Improving contraceptive method mix
Jane T. Bertrand, PhD, MBATulane SPHTM
Advance Family Planning Meeting: 9 April 2019
The distribution of contraceptive methods used in a given country reflects:
SUPPLY: Methods that are available and affordable
DEMAND: Consumer preferences, social norms
Two measures of method mix (distribution)
Measure #1: Method skew
• More than 50% of users reply on a single method (Bertrand et al, 2014)
• FP2020 – uses 60% as the criterion
• Skewed method mix is worrisome!
Example: Sudan: 2014 MICS
Pills 78.3%
Causes of a skewed method mix
Acceptable reasons• Community norms favor a particular method• “Everyone in my community uses the injection,
so that’s what I want.”• Historical: Zimbabwe is a “pill country” because
of a strong CBD program years ago
Worrisome reasons• Pressure from a service provider to use a specific
method• Lack of access to a facility with a full range of
methods• Inability to afford the preferred contraceptive• Stockouts of the preferred method
Second measure of method mix: “Average Deviation” (AD)
• A measure of “evenness” of method distribution (Ross et al, 2015)• If users were evenly divided across 8
methods, each method = 12.5%• AD = simple average of differences
around the mean• Potential range of AD: 0-21.9
• 0 if totally “even” (see pie graph)• 21.9 = all users rely on 1 method• Actual range: 6-19• “Middle 50%”: 8.6-12.2
Female Ster.
Vasectomy
IUD
ImplantInjection
Pills
Condoms
Traditional
Improved method mix and increased CPR may go hand in hand (but not always)
Rwanda (1983): CPR = 11.0%
Rhythm
Rwanda (2014/15): CPR = 53.2%
Injectable
Rwanda is the SSA country with the greatest method balance improvement (Ross et al, 2015)
Let’s look at method mix in the 8 AFP countries
• What is the method mix as of the last nationally representative survey?
• Do over 50% of users rely on a single method (“method skew”)?
• What is the “average deviation” (AD) from “evenness”?• The sweet spot ranges from 8.6-12.2
• If skewed, is the country evolving toward a more balanced method mix?
Female ster.7%
Vasectomy2% IUD
1%Implant
3%
Injectable20%
Pill43%
Male condom
10%
Traditional 14%
Method Mix:Bangladesh 2014
CPR: 62%mCPR: 54%Mean AD score: 10.6
AD: Bangladesh 1976-2014
0
2
4
6
8
10
12
14
16
18
20
19761979
19811983
19851988
19891991
19931996
19992004
20072011
20122014
AD V
alue
Survey Year
Indicates skewed method mix
Female ster.3%
Vasectomy0.5% IUD
1% Implant4%
Injectable6%
Pill4%
Male condom
17%Traditional 65%
Method Mix: DRC 2014
CPR: 20%mCPR: 8%Mean AD score: 15.5
AD: DRC 2001-2014
Indicates skewed method mix
0
2
4
6
8
10
12
14
16
18
20
2001 2007 2010 2014
AD V
alue
Survey Year
Female ster.68%
Vasectomy0.6%
IUD3%
Pill8%
Male condom
10%
Traditional 11%
Method Mix: India 2016
CPR: 53%mCPR: 48%Mean AD score: 14.0
AD: India 1981-2016
Indicates skewed method mix
0
2
4
6
8
10
12
14
16
18
20
1981 1988 1993 1999 2003 2006 2008 2016
AD V
alue
Survey Year
Method Mix: Indonesia 2017
Female ster.6%
IUD7%
Implant9%
Injectable52%
Pill20%
Male condom
2%
Traditional4%
CPR: 61%mCPR: 59%Mean AD score: 13.1
AD: Indonesia 1976-2017
0
2
4
6
8
10
12
14
16
18
20
19761979
19851987
19911994
19972003
20052006
20072008
20092010
20112012
20132014
20152016
2017
AD V
alue
Survey YearIndicates skewed method mix
Female ster.5%
IUD6%
Implant30%
Injectable45%
Pill8%
Male condom
3%
Traditional 3%
Method Mix: Kenya 2016
CPR: 61%mCPR: 60%Mean AD score: 10.5
AD: Kenya 1978-2016
0
2
4
6
8
10
12
14
16
18
20
1978 1984 1989 1993 1998 2003 2009 2014 2015 2016
AD V
alue
Survey Year
Indicates skewed method mix
Female ster.2%
IUD5%
Implant11%
Injectable34%Pill
18%
Male condom
9%
Traditional21%
Method Mix: Nigeria 2017
CPR: 13%mCPR: 11%Mean AD score: 10.5
AD: Nigeria 1982-2017
0
2
4
6
8
10
12
14
16
18
20
1982 1990 1994 1999 2003 2007 2008 2011 2012 2013 2016 2017
AD V
alue
Survey YearIndicates skewed method mix
Female ster.9% Vasectomy
0.3%IUD2%
Implant18%
Injectable33%
Pill15%
Male condom
6%
Traditional17%
Method Mix: Tanzania 2016
CPR: 38%mCPR: 32%Mean AD score: 10.3
AD: Tanzania 1992-2016
0
2
4
6
8
10
12
14
16
18
20
1992 1994 1996 1999 2004 2005 2010 2016
AD V
alue
Survey Year
Indicates skewed method mix
Female ster.7% IUD
2%
Implant19%
Injectable47%
Pill7%
Male condom
6%
Traditional12%
Method Mix: Uganda 2017
CPR: 38%mCPR: 34%Mean AD score: 10.0
AD: Uganda 2006-2016
0
2
4
6
8
10
12
14
16
18
20
2006 2011 2014 2015 2016 2017
AD V
alue
Survey Year
Indicates skewed method mix
Three take-away messages
1) The predominant method differs by country: (*) indicates >50% skew• Injectable: Indonesia (*), Kenya, Nigeria, Tanzania, Uganda• Female sterilization: India (*)• Pill: Bangladesh • Traditional: DRC (*)
2) Four patterns emerge from 8 countries:• Method skew has improved but CPR is low (DRC, Nigeria)• Method skew persists but CPR is relatively high (India, Indonesia)• Method mix is balanced with relatively high CPR (Bangladesh, Kenya)• Method mix is balanced but CPR < 35% (Tanzania, Uganda)
3) There is no “ideal method mix,” but method skew raises red flags:• Do clients have access to a full range of accessible and affordable methods, free of
provider bias?
Advocacy has a role in improving method mix
• Increase awareness of method mix among country leadership• Strengthen role of the private sector (e.g., EC, DMPA-SC)• Ensure availability of all methods in public and private sectors• Include all methods on the essential medicine lists, including
pharmaceutical medicine lists• National and subnational governments to budget for contraceptives,
equipment, personnel, and training• Operationalize task sharing guidelines at national and subnational
levels• Address barriers to contraceptive access for young people
Acknowledgements
• Dr. John Ross, independent consultant and expert on method mix
•Ms. Kate Schultz, Tulane graduate student