Measurement of Access to Family Planning in Demographic and Health Surveys: Lessons and Challenges
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1 Measurement of Access to Family Planning in Demographic and Health Surveys: Lessons and Challenges Yoonjoung Choi, Madeleine Short Fabic, Jacob Adetunji U.S. Agency for International Development September 17, 2014 PFRH Seminar, JHSPH
2 Outline Presentation Background Methods Data Analysis Results Discussion Audience Participation Thoughts? Questions? Suggestions?
3 Access to Family Planning Background Driving paradigm in the programmatic and policy communities: FP2020: expanding access to family planning to an additional 120 million women and girls by 2020 Post-2015 agenda Widely studied over decades as a determinant of utilization, from observational studies to randomized controlled trials Complex concept Challenges in measurement in large-scale surveys (going back to World Fertility Surveys) Frameworks to define access to healthcare/fp Five As: Penchansky and Thomas (1981) Bertrand et. al. (1995) AAAQ: UN Committee on Economic, Social, and Cultural Rights (2000)
4 Elements of Access to FP Background Geographic accessibility to SDP Economic accessibility Administrative accessibility to/at SDP Service quality at SDP Cognitive accessibility Psychosocial accessibility Five As AAAQ Bertrand SDP: Service Delivery Points
5 Elements of Access to FP Background Geographic accessibility to SDP Economic accessibility Administrative accessibility to/at SDP Service quality at SDP Cognitive accessibility Psychosocial accessibility Five As AAAQ Bertrand Accessibility Accessibility* Geographic/Phys ical accessibility Affordability Accessibility* Economic accessibility Accommodation Availability Accountability Availability Accessibility* Accountability Quality Accessibility* Administrative accessibility Cognitive accessibility Psychosocial accessibility
6 Measurement of Access Background Needed Data: Policy, Service Delivery, Community, Individual To understand bottle necks of achieving full access, data at each level required Data from Population-Based Surveys: Individual-Level Information on barriers at the individual-level or individual understanding of barriers that originate from other levels Large scale surveys have collected data on contraceptive use and barriers to use Demographic and Health Surveys (DHS): on-going & oldest global survey program in low-income countries
7 Study Objectives Background Our Motivation 1) How is access to FP defined? 2) What is DHS s contribution to our measurement of access to FP? Study Objective: To understand the elements of FP access captured by DHS, and document their strengths and limitations Our Approach Catalogue the DHS questions that map to elements of access Pinpoint questions that elicit the most information on access Examine data derived from the questions: to document common barriers to access, discuss limitations of the data collected, and discuss potential improvements to the measurement of FP access
8 Demographic and Health Surveys (DHS) Methods Data Nationally representative household surveys Main scope: Reproductive Health/Family Planning, Maternal and Child Health, Nutrition, HIV/AIDS, Malaria, etc Household questionnaire, & Women s questionnaire Data collection by local implementing agency usually National Statistics Office with technical assistance from the DHS Program Sponsored by USAID, increasingly with other donors 300+ surveys in 90+ countries since 1984 Open data access
9 Questions Related to FP Access in DHS Methods Data Most directly related questions: Reasons for not using (1) Can you tell me why you are not using a method to prevent pregnancy? Counseling about side effects and potential other methods to use (6) At that time*, were you told about side effects or problems you might have with the method? At that time*, were you told by a health or FP worker about other methods of family planning that you could use? Awareness of methods/ Knowledge on source (2) Have you ever heard of [Method]? Do you know of a place where you can obtain a method of FP? FP outreach (4) In the last 12 months, were you visited by a fieldworker who talked to you about family planning? Reasons for discontinuation (Contraceptive calendar)
10 Questions Related to FP Access in DHS Methods Data Most directly related questions: Reasons for not using (1) Can you tell me why you are not using a method to prevent pregnancy? Counseling about side effects and potential other methods to use (6) At that time*, were you told about side effects or problems you might have with the method? At that time*, were you told by a health or FP worker about other methods of family planning that you could use? Awareness of methods/ Knowledge on source (2) Have you ever heard of [Method]? Do you know of a place where you can obtain a method of FP? FP outreach (4) In the last 12 months, were you visited by a fieldworker who talked to you about family planning? Reasons for discontinuation (Contraceptive calendar)
11 Questions Related to FP Access in DHS Methods Data Element of access Geographic Administrative Denominator Among all women Among users Among non-users Reasons for not using Service quality Counseling Economic Cognitive Method awareness, source knowledge, FP outreach Psychosocial Study Question
12 Eligible respondants Methods Data Eligibility for Reasons for Non-Use Open-ended question response coding categories: Question
13 Eligible respondants Methods Data Eligibility for Reasons for Non-Use Open-ended question response coding categories: Question
