19 years, and early sexual debut, were strongly associated with adolescent pregnancy. These declined substantially between 2000 and 01 and 2006, leading to a decline in adolescent pregnancy. Their decline was in turn associated with rising levels of female education and household wealth. After 2006, education levels and household wealth gains stalled, with associated stalls in the decline of marriage among women aged 15-19 years and sexual debut, and a stall in the decline of adolescent pregnancy., Conclusions: The stall in the decline of adolescent pregnancies in Uganda was linked to a stall in the reduction of adolescent marriage, which in turn was associated with limited progress in female educational attainment between 2006 and 2016. We emphasize the need for a renewed focus on girl's education and poverty reduction to reduce adolescent pregnancy in Uganda and subsequently improve health outcomes for adolescent girls., (© 2021. The Author(s).)

Background: A number of factors may determine family planning decisions; however, some may be dependent on the social and cultural context. To understand these factors, we conducted a qualitative study with family planning providers and community stakeholders in a diverse, low-income neighborhood of Istanbul, Turkey., Methods: We used purposeful sampling to recruit 16 respondents (eight family planning service providers and eight community stakeholders) based on their potential role and influence on matters related to sexual and reproductive health issues. Interviews were audio-recorded with participants' permission and subsequently transcribed in Turkish and translated into English for analysis. We applied a multi-stage analytical strategy, following the principles of the constant comparative method to develop a codebook and identify key themes., Results: Results indicate that family planning decision-making-that is, decision on whether or not to avoid a pregnancy-is largely considered a women's issue although men do not actively object to family planning or play a passive role in actual use of methods. Many respondents indicated that women generally prefer to use family planning methods that do not have side-effects and are convenient to use. Although women trust healthcare providers and the information that they receive from them, they prefer to obtain contraceptive advice from friends and family members. Additionally, attitude of men toward childbearing, fertility desires, characteristics of providers, and religious beliefs of the couple exert considerable influence on family planning decisions., Conclusions: Numerous factors influence family planning decision-making in Turkey. Women have a strong preference for traditional methods compared to modern contraceptives. Additionally, religious factors play a leading role in the choice of the particular method, such as withdrawal. Besides, there is a lack of men's involvement in family planning decision-making. Public health interventions should focus on incorporating men into their efforts and understanding how providers can better provide information to women about contraception., (© 2021. The Author(s).)

Objective: Worldwide unmet need for contraception remains high at 21.6%. As access to health facilities is one of the potential barriers to contraceptive uptake, the aim of our study was to evaluate the effect of distance to a health facility, according to its service availability, on contraceptive uptake among married Turkish women., Methods: To calculate respondents' distance to a health facility, we used data from a household survey conducted among married women, as well as data from a health facility survey conducted among the facilities that were visited for contraceptive services by the respondents. The data were collected from the Istanbul area of Turkey under the Willows Impact Evaluation project in 2018. Health facilities were categorised according to contraceptive availability and the accurate distance from respondents' homes to each type of health facility was calculated. Logistic regression was used to estimate the effect of distance to each type of health facility on uptake of each type of contraception., Results: The prevalence of overall contraceptive use among urban Turkish women was 71.9%. The most common method was withdrawal (32.5%), followed by the intrauterine device (IUD) (14.9%) and male condoms (12.4%). Distance to a health facility that did not provide long-acting contraception was not associated with any type of contraceptive use. On the other hand, distance to a health facility that provided long-acting contraception was negatively associated with the use of long-acting methods such as the IUD but was positively associated with the use of short-acting contraception such as condoms., Conclusion: The effect of distance to a health facility on contraceptive use significantly differed according to contraceptive availability at the facility. Further distance to a health facility that provided long-acting contraception decreased the use of long-acting contraception but had a substitute effect on the use of short-acting contraception. We conclude that when women face an accessibility barrier to the provision of long-acting contraception, they modify their behaviour by shifting from long- to short-acting contraception, which is less effective.

Background: Increasing access to safe abortion methods is crucial for improving women's health. Understanding patterns of service use is important for identifying areas for improvement. Limited evidence is available in Ghana on factors associated with the type of method used to induce abortion. This paper examined the methods and sources of services used for abortion by women living in poor urban settings of Accra., Methods: Data are from a survey that was conducted in 2018 among 1233 women aged 16-44 years who reported ever having had an induced abortion. We estimated a multinomial logistic regression model to examine factors associated with the type of abortion methods women used. We further generated descriptive statistics for the source of abortion services., Results: About 50% women used surgical procedures for their last abortion, 28% used medication abortion (MA), 12% used other pills, 3% used injection, and 7% used non-medical methods. However, nearly half (46%) of the women who terminated a pregnancy within the year preceding the survey used medication abortion (MA), 32% used surgical procedures, while 5% used non-medical methods. Women who terminated a pregnancy within three years preceding the survey had a 60% lower chance of using surgical procedures if they did not use MA compared to those who terminated a pregnancy more than 3 years before the survey (Relative Risk Ratio [RRR] 0.4; 95% CI 0.3-0.5). The vast majority (74%) of women who used MA obtained services from pharmacies., Conclusions: The use of MA pills to terminate pregnancies has increased in recent years in Ghana and these pills are mostly accessed from pharmacies. This suggests a need for a review of the national guidelines to include pharmacists and chemists in the provision of MA services., (© 2021. The Author(s).)

