This study examines whether the number of brothers a woman grows up with is associated with her ideal number of sons among Nigerian women. Using women's data from the 2018 Nigeria Demographic and Health Survey (n = 40,628), I estimated a weighted negative binomial regression model predicting ideal number of sons. The findings show a positive and statistically significant association between the number of brothers and ideal number of sons. Women who grew up with more brothers are more likely to express desire for a higher ideal number of sons, even after controlling for sociodemographic and economic factors. Additional robustness checks showed that the association remained after controlling for total sibship size, number of sisters, and ideal number of daughters. Interaction models further showed that the association varies by age-cohort and education, but not by region of residence. The association is strongest among younger women and is slightly stronger among women with higher levels of education. These results suggest that early sibling environments may play a role in shaping women's fertility preferences and son preference in Nigeria.
The aim of this study was to develop and psychometrically assess a client-experience-of-care metric tailored for women in Lilongwe, Malawi, using self-administered or provider-administered depot medroxyprogesterone acetate subcutaneous (DMPA-SC) and to assess differences in experiences of care between the two groups. A client exit interview was administered to 400 Malawian women who had self-injected (n = 198) or received provider-administered (n = 202) DMPA-SC within the three months preceding the study. Iterative exploratory factor analysis with a polychoric matrix was performed. Cronbach's alpha was used to assess scale reliability. Bivariate and multivariate generalized linear regression models with robust standard errors were used to test for differences in client experience between self-administered and provider-administered clients. Exploratory factor analysis yielded a two-factor solution, identifying a unifying scale for client experience of care (eight items) and a subscale for empowerment (ten items). The client experience of care scale had moderate construct validity, explaining 40 percent of the variance, high criterion validity with a positive and statistically significant (p < 0.05) correlation coefficient, and low-to-moderate reliability (alpha = 0.68). In adjusted models, statistically significant differences in client experience of care were detected by injection method, with self-injecting clients reporting better experiences of care compared to provider-administered clients.
People often engage social networks when navigating abortion access constraints, but limited research links this involvement to abortion outcomes. This cross-sectional study analyzed PMA2020 data from 1,144 women in Nigeria who had abortions, identified through population-based surveys and abortion-focused follow-ups conducted in 2018 and 2019-2020, respectively. We examined how social network involvement in care-seeking-specifically, in method or provider selection-related to abortion outcomes: medically defined abortion safety, use of preferred method and provider, and success of the initial abortion attempt. Social network involvement was common (63 percent) and varied across sociodemographic groups. Outcomes differed by involvement source: when both partners and family/friends were involved, women were least likely to have the least safe abortions (23.9 percent vs. 60.9 percent, p < 0.001) or make multiple abortion attempts (13.7 percent vs. 19.1 percent, p = 0.009), though they were equally likely to use preferred care as those seeking care alone. Partner-only involvement was also significantly associated with fewer least safe abortions (36.3 percent vs. 60.9 percent, p < 0.001), while family/friend-only involvement was significantly associated with non-preferred abortion options (36.6 percent vs. 21.6 percent, p < 0.001) and more repeated attempts (27.8 percent vs. 19.1 percent, p = 0.038). These findings suggest that social networks have the potential to improve or worsen abortion outcomes, with important variation across person-centered measures of abortion experiences.
Unintended pregnancy is a key marker of unmet sexual and reproductive health needs, yet quantitative evidence among female sex workers (FSWs) in Sri Lanka is scarce. We conducted a cross-sectional respondent-driven sampling survey among 551 FSWs aged 18-49 years in Colombo from March to June 2025. Using Gile's successive sampling estimator, we generated respondent-driven sampling-weighted prevalence estimates and described pregnancy awareness, testing, and mitigating actions taken following pregnancy recognition among this sample. We conducted multivariate logistic regressions to identify women-level correlates of ever unintended pregnancy. Pregnancy-level prevalence was contextualized against six Sri Lankan non-sex worker studies using meta-analysis. Most participants had ever been pregnant (88.5 percent). Among ever-pregnant women, 51.1 percent reported at least one unintended pregnancy, and 39.8 percent of 1,225 lifetime pregnancies were unintended. Around two-thirds of FSWs recognized their most recent pregnancy by four weeks' gestation, but routine pregnancy testing was uncommon (11.3 percent), 44.8 percent reported no preventive measure at their most recent unintended pregnancy, and the pregnancy-accounting cascade indicated important downstream consequences. The risk of unintended pregnancy was found to be more clustered among women initiating paid sex before age 19 and those with higher parity. Pregnancy-level unintended pregnancy exceeded pooled non-sex worker estimates by about 11-13 percentage points. Taken together, the findings point to missed opportunities at both the pregnancy recognition and preventive response stages of the pathway. These findings support targeted sexual and reproductive health programs for FSWs in Colombo that prioritize routine and outreach-based pregnancy testing, rapid access to acceptable contraceptive options, and focused support for women entering sex work early, those with repeated pregnancies, and those who took no preventive measures at unintended conception.
