Lower infant mortality and access to contraception reduce fertility in low- and middle-income nations

Although average contraceptive use has increased globally in recent decades, an estimated 222 million (26%) of women of child-bearing age worldwide face an unmet need for family planning - defined as a discrepancy between fertility preferences and contraception practice, or failing to translate desires to avoid pregnancy into preventative behaviours and practices. While many studies have reported relationships between availability of contraception, infant mortality, and fertility, these relationships have not been evaluated quantitatively across a broad range of low- and middle-income countries. Using publicly available data from 46 low- and middle-income countries, we collated test and control variables in six themes: (i) availability of family planning, (ii) quality of family planning, (iii) maternal education, (iv) religion, (v) mortality, and (vi) socio-economic conditions. We predicted that higher nation-level availability/quality of family-planning services, maternal education, and wealth reduce average fertility, whereas higher infant mortality and religious adherence increase it. Given the sample size, we first constructed general linear models to test for relationships between fertility and the variables from each theme, from which we retained those with the highest explanatory power within a final general linear model set to determine the partial correlation of dominant test variables. We also applied boosted regression trees, generalised least-squares models, and a generalised linear mixed-effects models to account for non-linearity and spatial autocorrelation. On average among all countries, we found an association between all main variables and fertility, with reduced infant mortality having the strongest relationship with reduced fertility. Access to contraception was the next-highest correlate with reduced fertility, with female secondary education, home health visitations, and adherence to Catholicism having weak, if any, explanatory power. Our models suggest that decreasing infant mortality and increasing access to contraception will have the greatest effect on decreasing global fertility. We thus provide new evidence that progressing the United Nation's Sustainable Development Goals for reducing infant mortality can be accelerated by increasing access to any form of family planning.

Impact of the SARS-CoV-2 pandemic on access to contraception and pregnancy intentions: a national prospective cohort study of the UK population

ObjectiveEvaluate the impact of the COVID-19 pandemic on access to contraception and pregnancy intentions.DesignNationwide prospective cohort study.SettingUnited Kingdom.ParticipantsWomen in the UK who were pregnant between 24 May and 31 December 2020.Main outcome measuresAccess to contraception and level of pregnancy intentions, using the London Measure of Unplanned Pregnancy (LMUP) in women whose last menstrual period was before or after 1 April 2020. While the official date of the first UK lockdown was 23 March, we used 1 April to ensure that those in the post-lockdown group would have faced restrictions in the month that they conceived.ResultsA total of 9784 women enrolled in the cohort: 4114 (42.0%) conceived pre-lockdown and 5670 (58.0%) conceived post-lockdown. The proportion of women reporting difficulties accessing contraception was higher in those who conceived after lockdown (n=366, 6.5% vs n=25, 0.6%, p<0.001) and continued to rise from March to September 2020. After adjusting for confounders, women were nine times more likely to report difficulty accessing contraception after lockdown (adjusted odds ratio (aOR) 8.96, 95% CI 5.89 to 13.63, p<0.001). There is a significant difference in the levels of pregnancy planning, with higher proportions of unplanned (n=119, 2.1% vs n=55, 1.3%) and ambivalent pregnancies (n=1163, 20.5% vs n=663, 16.1%) and lower proportions of planned pregnancies (n=4388, 77.4% vs n=3396, 82.5%) in the post-lockdown group (p<0.001). After adjusting for confounders, women who conceived after lockdown were still significantly less likely to have a planned pregnancy (aOR 0.88, 95% CI 0.79 to 0.98, p=0.025).ConclusionsAccess to contraception in the UK has become harder during the COVID-19 pandemic and the proportion of unplanned pregnancies has almost doubled.

Social norms, attitudes and access to modern contraception for adolescent girls in six districts in Uganda