Background: Integration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery., Methods: We applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework., Results: Findings indicated that providers were willing to adopt the intervention and reiterated the importance of postpartum family planning. However, the intervention was not consistently implemented as intended, including provider bias in counselling and lack of attention to women's preferences. Organisational barriers to implementation included time constraints and inadequate training. Providers suggested that a range of paramedical staff be trained in counselling and PPIUD insertion to mitigate barriers and to facilitate scaling up the intervention., Conclusions: To improve and scale up the PPIUD Initiative, training efforts should be expanded to primary and secondary care facilities and implementation strategies better utilised (eg, on-the-job training). The training can be strengthened by improving providers' knowledge of all types of methods and interpersonal communication skills, and emphasising the importance of unbiased, evidence-based contraceptive counselling techniques., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate rates of contraceptive discontinuation and method switching and examine their determinants in Istanbul, Turkey, because discontinuation of modern contraception leading to unintended pregnancy is a public health concern., Methods: We conducted a cross-sectional household survey between March and June 2018 among 4224 married women of reproductive age (16-44 years). Information on contraceptive use and discontinuation for the 31 months preceding the survey was recorded in a monthly calendar. Using single and multiple decrement life-table methods, we calculated the overall discontinuation and the cause-specific discontinuation rates., Results: The 12-month overall discontinuation rate was 12.32%. Intrauterine devices had the lowest discontinuation rate (7.12%). The most common reasons for discontinuation were the desire to become pregnant (6.56%) and method failure (2.76%). One in three episodes of discontinuation was not followed by method switching (32.16%). Age, education, and the method type were predictive of contraceptive discontinuation., Conclusion: To reduce method failure, women should be provided with information about method effectiveness, correct use of methods, and what to do if they anticipate their method failed (e.g., emergency contraception). Programs should focus on improving knowledge about discontinuation and method failure. Contraceptive counseling should also emphasize timely switching to an effective method after discontinuation., (© 2021 International Federation of Gynecology and Obstetrics.)

Recent data suggest increasing rates of emergency contraception (EC) use in Ghana, particularly in urban areas. In 2018, we collected survey data from 3,703 sexually experienced women aged 16-44 years living in low-income settlements of Accra. We estimated the prevalence of lifetime and current EC use. Multivariate logistic regression was used to assess factors associated with current use of EC. Retrospective monthly calendar data on contraceptive use were analyzed to identify patterns of EC use, including repeat and continuous use, and uptake of other contraceptive methods in the months following EC use. Nearly 15 percent of women had ever used EC. About half of recent EC users (52 percent) used EC for at least four months cumulatively within a 12-month window. There was no evidence of adoption of other modern methods in the months after using EC. Our results suggest that EC is a common method for pregnancy prevention in Accra, particularly among young, unmarried, highly educated women. Counseling on effective EC use and strategies that promote equitable access should be prioritized., (© 2021 The Population Council, Inc.)

Introduction: Birth spacing is a critical pathway to improving reproductive health. WHO recommends a minimum of 33-month interval between two consecutive births to reduce maternal, perinatal, infant morbidity and mortality. Our study evaluated factors associated with short birth intervals (SBIs) of less than 33 months between two consecutive births, in Karachi, Pakistan., Methods: We used data from a cross-sectional study among married women of reproductive age (MWRA) who had at least one live birth in the 6 years preceding the survey (N=2394). Information regarding their sociodemographic characteristics, reproductive history, fertility preferences, family planning history and a 6-year reproductive calendar were collected. To identify factors associated with SBIs, we fitted simple and multiple Cox proportional hazards models and computed HRs with their 95% CIs., Results: The median birth interval was 25 months (IQR: 14-39 months), with 22.9% (833) of births occurring within 33 months of the index birth. Women's increasing age (25-30 years (aHR 0.63 (0.53 to 0.75), 30+ years (aHR 0.29, 95% CI 0.22 to 0.39) compared with 20-24 years; secondary education (aHR 0.75, 95% CI 0.63 to 0.88), intermediate education (aHR 0.62, 95% CI 0.48 to 0.80), higher education (aHR 0.69, 95% CI 0.51 to 0.92) compared with no education, and a male child of the index birth (aHR 0.81, 95% CI 0.70 to 0.94) reduced the likelihood of SBIs. Women's younger age <20 years (aHR 1.24, 95% CI 1.05 to 1.24) compared with 20-24 years, and those who did not use contraception within 9 months of the index birth had a higher likelihood for SBIs for succeeding birth compared with those who used contraception (aHR 2.23, 95% CI 1.93 to 2.58)., Conclusion: Study shows that birth intervals in the study population are lower than the national average. To optimise birth intervals, programmes should target child spacing strategies and counsel MWRA on the benefits of optimal birth spacing, family planning services and contraceptive utilisation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Postpartum women have high rates of unmet need for modern contraception in the two years following birth in Nepal. We assessed whether providing contraceptive counseling during pregnancy and/or prior to discharge from the hospital for birth or after discharge from the hospital for birth was associated with reduced postpartum unmet need in Nepal., Methods: We used data from a larger a stepped-wedge, cluster randomized trial, including contraceptive counselling in six tertiary hospitals. Group 1 hospitals (three hospitals) initiated the intervention after three months of baseline data collection, while Group 2 hospitals (three hospitals) initiated the same intervention after nine months. We have enrolled 21,280 women in the baseline interviews and conducted two follow-up interviews with them, one and two years after they had delivered in one of our study hospitals. We estimated the effect of counseling and its timing (pre-discharge, post- discharge, both, or neither) on unmet need for modern contraception in the postpartum period, using random-effects logistic regressions., Results: Unmet need for modern contraception was high (54% at one year and 50% at two years). Women counseled in either the pre-discharge period (Odds ratio [OR] 0·86; 95% CI: 0·80, 0·93) or in the post-discharge period (OR 0·86; 95% CI: 0·79, 0·93) were less likely to have an unmet need in the postpartum period compared to women with no counseling. However, women who received counseling in both the pre- and post-discharge period were 27% less likely than women who had not received counseling to have unmet need (OR 0.73; 95% CI: 0·67, 0·80)., Conclusions: Counseling women either before or after discharge reduces unmet need for postpartum contraception but counseling in both periods is most effective., Competing Interests: The authors have declared that no competing interests exist.