Conventional metrics of contraceptive need focus on contraceptive use among those not seeking pregnancy, ignoring individuals' contraceptive preferences beyond pregnancy prevention. We examine contraceptive alignment, a novel metric describing agreement between actual and preferred method use/nonuse, among a 2022 nationally representative U.S. sample of 15-44-year-olds assigned female sex at birth (unweighted n = 3,044). Most respondents (62.2 percent) were classified as having contraceptive alignment (using a method they preferred or not using a method when they preferred not to), while 37.8 percent did not have contraceptive alignment. Contraceptive alignment was higher among contraceptive nonusers who were older and in a serious relationship, as well as both contraceptive users and nonusers who were classified as having higher contraceptive self-efficacy. Contraceptive alignment was lower among contraceptive users who selected their current method due to being unable to obtain the method they originally wanted and those who were using more than one method of contraception. Our findings suggest that conventional measures of contraceptive need may mask important discordance in individuals' contraceptive preferences and actual use that can contribute to misdirected efforts to expand contraceptive access and undermine reproductive autonomy. Contraceptive alignment may more accurately portray individuals' contraceptive needs.
Return migration, whether voluntary or forced, can disrupt individuals' lives as they navigate life in a country that may feel unfamiliar. This disruption often extends to healthcare, including reproductive care. The migration experience, combined with differences between healthcare systems-in terms of availability, accessibility, and affordability-may create barriers to contraceptive access. This study utilizes data from the 2014, 2018, and 2023 National Survey of Demographic Dynamics (ENADID) surveys to analyze contraceptive use and access among female Mexican returnees. Findings indicate that returnees are more likely to use contraception than nonmigrants, particularly short-acting hormonal methods (SACs), while being less likely to rely on permanent methods. These patterns suggest that both migrant selectivity and adaptation shape contraceptive behavior. However, important differences emerge by time since return. Women who recently returned are less likely to use SACs and long-acting contraceptives and are more likely to obtain contraception from private clinics and pharmacies, compared to those with longer residence in Mexico. At the same time, there is little evidence that these patterns reflect shifts in fertility preferences. Instead, findings point more strongly to disruption and barriers to public healthcare following return. Overall, results highlight the need for reproductive healthcare interventions that better support return migrants during reintegration.
Senegal faces high maternal mortality, elevated levels of short‑interval births, and substantial unmet need for postpartum contraception. Supply chain challenges contribute to contraceptive nonuse in the country. Before 2013, Senegal used a pull‑based contraceptive supply chain, in which facility staff estimated demand and procured supplies, leading to frequent stockouts. The informed push model (IPM), launched in 2012, aimed to streamline distribution. We used 2014-2019 DHS data (N = 32,373) and applied an event‑study difference‑in‑differences design with district‑level data to assess changes in the prevalence of modern, long-acting, reversible, and short‑acting contraceptive methods. We further conducted subgroup analyses by wealth and urbanicity. IPM significantly increased contraceptive prevalence. Modern contraceptive use in the postpartum period rose by 7.8 percentage points within 10 quarters post-IPM. Increases were most pronounced for wealthier and more urban districts. Results underscore the value of strong supply chains but show that supply‑side efforts alone may not reach low-income and rural populations. Future work should evaluate the cost-effectiveness and sustainability of alternative financing models and integrated strategies to address persistent supply and access barriers.
Personally important decisions, like reproductive choices, may be challenging for individuals with clinical depressiveness, as indecisiveness is a common depressive symptom. This study examines whether decision-making modes related to reproductive behavior differ between individuals with and without clinical depressiveness (H1) and whether these modes remain stable over time, even after the birth of the first child (H2). Data stem from the German Panel Analysis of Intimate Relationships and Family Dynamics (pairfam). Clinical depressiveness was measured using State-Trait Depression Scales and decision-making modes through items on reproductive behavior. H1 was analyzed using multivariate analysis of covariance (MANCOVA) and post hoc analysis of variance (ANOVA); H2 via fixed-effect regressions and cross-lagged panel model. A significant group difference emerged in the combined decision-making modes (Pillai's trace = 0.009, F(6, 4832) = 7.32, p < 0.001). Individuals with clinical depressiveness engaged more in rational and avoidant modes, whereas those without favored normative decision-making. Decision-making remained stable between subjects; within-subject analyses showed alterations over time. Between subjects, decision-making remained stable. Characteristics of depressive symptoms and individual circumstances may explain the results. Future research should incorporate other clinical conditions and qualitative analyses. Practitioners should consider individual costs, benefits, and decisional postponement.
