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Abstract Background Low use of modern methods of contraception has been linked to HIV seropositivity and to migration, but few studies have evaluated the intersection of both risk factors with contraceptive use. Methods We analyzed cross-sectional data from sexually active female participants aged 15 to 49 years in the Rakai Community Cohort Study (RCCS) between 2011 and 2013. The RCCS is an open population-based census and individual survey in south-central Uganda. Recent in-migrants (arrival within approximately 1.5 years) into RCCS communities were identified at time of household census. The primary outcome was unsatisfied demand for a modern contraceptive method (injectable, oral pill, implant, or condom), which was defined as non-use of a modern contraceptive method among female participants who did not want to become pregnant in the next 12 months. Poisson regression models with robust variance estimators were used to identify associations and interactions between recent migration and HIV serostatus on unsatisfied contraceptive demand. Results There were 3,417 sexually active participants with no intention of becoming pregnant in the next year. The mean age was 30 (± 8) years, and 17.3% (n = 591) were living with HIV. Overall, 43.9% (n = 1,500) were not using any modern contraceptive method. Recent in-migrants were somewhat more likely to have unsatisfied contraceptive demand as compared to long-term residents (adjusted prevalence risk ratio [adjPRR] = 1.14; 95% confidence interval [95%CI]: 1.02–1.27), whereas participants living with HIV were less likely to have unsatisfied contraceptive demand relative to HIV-seronegative participants (adjPRR = 0.80; 95%CI = 0.70–0.90). When stratifying on migration and HIV serostatus, we observed the highest levels of unsatisfied contraceptive demand among in-migrants living with HIV (48.7%); however, in regression analyses, interaction terms between migration and HIV serostatus were not statistically significant. Conclusions Unsatisfied contraceptive demand was high in this rural Ugandan setting. Being an in-migrant, particularly among those living with HIV, was associated with higher unsatisfied contraceptive demand.

Objectives: To estimate levels of person-centered contraceptive counseling among current and recent contraceptive users, assess for whom counseling differs, and examine the relationship between counseling and contraceptive practices, specifically use of provider-dependent methods and use of one’s preferred method, among women in Ethiopia. Study design: This cross-sectional study uses nationally representative data collected by the Performance Monitoring for Action Ethiopia project among current and recent contraceptive users (n = 2731) aged 15–49 between October and November 2021. Descriptive analyses estimated person-centered counseling levels via the recently validated quality of contraceptive counseling short scale (QCC-10). Bivariable and multivariable logistic regression estimated associations with contraceptive practices. Results: Contraceptive users in Ethiopia receive moderate quality counseling (mean QCC-10 score=2.69, range: 1.1–4.0) with significant social inequities in the receipt of person-centered care. Women who are younger, uneducated, not in union, from poorer households, or who sourced their method from a non-public facility reported less person-centered care. Strong relationships were observed between higher quality counseling and women’s contraceptive practices. Those receiving highest quality counseling had nearly double the odds of using provider-dependent methods compared to those reporting lowest quality counseling (AOR: 1.92; 95% CI: 1.16–3.18). Among current users, women reporting highest quality counseling had 62% higher odds of using their preferred method relative to women receiving poorest quality care (95% CI: 1.06–2.48). Conclusion: Poorer quality care is associated with use of non-preferred methods and reliance on provider-independent methods. Efforts to reduce reproductive health disparities and promote contraceptive autonomy should prioritize a person-centered approach to contraceptive counseling for all. Implications: Inequitable delivery of person-centered contraceptive care based on individuals’ sociodemographic characteristics, such as education or marital status, undermines women’s reproductive autonomy and hinders contraceptive experiences. Person-centered contraceptive counseling should be provided to all women in Ethiopia, regardless of their background, to support individuals in achieving their reproductive goals.

IntroductionThe challenge of achieving maternal and neonatal health-related goals in developing countries is significantly impacted by high fertility rates, which are partly attributed to limited access to family planning and access to the healthcare systems. The most widely used indicator to monitor family planning coverage is the proportion of women in reproductive age using contraception (CPR). However, this metric does not accurately reflect the true family planning coverage, as it fails to account for the diverse needs of women in reproductive age. Not all women in this category require contraception, including those who are pregnant, wish to become pregnant, sexually inactive, or infertile. To effectively address the contraceptive needs of those who require it, this study aims to estimate family planning coverage among this specific group. Further, we aimed to explore the geographical variation and factors influencing contraceptive uptake of contraceptive use among those who need.MethodWe used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) survey of women of reproductive age and the service delivery point (SDP) survey conducted in 2019. A total of 4,390 women who need contraception were considered as the analytical sample. To account for the study design, sampling weights were considered to compute the coverage of modern contraceptive use disaggregated by socio-demographic factors. Bayesian geostatistical modeling was employed to identify potential factors associated with the uptake of modern contraception and produce spatial prediction to unsampled locations.ResultThe overall weighted prevalence of modern contraception use among women who need it was 44.2% (with 95% CI: 42.4%-45.9%). Across regions of Ethiopia, contraceptive use coverage varies from nearly 0% in Somali region to 52.3% in Addis Ababa. The average nearest distance from a woman's home to the nearest SDP was high in the Afar and Somali regions. The spatial mapping shows that contraceptive coverage was lower in the eastern part of the country. At zonal administrative level, relatively high (above 55%) proportion of modern contraception use coverage were observed in Adama Liyu Zone, Ilu Ababor, Misrak Shewa, and Kefa zone and the coverage were null in majority of Afar and Somali region zones. Among modern contraceptive users, use of the injectable dominated the method-mix. The modeling result reveals that, living closer to a SDP, having discussions about family planning with the partner, following a Christian religion, no pregnancy intention, being ever pregnant and being young increases the likelihood of using modern contraceptive methods.ConclusionAreas with low contraceptive coverage and lower access to contraception because of distance should be prioritized by the government and other supporting agencies. Women who discussed family planning with their partner were more likely to use modern contraceptives unlike those without such discussion. Thus, to improve the coverage of contraceptive use, it is very important to encourage/advocate women to have discussions with their partner and establish movable health systems for the nomadic community.