Background: This paper provides estimates of contraceptive discontinuation and failure rates in a poor urban setting in Ghana. Contraceptive use is for the purposes of preventing unintended or mistimed pregnancies. Unfortunately, evidence abounds in many parts of the world where there is considerable levels of contraceptive failure and high levels of discontinuation resulting in unintended pregnancies., Methods: We estimated discontinuation rates during a 12-month period since starting use by applying single and multiple decrement life table methods to the contraceptive calendar data collected in a survey of women in reproductive age of 15-49 years., Results: Modern contraceptive method use was estimated to be 13.7% at the time of the survey. The results show that contraceptive method discontinuation vary markedly by type of contraceptive method but are high for almost all methods, except for implants (23.7%). Discontinuation rate for emergency contraception was estimated at 88.5%, withdrawal 87.6%, and male condom use 80.9%. However, discontinuation rates were moderately high for rhythm (63.6%), pills (65.6%) and injectables (56%). In terms of failure rates, overall contraceptive failure for all methods was estimated at 7.9%. The factors significantly associated with method failure include being within age bracket 40-44 years (OR = 0.3, p < 0.05), having secondary/higher education (OR = 0.4, p < 0.01), belonging to the richest household wealth scale (OR = 3.3, p < 0.01), currently in union with a partner (OR = 2.2, p < 0.01), and using contraceptive methods such as rhythm (OR = 5.6, p < 0.01) and withdrawal (OR = 3.7, p < 0.01). On the flip side, the odds for method discontinuation were significantly higher for women in their 20s and mid 30s, formerly in union (OR = 1.9, p < 0.05) and use of withdrawal method (OR = 1.4, p < 0.05) and lower for women formerly in union (OR = 0.4, p < 0.01) and use of implants (OR = 0.2, p < 0.01) and injectables (OR = 0.6, p < 0.01)., Conclusion: While contraceptives use is low, both discontinuation and failure rates are high and variable among different methods. Failure and discontinuation rates are lowest for long-acting methods such as implants while higher failure rates are more prevalent among women who rely on withdrawal and the rhythm methods.

Background: Data collection is the most critical stage in any population health study and correctly implementing fieldwork enhances the quality of collected information. However, even the most carefully planned large-scale household surveys can encounter many context-specific issues. This paper reflected on our research team's recent experience conducting surveys for a quasi-experimental evaluation of a reproductive health program in urban areas of Karachi, Pakistan. We aim to describe the issues encountered and lessons learned from this process, and present some potential solutions for conducting future household surveys in similar urban environments., Methods: The study followed a three-stage random sampling design. Initially, a Geographical Information System (GIS) was used to construct the sampling frame with union council (UC) area mapping and cluster demarcation followed by random selection of clusters in the selected UCs within the intervention and control sites. The second stage involved a complete household listing in selected clusters and the final stage was a random sampling of households with eligible women., Result: This paper describes the issues that were encountered including technical problems related to GIS demarcation of cluster boundaries and hand-held devices for computer assisted personal interviews (CAPI), household listing, interviewing respondents on sensitive topics and their expectations, and ensuring privacy during the survey., Conclusion: This study identifies a number of unique barriers to conducting household surveys in Karachi and highlights some key lessons for survey research in urban settlements. GIS mapping technology is a cost-effective method for developing sampling frames in resource-constrained settings. Secondly, the strategy of interviewing women immediately after the cluster is listed may be applied to make it easier to re-locate selected respondents and to reduce loss-to-follow up. Understanding local norms and developing culturally appropriate strategies to build trust with communities may significantly improve survey participation. Researchers should hire experienced female enumerators and provide continuous training on best practices for interviewing women on sensitive reproductive health topics in urban communities.

