Jane T. Bertrand and Margaret Farrell-Ross T l Tulane S School h l off Public P bli Health H l h and d Tropical T i lm Medicine di i Supported by a grant from the Bill and Melinda Gates Foundation (#OPP1017071)
What do we already know about the dynamics of contraceptive use dynamic? Widely recognized: Contraceptive rates are lower in Francophone Africa Contraceptive rates are lower in Francophone Africa than in almost any other part of the developing world.
Many DHS surveys are now outdated Prevalence may have increased Method mix may have changed (e.g., implants, injections) Some countries have had only one survey No possibility to study trends Some countries defined LAM as traditional, others as modern: For consistency, we defined d LAM as modern
CPR (all methods) Ranges from 7.9% (Mauritania) to 33.8% (Gabon) 11 of 15 countries have a CPR < 20% Exceptions: Gabon (2000): 33.8% Cameron (2004): 25.9% Togo (1998): 23.5% DRC (2007): 20.7%
West Africa -- Contraceptive Prevalence Rate by Country Among MWRA Togo 1998 7.0 16.5 Benin 2006 6.2 10.9 Cote d'ivoire 1998 7.3 7.8 Burkina Faso 2003 88 8.8 50 5.0 Senegal 2005 10.3 1.5 Modern CPR Niger 2006 9.7 1.6 Traditional CPR Guinea 2005 5.7 3.4 Mali 2006 6.9 1.4 Mauritania 2000 54 5.4 25 2.5 0 5 10 15 20 25 Contraceptive Prevalence Rate
Central Africa -- Contraceptive Prevalence Rate by Country Among MWRA Gabon 2000 13.4 19.4 Cameroon 2004 13.0 12.9 DR-Congo 2007 5.8 14.9 Modern CPR CAR 1994 3.2 11.5 Traditional CPR Chad 2004 99 9.9 11 1.1 Burundi 1987 1.3 7.4 0 5 10 15 20 25 30 35 Contraceptive Prevalence Rate
Modern methods: Pill, IUD, implant, injection, condoms, sterilization In 7 of 15 countries, at least half of CPR is traditional method use: West: Benin, Togo, Cote d Ivoire Central: Burundi, CAR, DRC, Gabon Modern contraceptive prevalence (MCPR): Ranges from 1.3% (Burundi) to 13.4% (Gabon)
9 of 15 countries had more than one survey Most show some increase But Increases were small (average of 0.5 % per year) 3 of 9 countries plateaued or slightly decreased No country attained higher than 13 percent modern contraceptive use
West and Central Africa -- Modern Contraceptive Prevalence Rate Over Time 14 12 ce Rate Modern Contrac ceptive Prevalen 10 8 6 4 Benin Burkina Faso Cote d'ivoire Guinea Mali Niger Senegal Cameroon Chad 2 0 1985 1990 1995 2000 2005 2010 Year
15.0 14.0 13.0 12.0 Mod dern Contraceptiv ve Prevalence Ra ate 11.0 10.0 9.0 8.0 70 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Benin 2006 Burkina 2003 Cote 1998 Guinea 2005 Mali 2006 Mauritania 2000 Niger 2006 Senegal 2005 Togo 1998
What modern methods are most widely used among married women: West Africa? Senegal 2005 3.6 3.2 1.5 1.9 Niger 2006 3.0 1.5 4.7 0.4 Burkina Faso 2003 2.2 2.5 2.1 1.2 0.7 Pill Injections Cote d'ivoire 1998 3.5 1.4 1.8 0.6 Condom IUD Togo 1998 1.2 2.1 1.5 1.0 1.2 LAM Implant Rest Mali 2006 2.9 2.5 1.5 Benin 2006 1.5 1.8 1.1 1.8 0 2 4 6 8 10 12 Percent
What modern methods are most widely used among married women: Central Africa? Gabon 2000 4.8 5.1 1.6 1.0 0.8 Cameroon 2004 1.6 1.4 7.6 1.2 1.3 Chad 2004 8.3 1.6 Pill Injections Condom DR-Congo 2007 3.4 2.4 LAM Female Sterilization Rest CAR 1994 11 1.1 10 1.0 12 1.2 Burundi 1987 1.3 0 2 4 6 8 10 12 14 Percent
