OBJECTIVE:To describe and compare the sociodemographic and access to care characteristics, specifically travel patterns, funding, and wait times, following the Dobbs decision among people receiving assistance from a practical support abortion fund, and examine factors associated with variation in wait times within each period. METHODS:We used administrative data from a U.S. abortion fund that provides logistical support to people seeking abortions and prioritizes pregnancies of 15 weeks or greater. We included clients that received funding and with abortion appointments between July 2019 and June 2023. Bivariate analyses compared travel patterns, funding, and wait times between pre- and post-Dobbs groups. We used Wilcoxon-Mann-Whitney tests to compare median wait times between periods and Kruskal-Wallis tests to assess within-group differences. RESULTS:Among 3641 clients, 62.9% received support before Dobbs. More than half (56.0%) had pregnancies of 24 weeks or greater at the time of referral to the abortion fund. Compared with pre-Dobbs clients, post-Dobbs clients were more likely to originate from states with restrictive abortion policies (67.8% vs 53.1%) and from the South (69.4% vs 52.6%). Post-Dobbs clients also received more funding on average ($1732 vs $899) and experienced longer wait times (median 9 vs 6 days) for their abortion appointment. CONCLUSIONS:Following Dobbs, clients from a practical support abortion fund were more likely to travel from restrictive states, required more funding, and waited longer for abortion care. These findings highlight increasing barriers to abortion access and the critical role of practical support organizations in helping people obtain care.

Background Equity in health services use is related to utilizing equal treatment for equal health needs, irrespective of socioeconomic status. Inequity in maternal health services use in low- and middle-income countries has become a central public health policy and research issue in recent years to achieve universal health coverage by 2030. For Bangladesh, we examined if the socioeconomic equity for selected maternal health services use (viz., antenatal care from a medically trained provider, facility delivery, and management of complications) improved more in districts with high facility readiness than in the rest of the country during 2001‒2016. Methods We used data from three rounds of the Bangladesh Maternal Mortality and Health Care Survey and corresponding rounds of the Bangladesh Health Facility Survey to estimate the differential effect of facility readiness on equity in maternal health services use during 2001‒2016. We applied an adaptation of the Difference-in-Differences (DID) model based on linear probability models on a pooled dataset of 2001, 2010, and 2016 household surveys linked to corresponding health facility surveys. Results Bangladesh has made impressive improvements in the overall use of maternal health services, but the increase was not uniform for all the population groups. Though there have been modest improvements in equity for ANC and treatment for complications, inequity for facility delivery increased noticeably between 2001 and 2016. The nonpoor-poor gap in the high facility readiness districts increased faster than in the low readiness districts during 2001‒2016, resulting in a more inequitable distribution of facility delivery services (p < 0.05). We also found that ANC became more equitable between 2001 and 2016 among women living < 1 hour from a private facility (p < 0.05). Conclusions This is the first systematic investigation of the role of facility readiness on maternal health equity in Bangladesh using nationally representative data. This study found persistent socioeconomic inequities in the use of all three key maternal health services, and for facility delivery, socioeconomic inequity worsened over time. The empirical evidence and policy measures presented here provide a way forward for policymakers to provide equitable care for safe delivery services in Bangladesh.

OBJECTIVE:We evaluated the effect of the COVID-19 pandemic on abortion service utilization and delays to care among people in North Carolina and assessed whether there was a differential impact between Latinas and non-Hispanic white patients. METHODS:We used state-level data to examine abortions performed in North Carolina health facilities from 2016 to 2021 (N = 167,058). We employed an interrupted time-series analysis to assess changes in the monthly number of abortions and the monthly proportion of abortions at 13 weeks or later gestation both at the pandemic onset (March 2020) and after (April 2020-December 2021). Primary analyses were conducted for all abortion patients and secondary analyses were limited to Latina patients and compared with non-Hispanic white patients. MAIN FINDINGS:There was no significant change in the monthly number of abortions at the pandemic onset. After March 2020, there was a significant increase in the monthly number of abortions among the total study population. The monthly abortion count also increased for both groups between April 2020 and December 2021, though Latina patients had a greater monthly increase than non-Hispanic white patients. The proportion of abortions at 13 weeks or later dropped significantly at the pandemic onset among the total population by 1.5 (95% confidence interval [-2.3, -.7]) percentage points and remained at approximately the same level thereafter. PRINCIPAL CONCLUSIONS:The COVID-19 pandemic was associated with an increase in monthly abortion counts through 2021 and a decrease in the proportion of abortions after the first trimester at the pandemic's onset.