Community-based demand-generation family planning programmes have been associated with increased contraceptive use in rural areas of Ghana. However, rigorous evaluations of such programmes in urban contexts are lacking. We used a retrospective, cross-sectional with comparison group design to estimate the immediate and sustained impact of the Willows intervention on modern contraceptive use in Kumasi, Ghana. The Willows intervention is a home-based counselling and referral programme for women in low-income urban settlements. We analysed data from a cross-sectional representative survey of 1205 women of reproductive age in the intervention area and 1108 women in a matched comparison site. The main outcome was women's reported contraceptive use at: (1) baseline (January 2013); (2) programme close (December 2016); and (3) follow-up (August to October 2018). We estimated the programme effect at the community level and for women who reported receiving a family planning counselling visit. We used coarsened exact matching to assess the impact of the intervention relative to outcomes for matched comparison women. Comparing those who reported a family planning visit in the intervention area with matched comparison area women who reported no visit, we estimated a 10.5 percentage point increase in use of modern contraceptives from baseline to close (95%CI : 6.2, 14.8; P < 0.001) and a 7.6 percentage point increase from baseline to follow-up (95%CI : 3.3, 11.9; P < 0.001). However, only 20.2% of women in the Willows intervention area reported a visit. The Willows intervention, therefore, did not achieve its aim to reach all reproductive-aged women in the community. At the community level, we found no significant effect of the intervention at either programme close or 2 years later. We recommend that similar community-based interventions strive for greater outreach and simultaneously launch robust prospective impact evaluations., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Objectives: All Tanzanian abortion estimates rely on health facility data that do not take into account completely the incidence of abortion. This papers aims to estimate the lifetime incidence of induced abortion in Arusha, Tanzania via direct and double list-experiment methods using community data and evaluate outcomes and behaviors of women who had an abortion., Methods: From January to May 2018, a face-to-face interview survey was conducted on a representative sample of sexually active women (n = 3658) living in Arusha, Tanzania. Participants were selected in a three-stage random process and questions were asked about reproductive history, contraceptive use, and health seeking behaviors. A direct question and double list-experiment was used to estimate lifetime incidence of abortion., Results: Lifetime abortion incidence was 3% using the direct question compared to 7.7% using the double list-experiment method. However, post-estimation tests revealed a key study design violation thus invalidating list the experiment estimate. We find that 45% of women received their abortion outside the formal health care system, the most frequent method used was manyono pill (traditional medicine), and only 50% of women who experienced abortion complications sought treatment., Conclusions: We provide another example of the performance of list experiment in measuring abortion incidence. Nearly half of reported abortions took place outside of the formal health system highlighting the substantial underestimation while using facility data to measure abortion. Seeking health care for potential complications was low despite post-abortion care services being free and legal in Tanzania., Implications: Using administrative data to estimate lifetime incidence of abortion is inaccurate as we found half of our sample received abortions outside a health facility. Women should be encouraged to seek post-abortion care, when needed., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Context: Providers' and women's characteristics are associated with postpartum copper IUD (PPIUD) outcomes, but the relationship between providers' level of experience and PPIUD expulsion and discontinuation has not been established., Methods: Data on 1,232 women and 118 providers who took part in a randomized trial of a PPIUD counselling and provision intervention in Nepal between 2015 and 2017 were used to identify associations between providers' and women's characteristics and PPIUD outcomes. Multinomial logistic regression models were used to estimate PPIUD expulsion and discontinuation risks at two years after insertion., Results: Thirteen percent of women had had partial or complete expulsions and 29% had discontinued PPIUD use by two years. Having a provider who had done at least 10 previous insertions was associated with lower risk of expulsion rather than continuation (relative risk ratio, 0.5) relative to having a less-experienced provider. Women had a higher risk of both expulsion and discontinuation relative to continuation if they were younger than 21 rather than aged 26-30 (2.4 and 1.7, respectively) or if they belonged to the Dalit rather than Brahmin caste (2.2 and 1.9, respectively). Women whose husbands did not live at home also had elevated discontinuation risks., Conclusion: The findings highlight the need for increased training and supervision of providers during their first 10 PPIUD insertions. Counselling on risk of expulsion may especially benefit younger and Dalit women, and should include partners and other family members to avoid any stigma surrounding PPIUD use by women whose partner is away from home for a prolonged period.

Context: Abortion is particularly difficult to measure, especially in legally restrictive settings such as Pakistan. The List Experiment-a technique for measuring sensitive health behaviors indirectly-may minimize respondents' underreporting of abortion due to stigma or legal restrictions, but has not been previously applied to estimate abortion prevalence in Pakistan., Methods: A sample of 4,159 married women of reproductive age were recruited from two communities of Karachi in 2018. Participants completed a survey that included a double list experiment to measure lifetime abortion prevalence, as well as direct questions about abortion and other background characteristics. Data were used to calculate direct and indirect estimates of abortion prevalence for the overall sample and by sociodemographic characteristics, as well as to test for a design effect. Regression analyses were conducted to examine associations between characteristics and abortion reporting from direct questioning and the list experiment., Results: The estimate of abortion prevalence from the list experiment was 16%; the estimate from the direct question was 8%. No evidence of a design effect was found. Abortion reporting was associated with most selected characteristics in the regression model for direct questioning, but with few in the list experiment models., Conclusions: That the estimate of abortion prevalence in Karachi generated from the list experiment was twice that generated from direct questioning suggests that the indirect method reduced underreporting, and may have utility to estimate abortion in similar settings and to improve the accuracy of data collecting for other sensitive health topics.

In Africa, high discontinuation of contraceptive use is thwarting goals for healthy birth spacing or limiting childbearing. This paper investigates how well the contraception program is addressing the needs of women and couples in the Arusha region, Tanzania by studying contraceptive use continuation. We measured the overall and method-specific discontinuation rate, reasons for discontinuation, post-discontinuation reproductive behaviours/outcomes, and examined the determinants of contraceptive discontinuation. We used data from a household survey conducted in Arusha from January to May 2018. Information on contraceptive use during the 31 months preceding the survey was recorded in a monthly calendar. Using the single- and multiple-decrement life-table approach, we calculated the overall and cause-specific discontinuation of contraceptive methods. Logistic regression was used to evaluate the determinants of discontinuation. The 12-month overall discontinuation of contraceptive use was 44.6%. Discontinuation was lowest for implants (12.3%) and highest for male condoms (60.1%), the most common reason being side effects (11.7%). 59.8% of women who discontinued did not switch to another method within 3 months following discontinuation and 20.9% experienced pregnancy. Longer distance to a health facility is associated with higher discontinuation of hormonal methods such as injectables, but lower discontinuation of non-hormonal methods such as condoms. Discontinuation due to side effects is not explained by most of the women's background characteristics other than the method they used. Discontinuation of contraception is high among Arusha women. Effective contraception programs, especially improved counselling, need to address the reasons for the discontinuation of contraceptive use.