14 Reasons for Non-Use: Categories Methods Data Pre-structured coding categories Multiple reasons allowed
15 Reasons for Non-Use: Categories Methods Data Pre-structured coding categories Multiple reasons allowed knows no method knows no source not married* not having sex infrequent sex menopausal/hysterectomy Sub-fecund/infecund postpartum amenorrhea breastfeeding* respondent opposed husband/partner opposed others opposed religious prohibition lack of access/too far costs too much fear of side effects/health concerns* inconvenient to use interferes with body's processes preferred method not available no method available fatalistic other don't know
16 Analysis Methods - Data In-depth descriptive analyses around/of reasons for non-use question, using 4 selected surveys We examined: 1. Distribution across eligibility criteria 2. Background characteristics of women by eligibility 3. Among ineligible women, use of any contraception 4. Among eligible women, response pattern (number and type) 5. Among women who gave particular reasons, related data consistency Analysis for each country/survey separately, adjusted for sampling weight
17 Analysis Data Methods - Data Selected four surveys for illustrative purposes Zimbabwe Rwanda Ethiopia Senegal MCPR (%) Unmet need (%) Demand for FP satisfied with modern methods (%) Survey sample size (women years) 15,688 13,671 9,171 16,515
18 Results
19 Distribution of Women by Eligibility (%) Results 1 Zimbabwe Rwanda Ethiopia Senegal Total (All women yrs) Ineligible because: She never had sex She or her partner is sterilized She is currently pregnant When asked about future fertility intention, she: is undecided or does not know declares she cannot get pregnant wants a/another child in the next 24 mo wants a/another child after marriage wants a/another child but does not know when She uses a contraceptive method Eligible for the question
20 Distribution of Women by Eligibility (%) Results 1 Zimbabwe Rwanda Ethiopia Senegal Total (All women yrs) Ineligible because: She never had sex She or her partner is sterilized She is currently pregnant When asked about future fertility intention, she: is undecided or does not know declares she cannot get pregnant wants a/another child in the next 24 mo wants a/another child after marriage wants a/another child but does not know when She uses a contraceptive method Eligible for the question
21 Results 2 Modern Contraceptive Use by Eligibility Criterion (%) Zimbabwe Rwanda Ethiopia Senegal Ineligible because: She never had sex She or her partner is sterilized She is currently pregnant When asked about future fertility intention, she: is undecided or does not know declares she cannot get pregnant wants a/another child in the next 24 mo wants a/another child after marriage wants a/another child but does not know when She uses a contraceptive method Eligible for the question
22 Eligible women tend to be less educated & rural. In terms of union/sexual activity status Zimbabwe Rwanda Ethiopia Senegal Results 3 Who answers the question? Distribution of Background Characteristics by Eligibility (%) Ineligible Eligible Ineligible Eligible Ineligible Eligible Ineligible Eligible Residential area rural urban Education, highest level attended no education some primary some secondary > secondary Union/Sexual activity status in union single, SA, <1month single, SA, 1month single, never had sex
23 Results 3 Who answers the question? Distribution of Background Characteristics by Eligibility (%) Eligible women tend to be less educated & rural. In terms of union/sexual activity status Zimbabwe Rwanda Ethiopia Senegal Ineligible Eligible Ineligible Eligible Ineligible Eligible Ineligible Eligible Residential area rural urban Education, highest level attended no education some primary some secondary higher than secondary Union/Sexual activity status in union single, SA, <1month single, SA, 1month single, never had sex
24 Reasons for Not Using (%) Results 4 Zimbabwe Rwanda Ethiopia Senegal not married perceived no need no/infrequent sex sub/infecund postpartum* opposition knows no method or source method related method, quality** method, stock-out lack of access/too far costs too much fatalistic other don't know *breastfeeding, postpartum amenorrhea **fear of side effects/health concerns, inconvenient to use, interferes with body's processes
25 Reasons for Not Using (%) Results 4 Zimbabwe Rwanda Ethiopia Senegal not married perceived no need no/infrequent sex sub/infecund postpartum* opposition knows no method or source method related method, quality** method, stock-out lack of access/too far costs too much fatalistic other don't know *breastfeeding, postpartum amenorrhea **fear of side effects/health concerns, inconvenient to use, interferes with body's processes
26 Are responses valid? Internal Data Consistency for Selected Reasons Results 5 Zimbabwe Rwanda Ethiopia Senegal Among women with perceived no need due to no/infrequent sex sexually active <1 month (%) Among women with "perceived no need due to breastfeeding*/postpartum amenorrhea postpartum period (month) < 6-month postpartum (%) postpartum amenorrhea (%) meet part of LAM definition* (%) LAM: Lactation Amenorrhea Method. *6-month postpartum and amenorrhea, but without breastfeeding component
27 Discussion (Over to Madeleine)
