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November 16, 2017

News Brief: 2018 International Conference on Family Planning in Kigali, Rwanda

At the fifth International Conference on Family Planning (ICFP) in Kigali, Rwanda, which took place November 12 to 15, 2018, four new research findings were presented. The 2018 ICFP was co-hosted by the Bill & Melinda Gates Institute for Population and Reproductive Health, which is based at the Johns Hopkins Bloomberg School of Public Health, and the Ministry of Health of the Republic of Rwanda. 

Conference papers will touch upon a range of issues, including the conference theme of youth empowerment. These findings address family planning and contraception.

Reproductive Coercion in Kenya

Women in the urban settlements of Nairobi, Kenya are expected by their male partners and the wider community to be “constant reproducers” of children, and are apt to experience violence and other forms of coercion if they try to limit their pregnancies, according to a study conducted by researchers at the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Nursing and Ujamaa Africa.

Reproductive coercion has been studied extensively in the U.S., but, as lead author Shannon Wood, a PhD candidate at the Bloomberg School, notes, “little research has been done in low- and middle-income countries, particularly in high fertility settings, to understand how community and partner norms contribute to such coercion.”

The researchers set up focus group discussions in Nairobi’s three urban settlements with 19 informants who had experience working with domestic or partner violence in their communities, and 49 female survivors of intimate partner violence.

The discussions showed that community norms in this area, and male partner norms, discourage the limiting of pregnancies.

“The most commonly discussed form of reproductive coercion was men’s refusal to allow women to use condoms and other contraceptive methods,” Wood says. “When women requested condom use, for example, partners would react by refusing, accusing women of having other partners, threatening them or physically abusing them.” Consequently, women often avoided condom requests altogether.

The results indicate that in this high-fertility community, coercive practices regarding condoms and reproductive health are pervasive. Wood and colleagues conclude that future interventions should address, among other things, controlling dynamics over childbearing, sexual risk reduction and other aspects of sexual and reproductive health. The researchers are now conducting a follow-on randomized controlled trial to test the effectiveness of a safety decision aid in reducing intimate partner violence and enhancing safety behaviors and resilience.

The qualitative study, titled “‘He tells you your work is to give birth:’ Reproductive coercion among informal settlements in Nairobi, Kenya,” was led by Shannon Wood and principal investigator and associate professor Michele Decker of the Bloomberg School of Public Health, with support from IDEAS42.  The research team includes Zaynab Hameeduddin of the Bloomberg School of Public Health, Sydney Rachel Kennedy and professor Nancy Glass of the Johns Hopkins School of Nursing, and implementation colleagues Ben Asira and Benjamin Omondi of Ujamaa Africa.  

Health Insurance for Family Planning in Tanzania

Family planning advocacy by the Johns Hopkins Center for Communication Programs (CCP) Advance Family Planning (AFP) project in Tanzania has prompted the country’s largest private health insurer, AAR, to provide coverage for family planning services, according to a report jointly authored by AAR Tanzania and AFP. CCP is based at the Johns Hopkins Bloomberg School of Public Health.

“Private health insurance is an important avenue for expanding uptake of family planning given the access it provides to the corporate world,” says lead author Halima Shariff, AFP country director. “Since they introduced this coverage option, AAR Health Insurance company has seen an increasing number of corporate clientele endorsing family planning coverage for their staff.”

Although Tanzanian government health programs offer family planning services free of charge in public facilities, clients accessing these services in private health facilities are required to pay out of pocket. Tanzania’s total fertility remains high at about six children per woman and the adoption of contraception has been slow. “Promoting contraceptive use to a significantly higher proportion of couples requires the activation of critical partners such as private health insurers,” Shariff says.

AFP and its local partners employed an analysis of the costs of providing women in Tanzania with a full range of short- and long-acting modern contraceptive methods per year to convince AAR management of the savings that could accrue from integrating family planning into their health benefit package and other health-related programs. The evidence persuaded AAR’s management to provide family planning coverage starting in their 2016 health benefits package.

AAR’s clients have since been able to access modern family planning methods in the company’s 263 health facilities in Tanzania. The number of corporations that registered for the package with family planning coverage grew from 35 in 2016 to 119 in March 2018.

“The company expects continued increases in the numbers of corporations enrolling and utilizing the service,” Shariff says. “We think AAR has set a trend from which other private health insurers are learning in order to embrace the practice.”