Objectives: To assess: (1) the impact of a reproductive health program on modern contraceptive use from baseline to program close; (2) the sustained impact from baseline to follow-up 36 months later; and (3) the exposure-adjusted impact at program close and follow-up., Design: Retrospective, cross-sectional matched control study., Setting: Karachi, Pakistan., Participants: 2561 married women aged 16-49 years., Interventions: The Willows Program, a community-based family planning counselling and referral program implemented from 2013 to 2015., Primary and Secondary Outcome Measures: The primary outcome was community-level modern contraceptive prevalence rate (mCPR), measured for January 2013 (baseline), June 2015 (program close) and at follow-up 36 months later. A secondary outcome was exposure-adjusted mCPR (among women reporting a family planning home visit) at program close and at follow-up., Results: There was no significant effect on community-level mCPR at program close (2.4 percentage point increase in intervention over comparison; 95% CI -2.2 to 7.0) or at follow-up (1.9 percentage point decrease; 95% CI -6.7 to 2.8). Only 18% of women in the intervention area reported receiving a family planning visit in the preceding 5 years. Among those reporting a visit, we observed a significant 10.3 percentage point increase (95% CI 4.6 to 15.9) from baseline to close, and a non-significant 2.0 percentage point increase (95% CI -3.8 to 7.8) from baseline to follow-up, relative to matched women in the comparison area. The cost per new modern method user was US$1089, while the cost per user-year during the intervention period was US$455., Conclusions: The program had a positive short-term effect on women who received a family planning visit; however, this effect was not sustained. Program coverage was low and did not significantly increase community-level family planning use. Findings highlight the need to increase community coverage of high-quality counselling and contextually relevant interventions for family planning demand generation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The World Health Organization recommends that a woman waits at least 24 months after a live birth before getting pregnant again; however, an estimated 25% of birth intervals in low-income countries do not meet this recommendation for adequate birth spacing, and the unmet need for postpartum family planning (PPFP) services is high. Few randomized controlled trials have assessed the causal impact of access to PPFP services, and even fewer evaluations have investigated how such interventions may affect postpartum contraceptive use, birth spacing, and measures of health and well-being., Objective: This protocol paper aims to describe a randomized controlled trial that is being conducted to identify the causal impact of an intervention to improve access to PPFP services on contraceptive use, pregnancy, and birth spacing in urban Malawi. The causal effect of the intervention will be determined by comparing outcomes for respondents who are randomly assigned to an intervention arm against outcomes for respondents who are randomly assigned to a control arm., Methods: Married women aged 18-35 years who were either pregnant or had recently given birth were randomly assigned to either the intervention arm or control arm. Women assigned to the intervention arm received a package of services over a 2-year intervention period. Services included a brochure and up to 6 home visits from trained family planning counselors; free transportation to a high-quality family planning clinic; and financial reimbursement for family planning services, consultations, and referrals for services. Two follow-up surveys were conducted 1 and 2 years after the baseline survey., Results: A total of 2143 women were randomly assigned to either the intervention arm (n=1026) or the control arm (n=1117). Data collection for the first follow-up survey began in August 2017 and was completed in February 2018. A total of 1773 women, or 82.73% of women who were eligible for follow-up, were successfully contacted and reinterviewed at the first follow-up. Data collection for the second follow-up survey began in August 2018 and was completed in February 2019. A total of 1669 women, or 77.88% of women who were eligible for follow-up, were successfully contacted and reinterviewed at the second follow-up. The analysis of the primary outcomes is ongoing and is expected to be completed in 2021., Conclusions: The results of this trial seek to fill the current knowledge gaps in the effectiveness of family planning interventions on improving fertility and health outcomes. The findings also show that the benefits of improving access to family planning are likely to extend beyond the fertility and health domain by improving other measures of women's well-being., Trial Registration: American Economics Association Registry Trial Number AEARCTR-0000697; https://www.socialscienceregistry.org/trials/697 Registry for International Development Impact Evaluations (RIDIE) Trial Number RIDIE-STUDY-ID-556784ed86956; https://ridie.3ieimpact.org/index.php?r=search/detailView&id=320., International Registered Report Identifier (irrid): DERR1-10.2196/16697., (©Mahesh Karra, David Canning. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 14.08.2020.)