Objectives Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal.Methods We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred.Findings The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day.Conclusion Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals.

# Background Facility readiness is an important prerequisite for providing safe, effective childbirth care. This study assesses the readiness of health facilities in Ethiopia to provide childbirth services, describes variations in geographic access to service-ready facilities, and evaluates how facility readiness relates to childbirth service usage with a lens on equity. # Methods The study used cross-sectional data from a nationally representative sample of households in Ethiopia linked with data from health facilities serving the same areas. We explored variation in childbirth service readiness across facilities and classified facilities as "service-ready" if they had a readiness score of 0.75 or higher on a 0-1 scale. We used logistic regression modeling to examine the odds of residing within 10 kilometers of a service-ready facility by socioeconomic and geographic characteristics, and the odds of a facility delivery given the readiness of nearby facilities. # Results Childbirth service readiness was generally high for hospitals (median score: 0.92) with minimal variation (interquartile range, IQR: 0.88 to 0.96). Health centers and clinics displayed lower and more variable readiness (median: 0.75, IQR: 0.66 to 0.84). In both crude and adjusted regression analyses, odds of residing within 10 kilometers of a service-ready facility were significantly greater for women with higher education levels, greater wealth, and urban residence. We found the adjusted odds of using facility childbirth services were 1.23 (95% CI: 1.03, 1.48) times greater for each 0.10-unit increase in the readiness level of nearby facilities. # Conclusions Access to childbirth care is not equal for Ethiopian women. Those living in rural areas and the poor must travel farther to reach facility childbirth services, and the nearest facilities serving these women were less prepared to provide quality care. This may contribute to lower service utilization by such disadvantaged groups of women.

Abstract Background Studies in the literature have found mixed results on the effect of microcredit on health outcomes. Of the five previous experimental studies that included microcredit and a health intervention, three reported no significant changes in health status or behaviors. The purpose of this study was to test for marginal and interactive effects of increased microcredit and provision of basic health services. Methods This study had a 4-celled experimental design in 128 villages in rural Bangladesh. For villages in one cell, an additional microcredit worker was assigned. For those in a second cell, a health assistant visited households each month, provided simple medicines and announced a satellite clinic held monthly in each village. For a third cell, both interventions were combined, and villages in a fourth cell served as control. A baseline survey was completed and a follow-up survey was done three years later. Outcome measures were food security, contraceptive use, having a trained birth attendant at last birth, and measles immunization. Results Comparison of follow-up with baseline levels of the four outcome measures (for 3787 households (96% completeness) and 3687 women (94% completeness)) showed significant improvement in food security in all study arms and a significant increase in trained birth attendant at last birth in the health services villages. Due to confusion within Grameen Bank about which workers would provide the additional microcredit work, that intervention was poorly implemented so in multivariate analyses, the data for that intervention arm were grouped with data from the control arm. Logistic regression with values of the outcomes at follow-up as dependent variable and study arm and women’s schooling as covariates showed no significant effects of either separate or grouped study arms. Conclusion Two of the three health behaviors showed no significant changes over time but having a trained birth attendant at last delivery did increase significantly in the health services arm. Therefore, community health education can sometimes be effective in promoting healthy behaviors. Trial registration This was a field trial rather than a clinical trial, so trial registration was unnecessary.

Background: This study examines the association between family planning (FP) discussions with health professionals during contact points on the maternal, newborn and child health continuum of care and timing of modern contraceptive uptake and method type in the one-year following childbirth in six regions of Ethiopia among adolescent girls and young women (AGYW). Methods: This paper uses panel data of women aged 15-24 who were interviewed during pregnancy and the postpartum period between 2019-2021 as part of the PMA Ethiopia survey (n=652). Results: Despite the majority of pregnant and postpartum AGYW attending antenatal care (ANC), giving birth in a health facility, and attending vaccination visits, one-third or less of those who received the service reported discussion of FP at any of these visits. When considering the cumulative effect of discussions of FP at ANC, pre-discharge after childbirth, postnatal care and vaccination visits, we found that discussion of FP at a greater number of visits resulted in increased uptake of modern contraception by one-year postpartum. A greater number of FP discussions was associated with higher long-acting reversible contraceptive use relative to non-use and relative to short-acting method use. Conclusions: Despite high attendance, there are missed opportunities to discuss FP when AGYW access care.