28 DHS Data Challenges Discussion Reasons for Non-Use in DHS 1) Ineligible women include those with potential unmet need those who want a child after marriage, want a child but don t know when, are undecided, or are currently pregnant with an unintended pregnancy, introducing selection bias. 2) Interpretation of responses is challenging, especially for many common responses ( not married, breastfeeding, side effects ) 3) Interpretation of omissions is also challenging. Only a small percentage of reasons provided related to contraceptive cost or availability. Is this because they are not barriers or because the respondents haven t yet experienced these barriers? 4) Reporting inconsistency in selected reasons
29 DHS Data Challenges Discussion Reasons for Non-Use in DHS 1) Ineligible women include those with potential unmet need those who want a child after marriage, want a child but don t know when, are undecided, or are currently pregnant with an unintended pregnancy, introducing selection bias. 2) Interpretation of responses is challenging, especially for many common responses ( not married, breastfeeding, side effects ) 3) Interpretation of omissions is also challenging. Only a small percentage of reasons provided related to contraceptive cost or availability. Is this because they are not barriers or because the respondents haven t yet experienced these barriers? 4) Reporting inconsistency in selected reasons
30 DHS Data Challenges Discussion Reasons for Non-Use in DHS 1) Ineligible women include those with potential unmet need those who want a child after marriage, want a child but don t know when, are undecided, or are currently pregnant with an unintended pregnancy, introducing selection bias. 2) Interpretation of responses is challenging, especially for many common responses ( not married, breastfeeding, side effects ) 3) Interpretation of omissions is also challenging. Only a small percentage of reasons provided related to contraceptive cost or availability. Is this because they are not barriers or because the respondents haven t yet experienced these barriers? 4) Reporting inconsistency in selected reasons
31 DHS Data Challenges Discussion Reasons for Non-Use in DHS 1) Ineligible women include those with potential unmet need those who want a child after marriage, want a child but don t know when, are undecided, or are currently pregnant with an unintended pregnancy, introducing selection bias. 2) Interpretation of responses is challenging, especially for many common responses ( not married, breastfeeding, side effects ) 3) Interpretation of omissions is also challenging. Only a small percentage of reasons provided related to contraceptive cost or availability. Is this because they are not barriers or because the respondents haven t yet experienced these barriers? 4) Reporting inconsistency in selected reasons
32 Improving Measurement of Access Discussion Need to: 1) Arrive at a shared definition of access The elimination of barriers to contraceptive uptake and continuation among all who desire to prevent pregnancy, to stop childbearing, or to space their next birth. <for discussion> 2) Learn from our own history 3) Consider expanding DHS data on access 4) Better utilize household and facility-based data from non-dhs sources 5) Conduct qualitative research
33 Improving Measurement of Access Discussion Need to: 1) Arrive at a shared definition of access 2) Learn from our own history o Leadership of the 1970s and 1980s o World Fertility Survey Questions o Previous DHS Questions (older modules, country-specific adds) 3) Consider expanding DHS data on access 4) Better utilize household and facility-based data from non-dhs sources 5) Conduct qualitative research
34 Improving Measurement of Access Discussion Need to: 1) Arrive at a shared definition of access 2) Learn from our own history 3) Consider expanding DHS data on access o Hone response categories to Q709 by adding additional probes following reasons that are vague o Expand eligibility criteria to Q709 o Add questions to current contraceptive users to assess their challenges experienced to uptake and continuation o Add questions to better assess side effects 4) Better utilize household and facility-based data from non-dhs sources 5) Conduct qualitative research
35 Improving Measurement of Access Discussion Need to: 1) Arrive at a shared definition of access 2) Learn from our own history 3) Consider expanding DHS data on access 4) Better utilize household and facility-based data from non-dhs sources o Service Provision Assessments o PMA2020 5) Conduct qualitative research
36 Improving Measurement of Access Discussion Need to: 1) Arrive at a shared definition of access 2) Learn from our own history 3) Consider expanding DHS data on access 4) Better utilize household and facility-based data from non-dhs sources 5) Conduct qualitative research o Coordinated multi-site/multi-country qualitative research
37 Audience Participation Suggestions for taking our analysis further? Lessons from historic experience? (e.g., WFS, CPS, RHS) Lessons from other fields or health areas? Definition of access? Other key data sources to measure access? Suggestions for improvements to existing data sources?
38 Thank you very much! Questions and comments: Views and opinions expressed in this paper are the authors. They do not necessarily represent the views and opinions of the US Agency for International Development
39 DHS Data Challenges Discussion Measuring Access among FP Users in DHS Access barriers are not only experienced by non-users; they are also experienced by current contraceptive users. Soapbox: The FP community must also recognize that FP access is of concern to both FP users and non-users, and examine access-related data from both groups.
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