Objective: There is high unmet need for family planning in the postpartum period in Nepal. The current study assessed the effects of a contraceptive counseling and postpartum intrauterine device (PPIUD) insertion intervention on use of contraception in the postpartum period., Study Design: We utilized a cluster, stepped-wedge design to randomly assign two hospital clusters (compromised of six hospitals) to begin the intervention at time one or time two. From 2015 to 2017, women completed surveys after delivery but before discharge (n = 75,893), and then at one year and two years postpartum. We estimated the intent-to-treat effect of the intervention using weighted, linear probability models and the adherence-adjusted effect (antenatal counseling) using an instrumental variable approach. Outcomes included modern contraceptive use and method mix measured at one and two years postpartum in a sample of 19,298 women (year I follow-up sample) and a sample of 19,248 women (year II follow-up sample). We used inverse probability weights to adjust for incomplete follow-up and bootstrap methods to give correct causal inference with the small number of six clusters., Results: The intervention increased use of modern contraceptives by 3.8 percentage points [95% CI: -0.1, 9.5] at one-year postpartum, but only 0.3 percentage points [95% CI: -3.7, 4.1] at two years. The intervention significantly increased the use of PPIUDs at one year and two years postpartum, but there was less use of sterilization. Only 42% of women were counseled during the intervention period. The adherence-adjusted effects (antenatal counseling) were four times larger than the intent-to-treat effects., Conclusions: Providing counseling during the antenatal period and PPIUD services in hospitals increased use of PPIUDs in the one- and two-year postpartum period and shifted the contraceptive method mix., Implications: In order for antenatal counseling to increase postpartum contraceptive use, counseling may need to be provided in a wider range of prenatal care settings and at multiple time points. Healthcare providers should be trained on contraceptive counseling and PPIUD insertion, with the goal of expanding the available method mix and meeting postpartum women's contraceptive needs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The World Health Organization recommends postpartum family planning (PPFP) for healthy birth spacing. This study is an evaluation of an intervention that sought to improve women's access to PPFP in Tanzania. The intervention included counseling on PPFP during antenatal and delivery care and introducing postpartum intrauterine device (PPIUD) insertion as an integrated part of delivery services for women electing PPIUD in the immediate postpartum period., Methods: This cluster-randomized controlled trial recruited 15,264 postpartum Tanzanian women aged 18 or older who delivered in one of five study hospitals between January and September 2016. We present the effectiveness of the intervention using a difference-in-differences approach to compare outcomes, receipt of PPIUD counseling and choice of PPIUD after delivery, between the pre- and post-intervention period in the treatment and control group. We also present an intervention adherence-adjusted analysis using an instrumental variables estimation., Results: We estimate linear probability models to obtain effect sizes in percentage points (pp). The intervention increased PPIUD counseling by 19.8 pp (95% CI: 9.1 - 22.6 pp) and choice of PPIUD by 6.3 pp (95% CI: 2.3 - 8.0 pp). The adherence-adjusted estimates demonstrate that if all women had been counseled, we would have observed a 31.6 pp increase in choice of PPIUD (95% CI: 24.3 - 35.8 pp). Among women counseled, determinants of choosing PPIUD included receiving an informational leaflet during counseling and being counseled after admission for delivery services., Conclusions: The intervention modestly increased the rate of PPIUD counseling and choice of PPIUD, primarily due to low coverage of PPIUD counseling among women delivering in study facilities. With universal PPIUD counseling, large increases in choice of PPIUD would have been observed. Giving women informational materials on PPIUD and counseling after admission for delivery are likely to increase the proportion of women choosing PPIUD., Trial Registration: Registered with clinicaltrials.gov (NCT02718222) on March 24, 2016, retrospectively registered.

Context: Many community-based reproductive health programs use their program data to monitor progress toward goals. However, using such data to assess programmatic impact on outcomes such as contraceptive use poses methodological challenges. Inverse probability weighting (IPW) may help overcome these issues., Methods: Data on 33,162 women collected in 2013-2015 as part of a large-scale community-based reproductive health initiative were used to produce population-level estimates of the contraceptive prevalence rate (CPR) and modern contraceptive prevalence rate (mCPR) among married women aged 15-49 in Pakistan's Korangi District. To account for the nonrandom inclusion of women in the sample, estimates of contraceptive prevalence during the study's four seven-month intervention periods were made using IPW; these estimates were compared with estimates made using complete case analysis (CCA) and the last observation carried forward (LOCF) method-two approaches for which modeling assumptions are less flexible., Results: In accordance with intervention protocols, the likelihood that women were visited by intervention personnel and thus included in the sample differed according to their past and current contraceptive use. Estimates made using IPW suggest that the CPR increased from 51% to 64%, and the mCPR increased from 34% to 53%, during the study. For both outcomes, IPW estimates were higher than CCA estimates, were generally similar to LOCF estimates and yielded the widest confidence intervals., Conclusion: IPW offers a powerful methodology for overcoming estimation challenges when using program data that are not representative of the population in settings where cost impedes collection of outcome data for an appropriate control group.

Introduction: Studies on the determinants of contraceptive use often consider distance to the nearest health facility offering contraception as a key explanatory variable. Women, however, may not seek contraception from the nearest facility, rather opting for a more distant facility with better quality services or to ensure greater privacy and anonymity., Methods: The dataset used include the name of facility where each women obtained contraception, measures of facility quality, and the distance between each woman's home and 39 potential facilities she might visit. We use a conditional-multinomial logit model to estimate the determinants of her facility choice to visit and how women tradeoff travelling longer distances to use higher quality facilities., Results: Only 33% of woman who received contraception from a health facility used their nearest facility. While the nearest facility was 1.2 km away, the average distance to facility used was 2.9 km, indicating women are willing to travel significantly longer distances for higher quality. Women prefer facilities that specialise in providing contraception, provide a large range of methods, do not suffer from stock outs and do not charge fees. Furthermore, on average, women are willing to travel an additional 2 km for a facility that offers more family planning methods, 4.7 km for a facility without one additional health service, 9 km for a facility without fees for contraception and 11 km for a facility not experiencing stock out of an additional contraception., Conclusion: Our results suggest that quality of services provided is an important driver of facility choice in addition to distance to facility., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Abortions are difficult to measure; yet, accurate estimates are critical in developing health programs. We implemented and tested the validity of a list experiment of lifetime abortion prevalence in Istanbul, Turkey. We complemented our findings by understanding community perspectives using in-depth interviews with key informants., Methods: We conducted a household survey between March and June 2018. In a random sample of 4040 married women aged 16-44 years, we implemented a double list experiment. We averaged difference in mean values calculations between the average counts for each list to provide an estimated lifetime abortion prevalence. We conducted in-depth interviews with 16 key informants to provide insights into possible explanations for the quantitative results., Results: The abortion prevalence estimate from the list experiment was close to that of the direct question (3.25% vs 2.97%). Key informant narratives suggest that differing definitions of abortion, inaccessibility, provider bias, lack of knowledge of abortion laws and safety, and religious norms could contribute to under-reporting. Results from the qualitative study suggest that abortion is largely inaccessible and highly stigmatized., Conclusion: Measuring experiences of abortion is critical to understanding women's needs and informing harm-reduction strategies; however, in highly stigmatized settings, researchers may face unique challenges in obtaining accurate reports.