# Background Well-functioning health management information systems (HMIS) enable decision-making at all health system levels. This study develops an index to measure the use of HMIS data at the facility level. # Methods We used two rounds of cross-sectional data collected from 305 health facilities in Ethiopia in 2019 (pre-COVID-19) and 2020 (post-COVID-19). We constructed a summative, 10-item index using exploratory factor analysis and 2019 index development data; and used Cronbach's alpha to assess reliability. To examine content validity, we mapped items against a previously published conceptual framework and consulted Ethiopian experts. We then employed one-way ANOVA and t-tests comparing the mean index scores overall and by key facility characteristics between 2019 and 2020. # Results The 10-item index loaded on one factor (Cronbach's alpha=0.74), and the index scores did not differ significantly by facility characteristics in 2019. The mean index score increased from 7.2 in 2019 to 7.9 in 2020 (*P*\

Abstract Background Immediate postpartum family planning (IPPFP) helps prevent unintended and closely spaced pregnancies. Despite Ethiopia’s rising facility-based delivery rate and supportive IPPFP policies, the prevalence of postpartum contraceptive use remains low, with little known about disparities in access to IPPFP counseling. We sought to understand if women’s receipt of IPPFP counseling varied by individual and facility characteristics. Methods We used weighted linked household and facility data from the national Performance Monitoring for Action Ethiopia (PMA-Ethiopia) study. Altogether, 936 women 5–9 weeks postpartum who delivered at a government facility were matched to the nearest facility offering labor and delivery care, corresponding to the facility type in which each woman reported delivering (n = 224 facilities). We explored women’s receipt of IPPFP counseling and individual and facility-level characteristics utilizing descriptive statistics. The relationship between women’s receipt of IPPFP counseling and individual and facility factors were assessed through multivariate, multilevel models. Results Approximately one-quarter of postpartum women received IPPFP counseling (27%) and most women delivered government health centers (59%). Nearly all facilities provided IPPFP services (94%); most had short- and long-acting methods available (71 and 87%, respectively) and no recent stockouts (60%). Multivariate analyses revealed significant disparities in IPPFP counseling with lower odds of counseling among primiparous women, those who delivered vaginally, and women who did not receive delivery care from a doctor or health officer (all p

Objectives Studies in several sub-Saharan geographies conducted early in the COVID-19 pandemic suggested little impact on contraceptive behaviours. Initial results may mask widening disparities with rising poverty, and changes to women’s pregnancy desires and contraceptive use amid prolonged health service disruptions. This study examined trends in contraceptive behaviours in four sub-Saharan African settings 1 year into the pandemic.Design Nationally and regionally representative longitudinal surveys.Setting Burkina Faso, Kenya, Democratic Republic of Congo (Kinshasa) and Nigeria (Lagos).Participants Women aged 15–49 years with sample size ranging from 1469 in Nigeria to 9477 in Kenya.Outcome measures Fertility preferences, contraceptive use and unintended pregnancies measured before COVID-19 (November 2019 to January 2020) and during COVID-19 (November 2020 to January 2021).Analysis We described population-level and individual-level changes by socioeconomic characteristics using generalised equation modelling. We used logistic regression models to identify factors related to contraceptive adoption and discontinuation and to experiencing an unintended pregnancy.Results At the population level, we found no change in women’s exposure to unintended pregnancy risk, alongside 5–9 percentage point increases in contraceptive prevalence in Burkina Faso, Kenya and Lagos. Reliance on provider-dependent methods dropped by 2 and 4 percentage points in Kenya and Burkina Faso, respectively, although these declines were not statistically significant. Between 1.0% and 2.8% of women across sites experienced an unintended pregnancy during COVID-19, with no significant change over time. Individual-level trajectories showed contraceptive adoption was more common than discontinuation in Burkina Faso, Kenya and Lagos, with little difference by sociodemographic characteristics. Women’s COVID-19-related economic vulnerability was unrelated to unintended pregnancy across sites.Conclusions This study highlights the resilience of African women across diverse settings in sustaining contraceptive practices amid the COVID-19 pandemic. However, with reports of rising poverty in sub-Saharan Africa, there is continued need to monitor access to essential sexual and reproductive health services.