West Africa Multiple Logistic Regression Dependent Variable = Modern vs. Traditional/No Contraceptive Use Benin Burkina Faso Cote d'ivoire Guinea Mali Mauritania Niger Senegal Togo 2006 2003 1998 2005 2006 2000 2006 2005 1998 Socio dem factors MCPR=6.1 MCPR=8.8 MCPR=7.3 MCPR=5.7 MCPR=6.9 MCPR=5.4 MCPR=9.7 MCPR=10.3 MCPR=7.0 Education: None+ Primary 1.544** 2.057** 0.274** 1.633* 1.914** 0.490** 1.595** 2.829** 0.763* Secondary/Higher 2.134** 3.613** 0.175** 2.753** 3.152** 0.277** 2.337** 4.098** 0.520** Wealth quintile: Poorest+ Poorer 1.528* 2.517** 1.099 1.462 0.737 1.501* N/A N/A N/A Middle 2.058** 3.398** 1.515 1.317 0.710* 2.103** Richer 2.526** 3.438** 1.937* 2.141** 0.827 2.250** Richest 4.054** 7.116** 2.329* 3.873** 1.093 2.667** Age: 15 19+ 20 24 1.315 1.936* 0.975 1.264 1.470* 0.909 2.947** 1.353 0.607* 25 2929 1.456 1.590* 0.713 1.441 1.777** 0.759 3.305** 1.480 0.580* 30 34 1.896* 2.450** 0.738 1.263 1.520* 0.514* 3.237** 2.336** 0.532** 35 39 2.267* 1.871* 0.865 1.304 2.427** 0.374* 2.856** 3.104** 0.629* 40 44 2.575** 2.390** 0.498* 1.414 1.528* 0.685 2.452** 2.873** 0.472** 45 49 1.373 1.216 0.989 0.868 0.829 1.605 2.359* 1.657 0.779 Residence: Rural+ Urban 1.045 2.011** 0.488** 1.565 1.173 0.201** 1.981* 1.609* 0.879 Adjusted Odds ratio *p value < 0.05 +Reference group **p value < 0.001
West Africa Benin 2006 25.8 Burkina Faso 2003 23.5 Cote d'ivoire 1998 41.2 Guinea 2005 31.0 Mali 2006 16.6 66 Mauritania 2000 2.2 Niger 2006 41 4.1 Central Africa Burundi 1987 5.5 Cameroon 2004 28.2 CAR 1994 38.8 Chad 2004 11.3 DR Congo 2007 30.00 Gabon 2000 42.1 Senegal 2005 5.1 Togo 1998 32.2
Are married or unmarried/sexually active women more likely to use modern contraception? 4 countries that show the extremes Burkina Faso 2003 8.8 55.8 Cameroon 2004 13.0 46.6 Chad 2004 9.9 14.1 Unmarried Sexually Active MWRA Mauritania 2000 5.3 5.4 0 10 20 30 40 50 60 Contraceptive Prevalence Rate
Do unmarried sexually active women favor modern or traditional methods? West Africa Burkina Faso 2003 (n=295) 55.8 2.5 Cote d'ivoire 1998 (n=362) 26.7 29.4 Benin 2006 (n=672) 29.3 25.6 Togo 1998 (n=630) 23.22 30.4 Guinea 2005 (n=283) 36.3 9.2 Modern CPR Senegal 2005 (n=50) 43.3 Traditional CPR Niger 2006 (n=16) 42.1 Mali 2006 (n=113) 22.0 5.6 Mauritania 2000 (n=22) 53 5.3 0 10 20 30 40 50 60 70 Contraceptive Prevalence Rate
Do unmarried sexually active women favor modern or traditional methods? Central Africa Cameroon 2004 (n=597) 46.6 21.9 Gabon 2000 (n=977) 30.6 29.4 DR-Congo 2007 (n=653) 22.9 24.6 Modern CPR Burundi 1987 (n=17) 15.7 9.7 Traditional CPR CAR 1994 (n=492) 99 9.9 14.6 Chad 2004 (n=70) 14.1 0.5 0 10 20 30 40 50 60 70 Contraceptive Prevalence Rate
Which modern methods do unmarried sexually active women use? West Africa Burkina Faso 2003 (n=295) 46.2 1.9 6.6 1.1 Senegal 2005 (n=50) 24.6 3.2 5.1 9.3 1.1 Niger 2006 (n=16) 16.1 26.0 Guinea 2005 (n=283) 26.9 3.6 5.8 Male Condom Female Condom Benin 2006 (n=672) 22.6 2.5 3.3 0.9 Foam/Jelly IUD Cote d'ivoire 1998 (n=362) 16.0 1.5 8.9 0.2 Injections Pill Togo 1998 (n=630) 18.5 1.6 2.7 0.4 Rest Mali 2006 (n=113) 9.3 5.5 7.3 Mauritania 2000 (n=22) 53 5.3 0 10 20 30 40 50 60 Percent
Which modern methods do unmarried sexually active women use? Central Africa Cameroon 2004 (n=597) 42.8 2.0 1.8 Gabon 2000 (n=977) 21.9 7.4 1.3 DR-Congo 2007 (n=653) 21.3 1.6 Male Condom Injections Burundi 1987 (n=17) 5.7 10.0 LAM Pill Rest Chad 2004 (n=70) 4.0 3.2 4.0 2.2 0.7 CAR 1994 (n=492) 5.9 3.2 0.9 0 5 10 15 20 25 30 35 40 45 50 Percent
Low overall use of contraception More demand among unmarried sexually active than married women in many countries Correlates of CPR (among married women): Education, wealth index, urban/rural Method preference differs by marital status: Method preference differs by marital status: Married: pill, injection Unmarried: condom, traditional
Is CPR low because of limited access to services? How quickly would CPR increase if FP services were available nearby at low cost? What explains the widespread use of condoms? Most readily available method in countries with Most readily available method in countries with strong HIV programs, weak FP programs? (e.g. DRC) Client preference or provider bias?
Questions?