Propagation losses in transmission media limit the transmission distance of optical signals. In the case where the signal is made up of quantum optical states, conventional deterministic optical amplification schemes cannot be used to increase the transmission distance as the copying of an arbitrary and unknown quantum state is forbidden. One strategy that can offset propagation loss is the use of probabilistic, or non-deterministic, amplification schemes - an example of which is the state comparison amplifier. Here we report a state comparison amplifier implemented in a compact, fiber-coupled femtosecond laser-written waveguide chip as opposed to the large, bulk-optical components of previous designs. This pathfinder on-chip implementation of the quantum amplifier has resulted in several performance improvements: the polarization integrity of the written waveguides has resulted in improved visibility of the amplifier interferometers; the potential of substantially-reduced losses throughout the amplifier configuration; and a more compact and environmentally-stable amplifier which is scalable to more complex networks.

Background: Many low- and middle-income countries are experiencing high and increasing exposure to ambient fine particulate air pollution (PM2.5). The effect of PM2.5 on infant and child mortality is usually modelled using concentration response curves extrapolated from studies conducted in settings with low ambient air pollution, which may not capture its full effect., Methods: We pool data on more than half a million births from 69 nationally representative Demographic and Health Surveys that were conducted in 43 low- and middle-income countries between 1998 and 2014, and we calculate early-life exposure (exposure in utero and post partum) to ambient PM2.5 using high-resolution calibrated satellite data matched to the child's place of residence. We estimate the association between the log of early-life PM2.5 exposure, both overall and separated by type, and the odds of neonatal and infant mortality, adjusting for child-level, parent-level and household-level characteristics., Results: We find little evidence that early-life exposure to overall PM2.5 is associated with higher odds of mortality relative to low exposure to PM2.5. However, about half of PM2.5 is naturally occurring dust and sea-salt whereas half is from other sources, comprising mainly carbon-based compounds, which are mostly due to human activity. We find a very strong association between exposure to carbonaceous PM2.5 and infant mortality, particularly neonatal mortality, i.e. mortality in the first 28 days after birth. We estimate that, at the mean level of exposure in the sample to carbonaceous PM2.5-10.9 µg/m3-the odds of neonatal mortality are over 50% higher than in the absence of pollution., Conclusion: Our results suggest that the current World Health Organization guideline of limiting the overall ambient PM2.5 level to less than 10 µg/m³ should be augmented with a lower limit for harmful carbonaceous PM2.5., (© The Author(s) 2019; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Background: The International Federation of Gynaecology and Obstetrics (FIGO), in collaboration with the Sri Lankan College of Obstetrics and Gynaecologists (SLCOG), launched an initiative in 2014 to institutionalize immediate postpartum IUD (PPIUD) services as a routine part of antenatal counseling and delivery room services in Sri Lanka. In this study, we evaluate the effect of the FIGO-SLCOG PPIUD intervention in six hospitals by means of a cluster-randomized stepped-wedge trial., Methods/design: Six hospitals were randomized into two groups of three using matched pairs. Following a 3-month baseline period, the intervention was administered to the first group, while the second group received the intervention after 9 months of baseline data collection. We collected data from 39,084 women who delivered in these hospitals between September 2015 and January 2017. We conduct an intent-to-treat (ITT) analysis to determine the impact of the intervention on PPIUD counseling and choice of PPIUD, as measured by consent to receive a PPIUD, as well as PPIUD uptake (insertion following delivery). We also investigate how factors related to counseling, such as counseling timing and quality, are linked to choice of PPIUD., Results: We find that the intervention increased rates of counseling, from an average counseling rate of 12% in all hospitals prior to the intervention to an average rate of 51% in all hospitals after the rollout of the intervention (0.307; 95% CI 0.148-0.465). In contrast, we find the impact of the intervention on choice of PPIUD to be less robust and mixed, with 4.1% of women choosing PPIUD prior to the intervention compared to 9.8% of women choosing PPIUD after the rollout of the intervention (0.027; 95% CI 0.000-0.054)., Conclusions: This study demonstrates that incorporating PPIUD services into postpartum care is feasible and potentially effective. Taking the evidence on both counseling and choice of PPIUD together, we find that the intervention had a generally positive impact on receipt of PPIUD counseling and, to a lesser degree, on choice of the PPIUD. Nevertheless, it is clear that the intervention's effectiveness can be improved to be able to meet the demand for postpartum family planning of women., Trial Registration: ClinicalTrials.gov, NCT02718222 . Registered on 11 March 2016 (retrospectively registered).