The report, titled “Tanzania’s Largest Health Insurer Covers Family Planning: An evidence-based advocacy success story,” was authored by Halima Shariff, Tabia Massudi, John Ngonyani and James Mlali.

Tracking the Adoption of Contraception in Five African Countries

The use of modern contraceptive techniques is increasing rapidly in some parts of Ethiopia, Kenya, Ghana, Uganda and Burkina Faso, a trend which potentially offers lessons for regions with slower adoption rates, according to a study led by researchers at the Johns Hopkins Bloomberg School of Public Health.

The Family Planning 2020 (FP2020) initiative, launched in 2012 at the London Summit on Family Planning, proposes to add 120 million modern contraceptive users in the world’s 69 poorest countries by 2020. Bloomberg School Graduate student Qingfeng Li and colleagues examined FP2020 and USAID data to determine how well Ethiopia, Kenya, Ghana, Uganda and Burkina Faso are progressing towards this goal—not just at national levels but also at sub-national regional levels.

The researchers found that from 2012 to 2017 the prevalence of modern contraceptive use (mCPR) went from 13.5 percent to 21.2 percent in Burkina Faso, 20.5 percent to 25.5 percent in Ethiopia, 14.8 percent to 21.9 percent in Ghana, 40.0 percent to 44.7 percent in Kenya, and 20.8 percent to 27.3 percent in Uganda. Based on the observed country growth rates, they projected that the five countries collectively would contribute 8.1 million additional contraceptive users towards the overall FP2020 goal.

Meeting the FP2020 goal would require average annual growth rates in contraceptive use of more than 1.5 percent. None of the five countries achieved such rates, but Li and colleagues found considerable in-country variation, with some regions showing relatively fast increases in mCPR use. In Ethiopia, for example, the mCPR increased at an annual rate of 1.4 percent in the Southern Nations, Nationalities and Peoples' Region; that and two other regions (out of a total of nine in Ethiopia) accounted for 87 percent of increased mCPR users up to 2017.

“The fact that some regions have done so much better than others suggests that there may be ways to improve adoption rates in less-performing regions,” Li says.

The study, titled “Potentials of Achieving FP2020 Goals of 120 million Additional Contraceptive Users by 2020,” was co-authored by Qingfeng Li, Amy Tsui and Saifuddin Ahmed.

Maternal Care and Postpartum Family Planning in Ethiopia

Better maternal health services could improve the rates of postpartum contraceptive use in Ethiopia’s Southern Nations, Nationalities and Peoples' Region (SNNPR), suggests a study by researchers at the Johns Hopkins Bloomberg School of Public Health.

One of the reasons for high birth rates as well as high infant and maternal mortality in developing countries is the inadequate use of contraception by women who have recently given birth. Although the World Health Organization recommends that women wait at least 24 months after giving birth before becoming pregnant again, studies suggest that about 60 percent of women in low- and middle-income countries don’t use effective contraception to prevent pregnancy during this two-year postpartum period.

A team led by the Bloomberg School’s Linnea A. Zimmerman, PhD, MPH, assistant professor in Population, Family and Reproductive Health, used data from the Performance Monitoring and Accountability 2020 Maternal and Newborn Health survey (PMA-MNH) in SNNPR to analyze relationships between maternal health services, including counseling on family planning, and the uptake of contraceptive use.

The analysis, based on interviews with 329 women during and following their pregnancies, showed that fewer than half (47.2 percent) reported receiving any postpartum family planning counseling prior to giving birth, and only 43.1 percent reported using any method of contraception at six months postpartum.

Moreover, women, who during the antenatal period received at least one visit from a skilled health professional—not including Ethiopian government health extension workers (HEWs)—initiated contraceptive use at 1.6 times the rate of women who did not.

“The difference between women who see a skilled antenatal care provider, other than an HEW, at least once in their pregnancy and women who don’t suggests that postpartum family planning counseling is not being delivered effectively by HEWs alone,” Zimmerman says.

Increased training for postpartum family planning counseling may be needed for HEWs, she adds.

The study, “Do Maternal Care Contacts Improve Postpartum Family Planning?  Evidence from a Longitudinal Cohort Study in SNNPR, Ethiopia,” was co-authored by Linnea A. Zimmerman, PhD, MPH.

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Media contacts for the Johns Hopkins Bloomberg School of Public Health: Barbara Benham at 410-614-6029 or bbenham1@jhu.edu and Christina Cherel at 410-502-8956 or ccherel@jhu.edu.