OBJECTIVE: This study aimed to estimate the proportion of health facilities without the capability to remove contraceptive implants and those that have the capability to insert them and to understand facility-level barriers to implant removal across 6 countries in sub-Saharan Africa. STUDY DESIGN: Using facility data from the Performance Monitoring for Action in Burkina Faso, the Democratic Republic of Congo, Ethiopia, Kenya, Nigeria, and Uganda from 2020, we examined the extent to which implant-providing facilities (1) lacked necessary supplies to remove implants, (2) did not have a provider trained to remove implants onsite, (3) could not remove deeply placed implants onsite, and (4) reported any of the above barriers to implant removal. We calculated the proportion of facilities that report each barrier, stratifying by facility type. RESULTS: Between 31% and 58% of implant-providing facilities reported at least 1 barrier to implant removal in each country (6 sub-Saharan African countries). Lack of trained providers was the least common barrier to implant removal (0%–17% of facilities), whereas lack of supplies (17%–44% of facilities) and the inability to remove a deeply placed implant (16%–42%) represented more common obstacles to removal. Blades and forceps were commonly missing supplies across all 6 countries. Barriers to implant removal were less commonly reported at hospitals than at lower-level facilities in all countries except Burkina Faso. CONCLUSION: This multicountry analysis showed that facility-level barriers to contraceptive implant removal are widespread among facilities that offer implant insertion. By preventing users from being able to discontinue their implants on request, these barriers pose a threat to contraceptive autonomy and reproductive health.

BackgroundThe COVID-19 pandemic and response have the potential to disrupt access and use of reproductive, maternal, and newborn health (RMNH) services. Numerous initiatives aim to gauge the indirect impact of COVID-19 on RMNH.MethodsWe assessed the impact of COVID-19 on RMNH coverage in the early stages of the pandemic using panel survey data from PMA-Ethiopia. Enrolled pregnant women were surveyed 6-weeks post-birth. We compared the odds of service receipt, coverage of RMNCH service indicators, and health outcomes within the cohort of women who gave birth prior to the pandemic and the COVID-19 affected cohort. We calculated impacts nationally and by urbanicity.ResultsThis dataset shows little disruption of RMNH services in Ethiopia in the initial months of the pandemic. There were no significant reductions in women seeking health services or the content of services they received for either preventative or curative interventions. In rural areas, a greater proportion of women in the COVID-19 affected cohort sought care for peripartum complications, ANC, PNC, and care for sick newborns. Significant reductions in coverage of BCG vaccination and chlorohexidine use in urban areas were observed in the COVID-19 affected cohort. An increased proportion of women in Addis Ababa reported postpartum family planning in the COVID-19 affected cohort. Despite the lack of evidence of reduced health services, the data suggest increased stillbirths in the COVID-19 affected cohort.DiscussionThe government of Ethiopia's response to control the COVID-19 pandemic and ensure continuity of essential health services appears to have successfully averted most negative impacts on maternal and neonatal care. This analysis cannot address the later effects of the pandemic and may not capture more acute or geographically isolated reductions in coverage. Continued efforts are needed to ensure that essential health services are maintained and even strengthened to prevent indirect loss of life.

IntroductionThe modern contraceptive prevalence rate (mCPR) among married women has increased by nearly five-fold in Ethiopia from 8.1% in 2000 to 37% in 2019. Despite this increase, receipt of high quality contraceptive counselling, as measured by the percentage of contraceptive users who were told about other methods, counseled on side effects and counseled what to do in the event that they encountered side effects, has declined in recent years. The quality of family planning counseling service measured by using these three components, known as the Method Information Index(MII), is an index designed to measure quality and a key indicator of the FP2020 initiative. The effects of potential client and service provider-level factors on receipt of high quality counseling and its progress over time have not been well studied in Ethiopia.MethodsWe pooled data from seven Performance Monitoring for Action (PMA), formerly PMA2020, survey-rounds to examine the trend and effect of potential factors on receiving high quality of family planning counseling service in Ethiopia. Data from a total of 15,597 women aged 15 to 49 from seven survey-rounds were used in the analysis. To account for the study design and unequal probabilities of selection from target-populations for sampled women, design-based analysis was used to compute proportions. Multilevel ordinal regression model with enumeration area as a second level were employed to examine potential factors associated with quality of family planning counseling service.ResultsWe found that the percentage of women who received high quality family planning counseling service declined from 39% (95%CI: 33%, 44%) in 2015 to 12% in 2019 (95% CI: 10%, 14%) nationally. Amhara region had the lowest percentage of women receiving high quality counseling at both the earliest(2014) and latest(2019) survey rounds(17% and 6%, respectively). Results show that lack of media exposure about family planning, having no formal education, using short-acting methods, and getting the service from pharmacy were the main factors associated with receiving low quality family planning counseling service.ConclusionsGiven the importance of continuous provision of information on the range of family planning methods, it is imperative to use media and particularly regional media which can effectively address the rural populations in local languages as an important vehicle of information on family planning. Interventions aimed at improving quality of family planning counseling need to be mindful of regional disparities in the severity of the problem to ensure equity in service access. To improve the coverage of high quality family planning counseling service, there is an urgent need to re-visit the format of family planning counselling services.