INTRODUCTION:Medicaid expansion has the potential to increase access to contraception and improve women's health, although existing research examining state-level variation provides mixed evidence. The neighborhood context plays a crucial role in understanding the effects of Medicaid expansion on contraceptive use, as structural inequalities within neighborhoods may shape access to health care and reproductive services. MATERIALS AND METHODS:We used a unique restricted dataset of 13,224 female respondents ages 15-44 years interviewed in the 2011-2019 waves of the National Survey of Family Growth (NSFG). We merged these data with indicators of state Medicaid expansion status and respondents' neighborhood context, operationalized as Index of Concentration at the Extremes (ICE) scores. We used quasi-experimental difference-in-differences models to assess if Medicaid expansion impacted provider-dependent contraceptive use and method type differentially by neighborhood-level context. We used multivariable linear probability and multinomial logistic regression models adjusting for individual and community covariates and state/region fixed effects. RESULTS:Living in a Medicaid expansion state was associated with significant increases in provider-dependent contraceptive method use among respondents in the most deprived neighborhoods (17.9 percentage points, 95% CI [9.0, 26.9], by 2017-2019). Specifically, long-acting reversible contraception (LARC) use increased 7.6 percentage points (95% CI [0.6-14.7]) and use of no method or barrier/coital methods declined 17.5 percentage points (95% CI [-26.3, -8.7]) among those in the most deprived neighborhoods by 2017-2019. CONCLUSIONS:Changes in state-level policies can have major impacts on health systems, but the example of Medicaid expansion underscores the differential impacts on people with less access to health resources, such as those living in structurally disadvantaged neighborhoods. Ultimately, further expansion of Medicaid could facilitate access to the full range of contraceptive methods and advance population health equity in additional U.S. states.

Background After a 40% reduction in maternal mortality ratio (MMR) during 2001-2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001-2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh. Methods We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001-2010 and 2010-2016. We carried out Poisson regression analyses with random effects at the sub -district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors. Results Between 2001 and 2016, the proportion of high -risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001-2010 and 2010-2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010-2016, increasing the risk of maternal deaths by nearly 3 -fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001-2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010-2016. Conclusions Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at -risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.

IntroductionThe social and structural environments where people live are understudied in contraceptive research. We assessed if neighborhood measures of racialized socioeconomic deprivation are associated with contraceptive use in the United States.MethodsWe used restricted geographic data from four waves of the National Survey of Family Growth (2011-2019) limited to non-pregnant women ages 15-44 who had sex in the last 12 months. We characterized respondent neighborhoods (census tracts) with the Index of Concentration at the Extremes (ICE), a measure of spatial social polarization, into areas of concentrated privilege (predominantly white residents living on high incomes) and deprivation (predominantly people of color living on low incomes). We used multivariable binary and multinomial logistic regression with year fixed effects to estimate adjusted associations between ICE tertile and contraceptive use and method type. We also assessed for an interactive effect of ICE and health insurance type.ResultsOf the 14,396 respondents, 88.4% in neighborhoods of concentrated deprivation used any contraception, compared to 92.7% in the most privileged neighborhoods. In adjusted models, the predicted probability of using any contraception in neighborhoods of concentrated deprivation was 2.8 percentage points lower than in neighborhoods of concentrated privilege, 5.0 percentage points higher for barrier/coital dependent methods, and 4.3 percentage points lower for short-acting methods. Those with Medicaid were less likely to use any contraception than those with private insurance irrespective of neighborhood classification.ConclusionsThis study highlights the salience of structural factors for contraceptive use and the need for continued examination of structural oppressions to inform health policy.

The average U.S. woman wants to have two children; to do so, she will spend about three years pregnant, postpartum, or trying to become pregnant, and three decades trying to avoid pregnancy. However, few studies have examined individual patterns of contraceptive use over time. These trajectories are important to understand given the high rate of unintended pregnancy and how little we know about the complex relationship between contraceptive use, pregnancy intention, and patterns of reproductive behavior. We use data from the 2015-2017 National Survey of Family Growth to examine reproductive behavior and pregnancies across three years of calendar data. We identify seven behavior typologies, their prevalence, how women transition between them, and how pregnancies affect transitions. At any given time, half of women are reliably using contraception. A small proportion belong to a high pregnancy risk profile of transient contraceptive users, but some transition to using condoms or other methods consistently. An unintended pregnancy may initiate a transition into stable contraceptive use for some women, although that is primarily condom use. These findings have important implications for the ways contraception fits into women's lives and how that behavior interacts with relationships, sex, and life stage trajectories.