Background Social norms continue to be entrenched in Uganda. Understanding social norms helps to uncover the underlying drivers that influence attitudes and behavior towards contraceptive access and use. This study therefore seeks to investigate the factors that influence the social norm – access to contraception by adolescent girls – in six districts in Uganda. Data and methods: Using data from a community cross-sectional survey in six districts (Amudat, Kaberamaido, Kasese, Moroto, Tororo and Pader) in Uganda, a binary logistic regression model was fitted to examine the variation in individual beliefs and socio-economic and demographic factors on ‘allowing adolescent girls to access contraception in a community’ – we refer to as a social norm. Results Results demonstrate that a higher proportion of respondents hold social norms that inhibit adolescent girls from accessing contraception in the community. After controlling for all variables, the likelihood for adolescent girls to be allowed access to contraception in the community was higher among respondents living in Kaberamaido (OR = 2.58; 95 %CI = 1.23–5.39), Kasese (OR = 2.62; 95 %CI = 1.25–5.47), Pader (OR = 4.35; 95 %CI = 2.15–8.79) and Tororo (OR = 9.44; 95 %CI = 4.59–19.37), those aged 30–34 years likely (OR = 1.73; 95 %CI = 1.03–2.91). However, the likelihood for respondents living in Moroto to agree that adolescent girls are allowed to access contraception was lower (OR = 0.27; 95 %CI = 0.11–0.68) compared to respondents living in Amudat. Respondents who were not formally employed (OR = 0.63; 95 %CI = 0.43–0.91), and those who agreed that withdrawal prevents pregnancy (OR = 0.45; 95 %CI = 0.35–0.57) were less likely to agree that adolescent girls are allowed to access contraception in the community. Respondents who agreed that a girl who is sexually active can use contraception to prevent unwanted pregnancy (OR = 1.84; 95 %CI = 1.33–2.53), unmarried women or girls should have access to contraception (OR = 2.15; 95 %CI = 1.61–2.88), married women or girls should have access to contraception (OR = 1.55; 95 %CI = 0.99–2.39) and women know where to obtain contraception for prevention against pregnancy (OR = 2.35; 95 %CI = 1.19–4.65) were more likely to agree that adolescent girls are allowed to access contraception. Conclusions The findings underscore the need for context specific ASRH programs that take into account the differences in attitudes and social norms that affect access and use of contraception by adolescents.

Impacts of Access to Contraception and Abortion Services on Men’s Life Course Outcomes: Results of Add Health Analyses

A great deal of research demonstrates effects of access to contraception and abortion for women and their children, but much less research has considered the impacts of these developments for men. In this analysis, we leverage data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to explore the possibility of “spillover” effects on male high school classmates related to women’s access to contraception during adolescence and young adulthood. We use school-based surveys of sexual activity and use of birth control pills to ask whether males who attend schools with higher proportions of contracepting young women classmates have different adult outcomes than those attending schools with lower proportions. We hypothesized that higher rates of birth control use would lower the likelihood of pregnancy during the adolescent years, which would in turn increase young men’s future education levels, income levels, and age at first birth.Our analyses did not reveal statistically significant associations between birth control use and young men's longer-term education, income, and family formation outcomes. However, we speculate that these null results are more likely to reflect low statistical power and data limitations than a true lack of association between these factors. Specifically, because surveys only gather information on birth control use when women report being sexually active, the measure may not fully reflect the range of contraceptive users. Additionally, findings of “spillover” effects are expected to be smaller than main effects of contraception for women, limiting our ability to uncover these effects in modest-sized samples. Future research should explore whether larger samples allow more precision in estimates, but most data may suffer from an inability to measure “peer” young women of men under study. Nonetheless, it is important to continue examining the role of contraceptive access in men’s lives as it is a potentially important element to understanding the full range of impacts of contraceptive access on people’s life outcomes.

“Did I Choose a Birth Control Method Yet?” Health Care and Women’s Contraceptive Decision-Making

In the United States, unintended pregnancy is medicalized, having been labeled a health problem and “treated” with contraception. Scholars find women’s access to contraception is simultaneously facilitated and constrained by health care system actors and its structure. Yet, beyond naming these barriers, less research centers women’s experiences making contraceptive decisions as they encounter such barriers. Through in-depth, semi-structured interviews with 86 diverse, self-identified women, this study explores how the medicalization of unintended pregnancy has influenced women’s contraceptive access and decision-making. We highlight the breadth of such influence across multiple contraceptive types and health care contexts; namely, we find the two most salient forces shaping women’s contraceptive decisions to be their insurance coverage and providers’ contraceptive counseling. Within these two categories, we offer crucial nuance to demonstrate how these oft-cited barriers implicitly and explicitly influence women’s decisions. Paradoxically, it is the health care system, itself, that both offers yet constrains women’s contraceptive decisions.

Factors Associated with Support for Adolescent Access to Contraception Among Mexican Catholic Parents

We used a nationally representative survey of 2186 Mexican Catholic parents to assess two outcomes: support for adolescent access to modern contraception and whether adolescents unaccompanied by an adult should have access to contraceptive methods. A majority (85%) of Mexican Catholic parents support adolescent access to modern contraceptive methods, but there was less support (28%) for access to contraception unaccompanied. Further, our results show strong support (92%) for sex education in schools. Parents who believe that good Catholics can use contraception had higher odds of support for adolescent access and unaccompanied access to modern contraception. Mexican Catholic parents support adolescent access to modern contraception, but support for unaccompanied access to contraception is lower. This may reflect an interest in being involved, and not necessarily opposition to contraceptive use. Measures of Catholicism that focus on behaviors may better explain opinions about adolescent access to contraception.