Abortion care in Britain has undergone significant transformation in recent years, with increasing use of medication, home management, and telemedicine. However, provision remains predominantly through specialist standalone clinics, particularly in England. Drawing on the interlinking frameworks of abortion exceptionalism, stigma, and quality of care, we analyzed 48 qualitative interviews with people who recently had abortions to explore how service-users perceive different models of care in terms of access, continuity, holistic care, and the normalization of abortion. Participants highlighted the importance of both place (standalone vs. integrated) and provider (specialist vs. generalist). Primary care was seen as convenient and supportive of continuity (e.g., for post-abortion contraception) and normalization of abortion as routine healthcare. Specialist clinics, however, were valued for expertise and nonjudgmental care. Community sexual and reproductive health services offered a blend of these benefits. Preferences varied depending on individual circumstances, pointing to the need for flexible, person-centered care. This study contributes to ongoing discussions about how best to organize abortion services to support reproductive autonomy and equity. Importantly, structural change alone is insufficient; attention to the ongoing experience of stigma remains essential to delivering high-quality, person-centered abortion care.
Even though one-year pregnancy rates following contraceptive discontinuation are similar to pregnancy rates following nonuse of contraception, there are widespread perceptions that modern contraceptives will have adverse effects on future fertility. There are likely a variety of factors that contribute to these perceptions. One explanation could be the short-term (<12 months) delays in return to fertility following contraceptive cessation, which may be interpreted as evidence of subfertility. In this commentary, we argue that the contraceptive field should embrace evidence-based nuance about return to fertility (including, but not limited to, during contraceptive counseling) to minimize confusion and distrust. Further, greater emphasis on the fertility-preserving aspects of contraception and multipurpose prevention technologies may be helpful in bringing understanding about the effects of contraception into alignment with scientific evidence.
Despite greater availability and affordability of modern contraception, the use of traditional contraception is rising in India. We examined the relationship between Indian women's contact with a community health worker (CHW) and discussion of family planning (FP) with their contraceptive use. We analyzed data from 306,037 nonpregnant, non-sterilized married women in the 2019-2021 National Family Health Survey (NFHS). Multinomial regression models estimated the association between CHW contact and contraceptive use (consistent use, switching, and discontinuation) in the past three months. Nearly 22 percent of women reported current use of traditional contraception, with 18 percent reporting exclusive use and 4.1 percent concurrent method use. Traditional contraception was more common among older women, women with lower education, higher parity, and in nuclear households. CHW discussion on FP was associated with higher traditional contraceptive use [Adjusted Odds Ratio (AOR) = 1.11 (95 percent Confidence Interval (CI): 1.04, 1.19)], reversible modern method use [AOR = 1.92 (95 percent CI: 1.82, 2.02)], and concurrent use [AOR = 2.19 (95 percent CI: 1.95, 2.45)]. Recent CHW engagement was associated with consistent modern method use [Adjusted Relative Risk Ratio (ARRR) = 2.02 (95 percent CI: 1.91, 2.13)], switching from traditional to modern method [ARRR = 1.67 (95 percent CI: 1.14, 2.46)], and discontinuation of modern contraception [ARRR = 2.10 (95 percent CI: 1.81, 2.44)]. CHW engagement on FP may enable initiation and consistent use of traditional and modern methods, switching, and discontinuation of contraception.
Adolescent girls in low- and middle-income countries (LMIC) with high levels of poverty face barriers to education, health, and life opportunities. In Northern Nigeria, patriarchal norms and gendered expectations heighten girls' risk of early marriage and high-risk childbearing. Birth spacing, or extending the length of time between births, can be a socially acceptable strategy that girls use to maintain their health. The Centre for Girls Education (CGE)'s Married Adolescent Girls Safe Spaces (MAS) program in rural Northern Nigeria included lessons on birth spacing and visits to health facilities. We conducted a case study of the MAS program, drawing from three years of ethnographic field research, including participant observation, in-depth interviews, and focus groups. Combining scientific evidence and Islamic teachings in MAS safe spaces shaped girls' understanding and appreciation of modern birth spacing methods, and their agency in negotiating usage. However, girls' agency remained constrained by structural and normative barriers limiting their ability to practice birth spacing. The MAS program suggests that integrating scientific information and Islamic teachings on birth spacing in safe spaces can strengthen married adolescent girls' knowledge and agency to use modern methods, while underscoring the need to address persistent structural and gender norms.
