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
Outline
Presentation
• Background
• Methods
– Data
– Analysis
• Results
• Discussion
Audience Participation
Thoughts? Questions? Suggestions?
Background
Access to Family Planning
• 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)
Background
Elements of Access to FP
Five As
Geographic
accessibility to SDP
Economic
accessibility
Administrative
accessibility to/at SDP
Service quality
at SDP
Cognitive
accessibility
Psychosocial
accessibility
SDP: Service Delivery Points
AAAQ
Bertrand
Background
Elements of Access to FP
Five As
AAAQ
Bertrand
Geographic
accessibility to SDP
Accessibility
Accessibility*
Geographic/Phys
ical accessibility
Economic
accessibility
Affordability
Accessibility*
Economic
accessibility
Administrative
Accommodation
accessibility to/at SDP
Service quality
at SDP
Cognitive
accessibility
Psychosocial
accessibility
Availability
Accountability
Administrative
accessibility
Availability
Accessibility*
Accountability
Quality
Accessibility*
Cognitive
accessibility
Psychosocial
accessibility
Background
Measurement of Access
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
Background
Study Objectives
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
Methods – Data
Demographic and Health Surveys (DHS)
• 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
Methods – Data
Questions Related to FP Access in DHS
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)
Methods – Data
Questions Related to FP Access in DHS
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)
Methods – Data
Questions Related to FP Access in DHS
Element of
access
Denominator
Among all women
Among users
Geographic
Among non-users
Reasons for not
using
Administrative
Service quality
Counseling
Economic
Cognitive
Psychosocial
“
“
Method awareness,
source knowledge,
FP outreach
“
“
Study Question
Methods – Data
Eligible respondants
Eligibility for
“Reasons for
Non-Use”
Open-ended question response
Question
coding categories:
Methods – Data
Eligible respondants
Eligibility for
“Reasons for
Non-Use”
Open-ended question response
Question
coding categories:
Methods – Data
Reasons for Non-Use: Categories
 Pre-structured coding categories
 Multiple reasons allowed
Methods – Data
Reasons for Non-Use: Categories
 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*
• lack of access/too far
• costs too much
•
•
•
•
respondent opposed
husband/partner opposed
others opposed
religious prohibition
• 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
Methods - Data
Analysis
• 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
Methods - Data
Analysis Data
• Selected four surveys for illustrative purposes
Zimbabwe
Rwanda
Ethiopia
Senegal
2010-11
2010
2011
2010
MCPR (%)
57.3
45.1
27.3
12.1
Unmet need (%)
14.6
20.8
26.3
30.1
Demand for FP
satisfied with
modern
methods (%)
78.4
62.3
49.7
28.0
Survey sample
size (women 1549 years)
15,688
13,671
9,171
16,515
Results
Results 1
Distribution of Women by Eligibility (%)
Zimbabwe Rwanda Ethiopia Senegal
2010-11
Total (All women 15-49 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
2010
2011
2010
100.0
100.0
100.0
100.0
18.1
0.9
8.3
30.0
0.5
7.0
25.2
0.4
7.3
26.1
0.2
7.7
4.3
1.1
13.0
1.2
0.9
32.4
1.1
0.7
5.0
4.2
0.7
26.2
2.2
1.8
11.5
1.0
1.6
16.0
1.3
2.1
18.3
5.8
3.1
6.7
19.9
24.7
33.0
28.8
Results 1
Distribution of Women by Eligibility (%)
Zimbabwe Rwanda Ethiopia Senegal
2010-11
Total (All women 15-49 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
2010
2011
2010
100.0
100.0
100.0
100.0
18.1
0.9
8.3
30.0
0.5
7.0
25.2
0.4
7.3
26.1
0.2
7.7
4.3
1.1
13.0
1.2
0.9
32.4
1.1
0.7
5.0
4.2
0.7
26.2
2.2
1.8
11.5
1.0
1.6
16.0
1.3
2.1
18.3
5.8
3.1
6.7
19.9
24.7
33.0
28.8
Results 2
Modern Contraceptive Use by Eligibility Criterion (%)
Zimbabwe Rwanda Ethiopia Senegal
2010-11
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
2010
2011
2010
0.0
100.0
0.0
0.0
100.0
0.0
0.1
100.0
0.0
0.1
100.0
0.0
59.2
8.6
35.4
19.3
56.0
100.0
46.7
2.1
20.0
6.7
19.3
100.0
21.5
1.5
20.0
11.2
16.8
100.0
8.4
1.6
6.0
13.4
11.6
100.0
0.0
0.0
0.0
0.0
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
2010-11
2010
2011
2010
Ineligible Eligible Ineligible Eligible Ineligible Eligible Ineligible Eligible
Residential area
60
rural
urban
40
Education, highest level attended
no education
2
some primary
26
some secondary
67
> secondary
5
Union/Sexual activity status
65
in union
single, SA, <1month
3
single, SA, ≥1month
9
single, never had sex
23
66
34
84
16
87
13
72
28
85
15
46
54
62
38
5
35
55
4
11
70
17
2
28
63
8
1
42
44
9
6
69
26
3
2
51
24
23
3
75
17
7
1
49
3
48
0
48
2
11
40
58
2
40
0
55
1
6
38
77
1
22
0
54
1
9
35
95
0
5
0
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
2010-11
2010
2011
2010