Objective: There has been a growing focus on informed choice in contraceptive research. Because removal of long-acting reversible contraception (LARC), including implants and IUDs, requires a trained provider, ensuring informed choice in the adoption of these methods is imperative. We sought to understand whether information received during contraceptive counseling differed among women using LARC and those using other modern methods of contraception. Study Design: We used cross-sectional data from Burkina Faso, Côte d'Ivoire, the Democratic Republic of Congo (DRC), Kenya, Nigeria, and Uganda collected in 2019–2020 by the Performance Monitoring for Action project. We included 7969 reproductive-aged women who reported use of modern contraception. Our outcome of interest, information received during contraceptive counseling, was measured using a binary indicator of whether respondents answered “yes” to all 4 questions that make up the Method Information Index Plus (MII+). We used modified Poisson models to estimate the prevalence ratio between method type (LARC vs. other modern methods) and the MII+, controlling for individual- and facility-level covariates. Results: Reported receipt of the full MII+ during contraceptive counseling ranged from 21% in the DRC to 51% in Kenya. In all countries, a higher proportion of LARC users received the MII+ compared to other modern method users. A greater proportion of LARC users answered “yes” to all questions that make up the MII+ at the time of counseling compared to other modern method users in DRC, Kenya, Nigeria, and Uganda. There was no significant difference in the prevalence of reporting the full MII+ between users of LARC and other modern methods in Burkina Faso (Adjusted prevalence ratio (aPR): 1.16; 95% confidence interval (CI): 0.91, 1.48) and Côte d'Ivoire (aPR: 1.13; 95% CI: 0.87, 1.45). Conclusion: Information received during contraceptive counseling was limited for all modern contraceptive users. LARC users had significantly higher prevalence of receiving the MII+ compared to other modern method users in the DRC, Kenya, and Uganda. Family planning programs should ensure that all women receive complete, unbiased contraceptive counseling. Implications: Across 6 sub-Saharan African countries, a substantial proportion reproductive-aged women using contraception did not report receiving comprehensive counseling when they received their method. Women using long-acting reversible contraception received more information compared to women using other modern methods in the DRC, Kenya, Nigeria, and Uganda after controlling for individual- and facility-level factors.

BackgroundInterpersonal violence has physical, emotional, educational, social, and economic implications. Although there is interest in empowering young people to challenge harmful norms, there is scant research on how individual agency, and, specifically, the "power to" resist or bring about an outcome relates to peer violence perpetration and victimization in early adolescence. This manuscript explores the relationship between individual agency and peer violence perpetration and victimization among very young adolescents (VYAs) living in two urban poor settings in sub-Saharan Africa (Kinshasa, Democratic Republic of Congo (DRC) and Blantyre, Malawi).Methods and findingsThe study draws on two cross-sectional surveys including 2,540 adolescents 10 to 14 years from Kinshasa in 2017 (girls = 49.8% and boys = 50.2%) and 1,213 from Blantyre in 2020 (girls = 50.7% and boys = 49.3%). The sample was school based in Malawi but included in-school and out-of-school participants in Kinshasa due to higher levels of early school dropout. Peer violence in the last 6 months (dependent variable) was defined as a four categorical variable: (1) no victimization or perpetration; (2) victimization only; (3) perpetration only; and (4) both victimization and perpetration. Agency was operationalized using 3 scales: freedom of movement, voice, and decision-making, which were further divided into tertiles. Univariate analysis and multivariable multinomial logistic regressions were conducted to evaluate the relationships between each agency indicator and peer violence. The multivariable regression adjusted for individual, family, peer, and community level covariates. All analyses were stratified by gender and site. In both sites, adolescents had greater voice and decision-making power than freedom of movement, and boys had greater freedom of movement than girls. Boys in both settings were more likely to report peer violence in the last six months than girls (40% to 50% versus 32% to 40%, p < 0.001), mostly due to higher rates of a perpetration-victimization overlap (18% to 23% versus 10% to 15%, p < 0.001). Adolescents reporting the greatest freedom of movement (Tertile 3) (with the exception of girls in Kinshasa) had a greater relative risk ratio (RRR) of reporting a perpetrator-victim overlap (boys Kinshasa: RRR = 1.9 (1.2 to 2.8, p = 0.003); boys Blantyre: RRR = 3.8 (1.7 to 8.3, p = 0.001); and girls Blantyre: RRR = 2.4 (1.1 to 5.1, p = 0.03)). Adolescents with the highest decision-making power in Kinshasa also had greater RRR of reporting a perpetrator-victim overlap (boys: RRR = 3.0 (1.8 to 4.8, p < 0.001). Additionally, girls and boys in Kinshasa with intermediate decision-making power (tertile 2 versus 1) had a lower RRR of being victimized (Girls: RRR = 1.7 (1.02 to 2.7, p = 0.04); Boys: RRR = 0.6 (0.4 to 0.9, p = 0.01)). Higher voice among boys in Kinshasa (Tertile 2: RRR = 1.9 (1.2 to 2.9, p = 0.003) and Tertile 3: 1.8 (1.2 to 2.8, p = 0.009)) and girls in Blantyre (Tertile 2: 2.0 (1.01 to 3.9, p = 0.048)) was associated with a perpetrator-victim overlap, and girls with more voice in Blantyre had a greater RRR of being victimized (Tertile 2: RRR = 1.9 (1.1 to 3.1, p = 0.02)). Generally, associations were stronger for boys than girls, and associations often differed when victimization and perpetration occurred in isolation of each other. A main limitation of this study is that the cross-sectional nature of the data does not allow a causal interpretation of the findings, which need further longitudinal exploration to establish temporality.ConclusionsIn this study, we observed that peer violence is a gendered experience that is related to young people's agency. This stresses the importance of addressing interpersonal violence in empowerment programs and of including boys who experience the greatest perpetration-victimization overlap.