Access to timely postpartum family planning (PPFP) helps safeguard women's reproductive autonomy and supports healthy birth spacing, yet little is known about how reproductive coercion (RC) shapes women's ability to initiate contraception after childbirth. We analyzed prospective cohort data from 1,481 pregnant Ethiopian women followed for 12 months postpartum between 2021 and 2023. Time (in months) to contraceptive uptake by pre-pregnancy RC exposure and residence was assessed using Kaplan-Meier estimators and parametric survival models. Approximately one in seven women experienced pre-pregnancy RC, and, overall, 46.7 percent adopted a modern contraceptive method within 12 months postpartum. Overall differences in PPFP uptake were modest, but residence significantly modified this relationship. Rural women who experienced RC initiated postpartum contraception later and had a 40 percent lower hazard of initiating postpartum contraception compared to unexposed rural women (adjusted hazard ratio: 0.60, 95 percent confidence interval 0.37-0.98), while no significant association was observed among urban women. Urban women initiated PPFP more rapidly than rural women, regardless of RC exposure. These findings suggest that the effects of RC extend beyond pregnancy and are shaped by the wider structural context, particularly in rural settings where access to contraception may be limited. Recognizing RC as part of the PPFP context is essential for designing programs and health systems responses that support women to realize their reproductive goals and address interpersonal and structural barriers to timely contraceptive use.
Contraceptive prevalence estimates are indicators of the performance of family planning programs. Yet, available evidence suggests that national surveys may be underestimating the prevalence of traditional methods. The apparent underestimation of traditional methods stems from current approaches for collecting, analyzing, and reporting contraceptive data. We examined the effect of survey methodological innovations on the estimation of traditional and modern contraceptives. We used data from a cross-country comparative study conducted in the Democratic Republic of Congo (DRC), Ghana, Kenya, and Nigeria. The sample comprised 9,075 in union and sexually active women not in union aged 15-49 years. The results showed that follow-up method-by-method questioning increased the reporting of both traditional and modern methods, with the increase being much higher for modern methods, while reducing the percentage of nonusers. Revising the standard approach for computing contraceptive prevalence to account separately for concurrent traditional and modern method use revealed substantial underestimation of traditional method use, particularly in DRC and Ghana. These findings underscore the need to revise the current framing of questions and estimation approaches to improve the accuracy of contraceptive use estimates. The findings also highlight the importance of taking into account concurrent use of traditional and modern methods, which is often ignored in family planning research.
Educational expansion is widely regarded as a central mechanism in fertility transitions, yet some research suggests its role may be more modest. This study analyzes birth histories from 414 surveys in 72 low- and middle-income countries to reassess the contribution of the shift in the educational composition of the population to fertility declines. We reconstruct fertility trends by educational level over several decades and apply the Kitagawa decomposition method to determine whether declines primarily reflect shifts in educational composition or changes in fertility within educational groups. On average, educational expansion accounts for approximately 30 percent of the decline in fertility, with substantial variation across regions, countries, and over time. The declines primarily reflect fertility changes within educational groups, especially among women without secondary education, rather than shifts in the educational composition of the population. However, although educational progress is neither necessary nor sufficient for fertility decline, it has consistently contributed to fertility reductions and is likely to remain an important component of fertility transitions.
We examine the effect of Ghana's National Health Insurance Scheme's (NHIS) contraceptive coverage policy on modern contraceptive use among women in the country. We analyzed three rounds of Ghana Demographic and Health Survey data (2008-2022), using 2008-2014 as the pre-intervention period and 2022 as the post-intervention period. A propensity score matching was applied to the pre-intervention data to enhance comparability between intervention (NHIS) and control (non-NHIS) groups, before applying the difference-in-differences estimator. Multivariable linear probability models were used to estimate the effects. We also performed a placebo and sensitivity analysis to assess the validity and robustness of findings. Among the 26,713 weighted sample, 71.6 percent were in the intervention group and 28.4 percent in the control group. The NHIS contraceptive coverage policy significantly increased modern and long-term contraceptive use by 2.9 and 2.3 percentage points, respectively. We observed heterogeneous effects, with significantly higher increases in long-term method use among women in urban areas and smaller, nonsignificant increases among those in rural areas. Our findings underscore the potential for health insurance in enhancing access to and utilization of modern contraceptive methods. Sustained financing, timely provider reimbursement, and continuous monitoring are necessary to ensure reliable service availability and long-term policy sustainability.
