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unmet need - Integration for Impact
Rethinking Unmet Need for Family Planning among Women Living with HIV: A Dynamic Screening Model Susan E. Adamchak, Barbara Janowitz, Emily Keyes Integration for Impact Conference Nairobi, Kenya September 12-14, 2012 Basic algorithm to estimate unmet need of contraception Currently married women not using contraception Pregnant or amenorrheic Intended Mistimed Need for spacing Not pregnant or amenorrheic Unwanted Need for limiting Fecund Want later Want no more Need for spacing Need for limiting Total unmet need Bradley, Croft and Fishel, 2009 Infecund Want soon Basic algorithm to estimate unmet need of contraception Currently married women not using contraception Pregnant or amenorrheic Intended Mistimed Need for spacing Not pregnant or amenorrheic Unwanted Need for limiting Fecund Want later Want no more Need for spacing Need for limiting Total unmet need Bradley, Croft and Fishel, 2009 Infecund Want soon Basic algorithm to estimate unmet need of contraception Currently married women not using contraception Pregnant or amenorrheic Intended Mistimed Need for spacing Not pregnant or amenorrheic Unwanted Need for limiting Fecund Want later Want no more Need for spacing Need for limiting Total unmet need Bradley, Croft and Fishel, 2009 Infecund Want soon Basic algorithm to estimate unmet need of contraception Currently married women not using contraception Pregnant or amenorrheic Intended Mistimed Need for spacing Not pregnant or amenorrheic Unwanted Need for limiting Fecund Want later Want no more Need for spacing Need for limiting Total unmet need Bradley, Croft and Fishel, 2009 Infecund Want soon Basic algorithm to estimate unmet need of contraception Currently married women not using contraception Pregnant or amenorrheic Intended Mistimed Need for spacing Not pregnant or amenorrheic Unwanted Need for limiting Fecund Want later Want no more Need for spacing Need for limiting Total unmet need Bradley, Croft and Fishel, 2009 Infecund Want soon Comprehensive Strategy of PMTCT Prong 1 Prong 2 Prong 3 Prong 4 Primary prevention of HIV among women of childbearing age Prevention of unintended pregnancies among HIV positive women Prevention of infection transmission from HIVpositive mothers to infants Care and support for women, their children and family Key Question • How should the DHS-based algorithm for measuring the unmet need for FP be modified so that providers can respond better to the family planning needs of HIV service clients? • Consider: – both recent and plans for future sexual activity – desire for children in the near and distant futures – use effectiveness of contraceptive methods Methodology • Pooled data from multi-country study of integrated FP-HIV services • Data collected in Ethiopia, Kenya, Rwanda, South Africa and Uganda in 2007-2008 • Two samples of women aged 18-45 – Care and Treatment (C&Tx): n=266 – Counseling and Testing (HTC) n=713 • Calculated unmet need for FP based on various assumptions of sexual activity and pregnancy desires Analysis addressed 5 questions of unmet need logic 1. Is the assumption that all married women are sexually active reasonable? 2. Does lack of sexual activity imply no need for contraception? 3. How should current pregnancy be treated? 4. What time horizon should be used to measure FP need among women wanting more children? 5. Should the assessment of unmet need consider method mix? Unmet need among women in union in C&Tx Total Currently using contraception Not using contraception Among those not contracepting No sex in last 3 months Sex in last 3 months Among those not contracepting & sexually active Pregnant Not pregnant Among those not contracepting, sexually active & not pregnant Infecund Fecund Among those not contracepting, sexually active, not pregnant & fecund Do not want child in next 2 years Want child in next 2 years Among those pregnant Last pregnancy was intended Last pregnancy was unexpected Method failure Unmet Need Sexual Activity Assumed 158 75 83 83 11 72 72 21 51 51 40 11 11 6 1 4 26% Sexual Activity Specified 158 75 83 83 41 42 42 8 34 34 9 25 25 15 10 8 3 1 4 10% Unmet need among women in union in HTC Total Currently using contraception Not using contraception Among those not contracepting No sex in last 3 months Sex in last 3 months Among those not contracepting & sexually active Pregnant Not pregnant Among those not contracepting, sexually active, not pregnant & fecund Do not want child in next 2 years Want child in next 2 years Among those pregnant Last pregnancy was intended Last pregnancy was unexpected Method failure Unmet Need Sexual Activity Assumed 402 104 298 298 143 155 155 105 50 143 75 37 25 35% Sexual Activity Specified 402 104 298 298 73 225 225 138 87 87 54 33 138 74 35 26 22% Reasons for Seeking HIV Test among NonContracepting HTC Clients, No Sex in Last 3 Months Other 10% Missing 11% Multiple partners 8% Getting married 37% Unwell 8% n=225 Know HIV status/plan for future 20% Begin or resume sexual relationship, 6% Contraceptive Use among C&Tx and HTC Clients by whether They Want a Child in Next 2 Years 80 70 C&Tx HTC 60 50 40 Contracepting 30 Not Contracepting 20 10 0 Wants child Does not want Wants child Does not want child child Effectiveness of FP Methods Percent Distribution of Method Use among FP Users by Parity C&Tx HTC All FP users (n=107) 43 FP users with < 3 children (n=57) 44 FP users with 3+ children (n=50) 42 12 12 Injectables only1 28 Pills only Long acting or permanent method2 Condoms only Hormonal method plus condom Other and missing3 1. 2. 3. All FP users (n=183) 26 FP users with <3 children (n=132) 32 FP users with 3+ children (n=51) 16 12 3 3 4 28 28 38 33 49 2 2 2 15 14 2 10 7 14 9 7 16 5 7 2 9 11 14 Includes three women who reported using injectables and pills. Includes women using implants, IUCD or sterilization. Includes women using the rhythm method, cycle beads, etc. Basic algorithm to estimate unmet need of contraception Sexual activity, FP use effectiveness Pregnant or amenorrheic Intended Not pregnant or amenorrheic Post Partum FP Plan Need for spacing Need for limiting Fecund Want > 12 mos. Want none Need for spacing Need for limiting Total unmet need Bradley, Croft and Fishel, 2009 Infecund Want < 12 mos. In the dynamic context of the lives of women with HIV, providers should consider the following … 1. Current sexual activity and intentions to become sexually active in the near future 2. Client intentions about timing of future pregnancies within a shorter time period 3. Method choices that consider use effectiveness and fertility intentions (especially for high parity women) 4. Counseling to move from dual protection (condoms) to dual method use (condoms + other method) 5. Action plan for pregnant women to receive FP counseling soon after delivery