Background Since 2009, the International Conference on Family Planning (ICFP) has served as an opportunity for the global reproductive health community to share FP advances and practice lessons in the areas of research, programming, and advocacy. The purpose of this paper was to synthesize the key results and findings presented by members of the FP community at the 2018 ICFP Conference. Methods More than 700 abstracts from all 15 conference tracks were reviewed and 64 abstracts total were selected for this paper based on the novelty and urgency of the findings. The content analysis of conference abstracts were grouped into six final thematic areas. Results 1) Investing in family planning for a lifetime of returns. FP continues to face a shortage of funding. Domestically based and locally owned funding models provide alternative financing solutions. 2) Addressing inequities in family planning for key populations. Various populations still face challenges in accessing FP. Youth-inclusive and user-centered programming show promise in addressing such challenges. 3) Reproductive justice, Unsafe abortions tend to be more common among younger, poor, uneducated and rural women. Legislation is still needed to facilitate a culture of safe abortions. 4) Couple dynamics and decision-making. Couples who share equitable responsibility in decision-making processes are more likely to use contraceptives; couple disagreement influences women’s decisions to covertly use FP. 5) Male involvement in programming. Male champions can successfully promote uptake of FP. Gender-transformative programming promotes gender equity and impacts behavior change. 6) Breakthroughs in novel contraceptives and systems improvement in family planning. Recent advances include user-centered contraceptive technologies that allow for self-administration and information systems which optimize supply chain management. Conclusion The research, advocacy, and programmatic abstracts at ICFP 2018 highlighted research advances, showcased implementation science wins, and provided evidence of critical knowledge gaps in global FP access and use

Background: Performance Monitoring for Action Ethiopia (PMA-Ethiopia) is a survey project that builds on the PMA2020 and PMA Maternal and Newborn Health projects to generate timely and actionable data on a range of reproductive, maternal, and newborn health (RMNH) indicators using a combination of cross-sectional and longitudinal data collection. Objectives: This manuscript 1) describes the protocol for PMA- Ethiopia, and 2) describes the measures included in PMA Ethiopia and research areas that may be of interest to RMNH stakeholders. Methods: Annual data on family planning are gathered from a nationally representative, cross-sectional survey of women age 15-49. Data on maternal and newborn health are gathered from a cohort of women who were pregnant or recently postpartum at the time of enrollment. Women are followed at 6-weeks, 6-months, and 1-year to understand health seeking behavior, utilization, and quality. Data from service delivery points (SDPs) are gathered annually to assess service quality and availability. Households and SDPs can be linked at the enumeration area level to improve estimates of effective coverage. Discussion: Data from PMA-Ethiopia will be available at www.pmadata.org. PMA-Ethiopia is a unique data source that includes multiple, simultaneously fielded data collection activities. Data are available partner dynamics, experience with contraceptive use, unintended pregnancy, empowerment, and detailed information on components of services that are not available from other large-scale surveys. Additionally, we highlight the unique contribution of PMA Ethiopia data in assessing the impact of coronavirus disease 2019 (COVID-19) on RMNH.

Since 2009, the International Conference on Family Planning (ICFP) has served as an opportunity for the global reproductive health community to share FP advances and practice lessons in the areas of research, programming, and advocacy. The key takeaways from all 15 tracks were grouped into six thematic areas: 1) Investing in family planning for a lifetime of returns. FP may yield different health and monetary benefits but continues to face a shortage of funding, although locally owned models provide alternative financing solutions. 2) Addressing inequities in family planning for adolescents, youth, and key populations. Marginalized populations and youth still face challenges in accessing FP. Youth-inclusive and user-centered programming show promise in addressing such challenges. 3) Reproductive justice: Abortion care, family planning, and women’s wellbeing. Unsafe abortions tend to be more common among younger, poor, uneducated and rural women. Promising evidence show that providers may effectively shift from unsafe practices of dilation and curettage to safer manual vacuum aspiration or misoprostol. 4) Couple dynamics and family planning decision-making. Couples who share everyday life decision-making are more likely to use contraceptives; couple discordance on childbearing and fertility decisions directly influence women’s decisions to covertly use FP. 5) Male involvement in FP programming. Male champions and advocates can successfully promote couple uptake of FP. Gender-transformative programming promotes gender equity and can directly impact behavior change. 6) Breakthroughs in novel contraceptives and systems improvement in family planning. User-centered contraceptive technologies and information systems present an opportunity to facilitate self-care and optimal supply chain management. ICFP 2018 highlighted research advances, implementation science wins, and critical knowledge gaps in global FP access and use. More research is needed to determine the scalability of novel technologies, more effective programming and service delivery models to ensure multisectoral knowledge translation and utilization by policymakers.