Declining fertility preferences are recognized as a key driver of fertility reduction in sub-Saharan Africa, emphasizing the need to understand their determinants and evolution. This study investigates how the relationship between gender attitudes and desired fertility has changed over time among young women aged 15-24. Using Demographic and Health Surveys from Ethiopia, Malawi, Mali, Nigeria, and Zambia, we analyze country-specific associations between attitudes towards wife beating and ideal number of children across four consecutive surveys spanning approximately 15 years. A pooled cross-country model includes a context-specific education measure to assess its moderating effect on the association. Findings show that tolerance of wife beating is linked to higher desired fertility in all countries at one or more time points, though the strength and direction of this relationship vary over time and by context. As egalitarian gender attitudes spread, women endorsing gender equality begin to diverge from high-fertility norms, while those holding traditional attitudes remain pronatalist, widening the gap in fertility preferences between the two groups. This shift is more likely in countries where the national average of women's education is relatively high (more than 4.5 years), suggesting that rising education fosters both egalitarian attitudes and changing fertility ideals.
This Data Article describes a novel dataset from the "Re-Examining Traditional Method Use" (TEAM-UP) project, which systematically collected data on the measurement of and motivations for use of non-modern (traditional and folkloric) contraceptive methods and/or modern methods, in four sub-Saharan African countries: the Democratic Republic of Congo, Ghana, Kenya, and Nigeria. TEAM-UP comprises four datasets (two quantitative and two qualitative), enabling comprehensive analyses of (1) the impact of methodological innovations on reporting of modern and non-modern method use, and prevalence estimates; (2) motivations for, and user experiences related to traditional and folkloric methods, and (3) contraceptive use dynamics across all methods and method types, including nonuse. Data collection was conducted in four stages: qualitative (Stage 1; 54 focus group discussions and 81 key informant interviews) and quantitative (Stage 2; n = 918) pilots, followed by women's surveys (Stage 3; n = 13,625) and follow-up qualitative in-depth interviews (Stage 4; 469 interviews). The main TEAM-UP survey data are publicly available, with both the pilot and follow-up in-depth qualitative data available upon vetted request.
Sexual and reproductive health (SRH) research, programming, policy, and services have long relied on the narrow paradigm of "pregnancy intendedness and planning," including its "unintended pregnancy" measure. This framework is limited and problematic, overlooking diverse perspectives on pregnancy, structural factors, and non-parenting outcomes such as abortion and adoption. In response, we developed the Self-Assessed Pregnancy Acceptability (SAPA) framework and measure as a person-centered alternative. The SAPA framework was developed by centering the lived experiences of pregnant people in Texas, Tennessee, Pennsylvania, and California through baseline interviews shortly after pregnancy confirmation (N = 31) and follow-up post-pregnancy interviews (N = 14). Development was also informed by a diverse Expert Panel (N = 19) including reproductive justice leaders, reproductive measurement experts, and lived experience experts. Using cognitive interviews (N = 13), we refined an 11-item measure of SAPA that is currently being validated in a nationwide sample of nearly 600 people in early pregnancy. Following validation, SAPA could be integrated into national and state-level epidemiological surveillance surveys such as the National Survey of Family Growth and the Pregnancy Risk Assessment Monitoring System. This novel framework and measure offer an alternative to unintended pregnancy and contribute to an ecosystem of person-centered, rigorously developed measures of SRH equity.
Contraceptive stockouts are a major barrier to effective family planning (FP) service delivery in Nigeria, limiting access to modern methods and contributing to adverse reproductive health outcomes. Despite ongoing efforts to strengthen the supply chain, many health facilities continue to experience stockouts. A cross-sectional study was conducted in September 2024 across 1,050 service delivery points (SDPs) in Nigeria. Descriptive statistics and univariate mixed-effects logistic regression were used to explore associations between stockouts and facility characteristics, including location, supervision frequency, resupply methods, and logistics practices. Overall, 41.7 percent of SDPs reported at least one contraceptive stockout in the three months preceding the survey. Stockouts were slightly more common in rural facilities (56.8 percent) compared to urban facilities (43.2 percent), though this difference was not statistically significant ( p = 0.53). Monthly supervisory visits were associated with significantly lower stockout rates ( p = 0.014). Facilities relying on external agencies for resupply had 1.55 times higher odds of stockouts than those calculating needs internally ( p = 0.058). Delays exceeding two weeks between ordering and delivery were the strongest predictor of stockouts (odds ratio: 1.76, 95 percent confidence interval: 1.257–2.474, p < 0.001). Improving supply chain efficiency, supervision frequency, and resupply models is critical to reducing contraceptive stockouts and enhancing FP service delivery in Nigeria.