Background: In Nepal, 54% of women have an unmet need for family planning within the 2 years following a birth. Provision of a long-acting and reversible contraceptive method at the time of birth in health facilities could improve access to postpartum family planning for women who want to space or limit their births. This paper examines the impact of an intervention that introduced postpartum contraceptive counseling in antenatal care and immediate postpartum intra-uterine device (PPIUD) insertion services following institutional delivery, with the intent to eventually integrate PPIUD counseling and insertion services as part of routine maternity care in Nepal., Methods: This study took place in six large tertiary hospitals. All women who gave birth in these hospitals in the 18-month period between September 2015 and March 2017 were asked to participate. A total of 75,587 women (99.6% consent rate) gave consent to be interviewed while in postnatal ward after delivery and before discharge from hospital. We use a stepped-wedge cluster randomized design with randomization of the intervention timing at the hospital level. The baseline data collection began prior to the intervention in all hospitals and the intervention was introduced into the hospitals in two steps, with first group of three hospitals implementing the intervention 3 months after the baseline had begun, and second group of three hospitals implementing the intervention 9 months after the baseline had begun. We estimate the overall effect using a linear regression with a wild bootstrap to estimate valid standard errors given the cluster randomized design. We also estimate the effect of being counseled on PPIUD uptake., Results: Our Intent-to-Treat analysis shows that being exposed to the intervention increased PPIUD counseling among women by 25 percentage points (pp) [95% CI: 14-40 pp], and PPIUD uptake by four percentage points [95% CI: 3-6 pp]. Our adherence-adjusted estimate shows that, on average, being counseled due to the intervention increased PPIUD uptake by about 17 percentage points [95% CI: 14-40 pp]., Conclusions: The intervention increased PPIUD counseling rates and PPIUD uptake among women in the six study hospitals. If counseling had covered all women in the sample, PPIUD uptake would have been higher. Our results suggest that providing high quality counseling and insertion services generates higher demand for PPIUD services and could reduce unmet need., Trial Registration: Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Objectives: To investigate the associations between household wealth, household consumption, and chronic disease risk behaviors among older adults in rural South Africa., Methods: Data were from baseline assessments of 5059 adults aged ≥ 40 in the population-based "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" in 2015. Confounder-adjusted prevalence ratios were estimated for the associations between each of household wealth and household consumption quintiles with low moderate-to-vigorous physical activity (MVPA), current smoking, frequent alcohol intake, and overweight/obese body mass index (BMI)., Results: Low MVPA and overweight/obese BMI were common (57% and 58%, respectively), and linearly increased in prevalence across household wealth quintiles. Low MVPA decreased and overweight/obese BMI increased in prevalence across household consumption quintiles. Smoking and frequent alcohol intake were rare (9% and 6%, respectively); they decreased in prevalence across wealth quintiles, but did not vary by consumption quintile., Conclusions: Chronic disease risk behaviors are socioeconomically graded among older, rural South African adults. The high prevalence of overweight and obesity in rural South Africa is a public health concern requiring urgent attention.

We quantify the importance of health disparities in explaining consumption differences at older ages by estimating a panel VAR model of elderly consumption, health, and mortality using data from the Health and Retirement Study. We use the estimated model and initial joint distribution of health and consumption to simulate elderly life-cycle paths and construct a measure of the net present value of expected remaining lifetime consumption at age sixty (NPVC). We first document a steep education gradient in elderly lifetime consumption. We then decompose the gradient in NPVC to quantify the effect of 1) differences in the health distribution at age sixty and 2) differential health and mortality transitions after age sixty. Our decomposition results suggest that roughly 10-12% of the education gradient in NPVC at age sixty could be closed by eliminating elderly health differences.

A common approach when studying inequalities in health is to use a wealth index based on household durable goods as a proxy for socio-economic status. We test this approach for elderly health using data from an aging survey in a rural area of South Africa and find much steeper gradients for health with consumption adjusted for household size than with the wealth index. These results highlight the importance of the measure of socioeconomic status used when measuring health gradients, and the need for direct measures of household consumption or income in ageing studies., Competing Interests: Conflicts of interest: Dr. Riumallo-Herl, Professor Canning, and Dr. Kabudula report grants from National Institute of Aging, during the conduct of the study.

Context: Ethnic and linguistic concordance are important dimensions of the patient-physician relationship, and are linked to health care disparities. However, evidence on the associations between health behavior and outcomes and patient-provider concordance is limited, especially in low- and middle-income settings., Methods: To examine how concordance between women and their primary health midwife is associated with women's receipt of postpartum IUD counseling, observational data from a cluster-randomized trial assessing an intervention to increase postpartum IUD counseling were used. Data on 4,497 women who delivered at six hospitals in Sri Lanka between September 2015 and March 2017 were merged with data on 245 primary health midwives, and indicators of linguistic concordance, ethnic concordance and their interaction were generated. Multivariate logistic regression analyses were used to assess the associations between concordance and women's receipt of counseling., Results: Women from non-Sinhalese groups in Sri Lanka face disparities in the receipt of postpartum IUD counseling. Compared with the ethnolinguistic majority (Sinhalese women who speak only Sinhala), non-Sinhalese women have lower odds of having received postpartum IUD counseling, whether they speak both Sinhala and Tamil (odds ratio, 0.6) or only Tamil (0.5). Ethnic discordance- rather than linguistic discordance-is the primary driver of this disparity., Conclusions: The findings highlight the need for interventions that aim to bridge the sociocultural gaps between providers and patients. Matching women and their providers on ethnolinguistic background may help to reduce disparities in care.