Abstract Background Very young adolescents (VYA) in humanitarian settings are largely neglected in terms of sexual and reproductive health (SRH). This study describes the characteristics of VYA aged 10-14 years in two humanitarian settings, focusing on transitions into puberty and access to SRH information. Methods Data were collected through a cross-sectional survey with Somali VYA residing in the Kobe refugee camp in Ethiopia (N = 406) and VYA from Myanmar residing in the Mae Sot and Phop Phra migrant communities in Thailand (N = 399). The average age was 12 years (about half were girls) in both communities. Participants were recruited using multi-stage cluster-based sampling with probability proportional to size in each site. Descriptive statistics were used to describe the sociodemographic, family, peer, and schooling characteristics and to explore transitions into puberty and access to SRH information. Results Most VYA in both sites reported living with both parents; nine in ten reported feeling that their parents/guardians care about them, and over half said that their parents/guardians monitor how and with whom they spend their free time. High proportions in both sites were currently enrolled in school (91.4% Somali, 87.0% from Myanmar). Few VYA, particularly those aged 10-12, reported starting puberty, although one in four Somali indicated not knowing whether they did so. Most girls from Myanmar who had started menstruating reported access to menstrual hygiene supplies (water, sanitation, cloths/pads). No Somali girls reported access to all these supplies. While over half of respondents in both sites reported learning about body changes, less than 20% had learnt about pregnancy and the majority (87.4% Somali, 78.6% from Myanmar) indicated a need for more information about body changes. Parents/guardians were the most common source of SRH information in both sites, however VYA indicated that they would like more information from friends, siblings, teachers and health workers. Conclusions This study highlights gaps in SRH information necessary for healthy transitions through puberty and supplies for menstrual hygiene in two humanitarian settings. VYA in these settings expressed closeness to their parents/guardians and the majority were in school. Introducing early SRH interventions that involve parents and educational centers may thus yield promising results, providing VYA with the necessary skills for understanding and dealing with their pubertal and sexual development.

Abstract Background Kobe Refugee camp hosts roughly 39,000 refugees displaced from Somalia during the 2011–2012 Horn of Africa Crisis. Sexual and reproductive health, as with the greater issues of health and well-being for adolescents displaced from this crisis remain largely unknown and neglected. In 2013, the Women’s Refugee Commission, Johns Hopkins University, and International Medical Corps in Ethiopia, implemented qualitative and quantitative research to explore the factors and risks that impact the health of very young adolescents (VYAs), those 10–14 years of age, in this setting. This paper presents findings from the qualitative effort. Methods Focus group discussions (FGD), incorporating community mapping and photo elicitation activities, were conducted with 10–12 and 13–14 year-olds to obtain information about their own perspectives, experiences and values. FGDs were also implemented with 15–16 year-olds and adults, to consider their perspectives on the sexual and reproductive health needs and risks of VYAs. Results This research identified several factors that were found to influence the health and well-being of VYAs in Kobe refugee camp, including newfound access to education and security, combined with gender divisions and parental communication around early SRH and puberty that remained intact from traditional Somali culture. Girls were found to face an additional risk of child marriage and early pregnancy exacerbated since displacement, which significantly limited their ability to access education and achieve future aspirations. Conclusion Findings from this study could help to inform future programs in Kobe and similar contexts involving long-term displacement from conflict, focusing on the health and development needs of VYAs. Future programs should consider the determinants of positive VYA health and development, including access to education, gender equity, and safety. By better understanding the unique experiences, perspectives and needs of VYAs, practitioners, policy makers and donors can invest in the individual and community assets that reinforce positive behaviors established in early adolescence, in order to achieve long-term SRH impacts.

Contraception is essential to preventing unintended pregnancy. While contraceptive use has increased significantly over the past decade, discontinuation and gaps in use remain common. Although women cite side effects as the reason for discontinuing or stopping methods, little is known about the specific ways in which contraception affects women’s sexual experiences. This systematic scoping review aimed to understand how contraceptive-induced side effects relating to women’s sexual experiences have been measured, classified, and explored in the literature, specifically in low- and middle-income countries (LMICs). Studies were eligible for inclusion if they were peer-reviewed, English-language articles published between 2003 and 2018 that examined women’s sexual experiences related to their use of modern contraception, including sexual satisfaction, arousal, sexual dysfunction, discomfort, vaginal dryness, sexual frequency, and relationship or partner dynamics. Study populations were restricted to women of reproductive age in LMICs. Twenty-two studies were deemed eligible for inclusion, comprising a range of methods and geographies. Emergent sexual experience themes included: menstrual issues impacting sexual experience; libido; lubrication; sexual pleasure; dyspareunia; and female sexual function. Results highlight the variability in measures used, lack of a women-centred perspective, and void in research outside of high-income countries to study the influence of contraception on women’s sexual experiences. Very few studies focused on women’s sexual experiences as the primary outcome or predictor. Providers should adopt woman-centred contraceptive counselling that considers women’s relationships. Further research is needed to disentangle the nuanced effects of contraception on women’s sex lives, contraceptive decision-making, and method continuation.