Ineligible Eligible Ineligible Eligible Ineligible Eligible Ineligible Eligible
Residential area
60
rural
urban
40
Education, highest level attended
no education
2
some primary
26
some secondary
67
higher than secondary
5
Union/Sexual activity status
65
in union
single, SA, <1month
3
single, SA, ≥1month
9
single, never had sex
23
66
34
84
16
87
13
72
28
85
15
46
54
62
38
5
35
55
4
11
70
17
2
28
63
8
1
42
44
9
6
69
26
3
2
51
24
23
3
75
17
7
1
49
3
48
0
48
2
11
40
58
2
40
0
55
1
6
38
77
1
22
0
54
1
9
35
95
0
5
0
Results 4
Reasons for Not Using (%)
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
Zimbabwe Rwanda Ethiopia Senegal
2010-11
2010
2011
2010
24.0
5.4
13.6
2.7
69.9
73.6
45.7
50.7
52.8
43.3
15.6
17.1
11.3
5.4
4.3
5.7
8.4
28.3
27.7
30.7
9.4
4.4
11.8
26.3
0.3
0.4
5.2
4.1
7.6
12.4
19.3
11.4
7.2
12.4
19.1
11.1
0.5
0.0
0.3
0.3
0.7
0.0
1.7
0.8
2.1
0.0
0.2
2.3
2.4
6.0
9.7
4.0
3.0
20.9
7.3
0.9
0.4
0.2
1.0
4.2
*breastfeeding, postpartum amenorrhea
**fear of side effects/health concerns, inconvenient to use, interferes with body's processes
Results 4
Reasons for Not Using (%)
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
Zimbabwe Rwanda Ethiopia Senegal
2010-11
2010
2011
2010
24.0
5.4
13.6
2.7
69.9
73.6
45.7
50.7
52.8
43.3
15.6
17.1
11.3
5.4
4.3
5.7
8.4
28.3
27.7
30.7
9.4
4.4
11.8
26.3
0.3
0.4
5.2
4.1
7.6
12.4
19.3
11.4
7.2
12.4
19.1
11.1
0.5
0.0
0.3
0.3
0.7
0.0
1.7
0.8
2.1
0.0
0.2
2.3
2.4
6.0
9.7
4.0
3.0
20.9
7.3
0.9
0.4
0.2
1.0
4.2
*breastfeeding, postpartum amenorrhea
**fear of side effects/health concerns, inconvenient to use, interferes with body's processes
Results 5
Are responses valid?
Internal Data Consistency for Selected Reasons
Zimbabwe Rwanda
2010-11
2010
Ethiopia
Senegal
2011
2010
Among women with ”perceived no need due to no/infrequent sex”
sexually active <1 month (%)
9
8
10
19
Among women with "perceived no need due to breastfeeding*/postpartum
amenorrhea”
postpartum period (month)
15.8
9.9
16.3
11.0
< 6-month postpartum (%)
54
44
33
35
postpartum amenorrhea (%)
69
92
85
74
meet part of LAM definition* (%)
46
43
32
32
LAM: Lactation Amenorrhea Method.
*6-month postpartum and amenorrhea, but without breastfeeding component
Discussion
(Over to Madeleine)
Discussion
DHS Data Challenges
Reasons for Non-Use in DHS
1)
2)
3)
4)
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.
Interpretation of responses is challenging, especially for many
common responses (“not married”, “breastfeeding”, “side effects”…)
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?
Reporting inconsistency in selected reasons
Discussion
DHS Data Challenges
Reasons for Non-Use in DHS
1)
2)
3)
4)
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.
Interpretation of responses is challenging, especially for many
common responses (“not married”, “breastfeeding”, “side effects”…)
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?
Reporting inconsistency in selected reasons
Discussion
DHS Data Challenges
Reasons for Non-Use in DHS
1)
2)
3)
4)
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.
Interpretation of responses is challenging, especially for many
common responses (“not married”, “breastfeeding”, “side effects”…)
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?
Reporting inconsistency in selected reasons
Discussion
DHS Data Challenges
Reasons for Non-Use in DHS
1)
2)
3)
4)
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.
Interpretation of responses is challenging, especially for many
common responses (“not married”, “breastfeeding”, “side effects”…)
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?
Reporting inconsistency in selected reasons
Discussion
Improving Measurement of Access
Need to:
1)
2)
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>
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
Discussion
Improving Measurement of Access
Need to:
1)
2)
Arrive at a shared definition of access
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
Discussion
Improving Measurement of Access
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
Discussion
Improving Measurement of Access
Need to:
1)
Arrive at a shared definition of access
2)
Learn from our own history
3)
Consider expanding DHS data on access
4)
5)
Better utilize household and facility-based data from non-DHS sources
o Service Provision Assessments
o PMA2020
Conduct qualitative research
Discussion
Improving Measurement of Access
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
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?
Thank you very much!
Questions and comments:
[email protected], [email protected]
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
Discussion
DHS Data Challenges
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.