Summary: Background: The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. Methods: We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12–49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. Findings: Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553–873 in Ragh vs 166, 63–270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3–2·1 in Ragh vs 0·2, 0·1–0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6–122·3 in Ragh vs 24·8, 20·5–29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US$66·20, IQR $61·30 in Kabul and $9·89, $11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. Interpretation: Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings. Funding: United States Agency for International Development (USAID).

Background: Health priorities since the UN Millennium Declaration have focused strongly on children younger than 5 years. The health of older children (age 5–9 years) and younger adolescents (age 10–14 years) has been neglected until recently, especially in low-income and middle-income countries, and mortality measures for these age groups have often been derived from overly flexible models. We report global and regional empirical mortality estimates for children aged 5–14 years in low-income and middle-income countries, and compare them with ones from existing models. Methods: For this empirical analysis, we obtained birth-history data from surveys done over a 25-year period from 1986 by the Demographic and Health Surveys programme for 84 World Bank low-income and middle-income countries, and data about household deaths in China from their 1990 and 2010 censuses. We used these data to calculate mortality risks for children aged 5–14 years, and compare these risks to corresponding estimates of mortality in children younger than 5 years in the same countries. We used regression analysis to model these associations, generate estimates of the risks, and derive estimates of the numbers of deaths for 1990 and 2010 by applying those risks to population estimates from the UN World Population Prospects (WPP) 2012 Revision. We then compared the numbers of deaths with those given by the UN WPP itself and by the Institute for Health Metrics and Evaluation's Global Burden of Disease (GBD) 2010 study. Findings: The mean risk of a child dying at age 5–14 years in low-income and middle-income countries is about 19% of the risk of dying between birth and age 5 years (12% at age 5–9 plus 7% at age 10–14). According to our estimates, the total number of deaths at ages 5–14 years in low-income and middle-income regions fell from about 2·4 million (95% CI 1·9–2·7) in 1990 to about 1·5 million (1·2–1·8) in 2010. From our estimates we concluded there to have been 200 000 (16%) more deaths at ages 5–14 than in the UN report; however, our estimates exceeded GBD estimates by more than 700 000 (87%). The average annual rate of decline in mortality at age 5–9 years (about 3%) slightly exceeded that for ages 0–4 years (2·8%), but progress has been slower for age 10–14 years (about 2%). Interpretation: Our analysis suggests that mortality risks nowadays in the age range 5–14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. Our findings broadly lend support for the UN WPP mortality estimates, but are almost double those underpinning GBD 2010. Global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents. Funding: The Lancet Commission on Investing in Health and the Bill & Melinda Gates Foundation.

Most low- and middle-income countries lack fully functional civil registration systems. Measures of under-five mortality are typically derived from periodic household surveys collecting detailed information from women on births and child deaths. However, such surveys are expensive and are not appropriate for monitoring short-term changes in child mortality. We explored and tested the validity of two new analysis methods for less-expensive summary histories of births and child deaths for such monitoring in five African countries.The first method we explored uses individual-level survey data on births and child deaths to impute full birth histories from an earlier survey onto summary histories from a more recent survey. The second method uses cohort changes between two surveys in the average number of children born and the number of children dead by single year of age to estimate under-five mortality for the inter-survey period. The first method produces acceptable annual estimates of under-five mortality for two out of six applications to available data sets; the second method produced an acceptable estimate in only one of five applications, though none of the applications used ideal data sets.The methods we tested were not able to produce consistently good quality estimates of annual under-five mortality from summary birth history data. The key problem we identified was not with the methods themselves, but with the underlying quality of the summary birth histories. If summary birth histories are to be included in general household surveys, considerable emphasis must be placed on quality control.

OBJECTIVE: We assessed the change over time in the contribution of maternal mortality to a life expectancy calculated between ages 15 and 49, or Reproductive-Aged Life Expectancy (RALE). Our goal was to estimate the increase in RALE in developed countries over the twentieth century and the hypothetical gains in African countries today by eliminating maternal mortality. METHODS: Analogous to life expectancy, RALE is calculated from a life table of ages 15 to 49. Specifically, RALE is the average number of years that women at age 15 would be expected to live between 15 and 49 with current mortality rates. Associated single decrement life tables of causes of death other than maternal mortality are explored to assess the possible gains in RALE by reducing or eliminating maternal mortality. We used population-based data from the Human Mortality Database and the Demographic and Health Surveys. FINDINGS: In developed countries, five years in RALE were gained over the twentieth century, of which approximately 10%, or half a year, was attributable to reductions in maternal mortality. In sub-Saharan African countries, the possible achievable gains fluctuate between 0.24 and 1.47 years, or 6% and 44% of potential gains in RALE. CONCLUSIONS: Maternal mortality is a rare event, yet it is still a very important component of RALE. Averting the burden of maternal deaths could return a significant increase in the most productive ages of human life.