Objectives Health outcomes in the US vary by neighborhoods, but Medicaid research expansion may miss local heterogeneity. We assessed if state Medicaid expansion impacted contraceptive use differentially by neighborhood-level context. Methods Using restricted data from the National Survey of Family Growth, we identified state Medicaid expansion status in January 2014 and compared pre-expansion (2011–2013) data with post-expansion data. Neighborhood racialized socioeconomic deprivation/privilege was defined using respondents’ census tract Index of Concentration at the Extremes (ICE). We used a difference-in-differences approach with multivariable linear probability and multinomial logistic regression models with region fixed effects to estimate the impact of Medicaid expansion on contraceptive use and method type, by neighborhood ICE tertile. Results Of 13,224 respondents, 45% lived in non-expansion states, and a larger proportion of respondents lived in neighborhoods of concentrated deprivation. In adjusted models, living in an expansion state was associated with significant increases in contraceptive use, reduction in short-acting method use, and increases in use of long-acting reversible contraception (LARC). By neighborhood context, contraceptive use significantly increased in the most deprived neighborhoods (8.1 percentage points (95% CI, 0.6–15.6) by 2015–2017). Use of no method or barrier/coital methods declined 17.5 percentage points (95% CI, -26.3– -8.7) and LARC use increased by 7.6 percentage points (95% CI, 0.6–14.7) by 2017–2019. The impact of expansion was not significant in the middle or most privileged neighborhoods in fully adjusted models. Conclusions Changes in contraceptive use from Medicaid expansion were largest in neighborhoods of concentrated deprivation. Further expanding Medicaid would facilitate access to the full range of reproductive healthcare and advance population health equity. Health outcomes in the US vary by neighborhoods, but Medicaid research expansion may miss local heterogeneity. We assessed if state Medicaid expansion impacted contraceptive use differentially by neighborhood-level context. Using restricted data from the National Survey of Family Growth, we identified state Medicaid expansion status in January 2014 and compared pre-expansion (2011–2013) data with post-expansion data. Neighborhood racialized socioeconomic deprivation/privilege was defined using respondents’ census tract Index of Concentration at the Extremes (ICE). We used a difference-in-differences approach with multivariable linear probability and multinomial logistic regression models with region fixed effects to estimate the impact of Medicaid expansion on contraceptive use and method type, by neighborhood ICE tertile. Of 13,224 respondents, 45% lived in non-expansion states, and a larger proportion of respondents lived in neighborhoods of concentrated deprivation. In adjusted models, living in an expansion state was associated with significant increases in contraceptive use, reduction in short-acting method use, and increases in use of long-acting reversible contraception (LARC). By neighborhood context, contraceptive use significantly increased in the most deprived neighborhoods (8.1 percentage points (95% CI, 0.6–15.6) by 2015–2017). Use of no method or barrier/coital methods declined 17.5 percentage points (95% CI, -26.3– -8.7) and LARC use increased by 7.6 percentage points (95% CI, 0.6–14.7) by 2017–2019. The impact of expansion was not significant in the middle or most privileged neighborhoods in fully adjusted models. Changes in contraceptive use from Medicaid expansion were largest in neighborhoods of concentrated deprivation. Further expanding Medicaid would facilitate access to the full range of reproductive healthcare and advance population health equity.

Background Obstetric fistula, which develops after a prolonged or obstructed labour, is preventable and treatable. However, many women are still afflicted with the condition and remain untreated in low-income and middle-income countries. Concerns have also been raised that an increasing trend of caesarean sections is increasing the risk and share of iatrogenic obstetric fistula in these countries. The true prevalence of this condition is not known, which makes it difficult for health planners and policy makers to develop appropriate national health strategies to address the problem. The estimation of obstetric fistula with surveys is difficult because self-reporting of incontinence symptoms is subject to misclassification bias. In this study, we aimed to estimate the prevalence and burden of obstetric fistula in Bangladesh. Methods For a valid estimation addressing misclassification bias, we implemented the study in two steps. First, we did the Maternal Morbidity Validation Study (MMVS) among a population of 65 740 women in Sylhet, Bangladesh, to assess the sensitivity, specificity, positive predictive values (PPVs), and negative predictive values of the survey questions. This was done through confirmation of the diagnosis with clinical examinations of suspected cases by female physicians; a sample of women who screened positive for pelvic organ prolapse and other urinary incontinence symptoms were also examined and used as controls for clinical diagnosis confirmation. Second, we used the estimated diagnostic test values, after correcting for verification bias, to adjust the reported prevalence in the nationally representative Bangladesh Maternal Mortality and Health Care Survey 2016 for the unbiased estimation of obstetric fistula prevalence in Bangladesh. Findings The MMVS, done from Aug 3 to Dec 9, 2016, identified 67 potential cases of obstetric fistula; of them, 57 (85%) women completed the clinical examination, and 19 were confirmed as obstetric fistula cases. The adjusted sensitivity of the self-reports of obstetric fistula was 100% (95% uncertainty interval [UI] 99.8-100) and the observed specificity was 99.9% (95% UI 99.9-100) among women aged 15-49 years. However, the PPV was low, at 31.6% (95% UI 19.2-46.2), suggesting that almost two thirds of the self-reported cases were not true obstetric fistula cases. We estimated an adjusted obstetric fistula prevalence rate of 38 (90% UI 25-58) per 100 000 women aged 15-49 years in Bangladesh. Nationally, we estimated about 13 376 (90% UI 8686-20112) women of reproductive age living with obstetric fistula. Additionally, we estimated 4081 (1773-8790) women aged 50-64 years to be living with obstetric fistula in Bangladesh; overall, we estimated that there are 17 457 (10 459-28 902) women aged 15-64 years in Bangladesh with obstetric fistula. Interpretation The burden of obstetric fistula is still high in Bangladesh. Prevention and provision of surgical treatment to so many women will need coordinated efforts, planning, allocation of resources, and training of surgeons. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd.

Reproductive autonomy necessitates that women have access to high quality family planning information and services. Additionally, closely spaced pregnancies increase maternal and infant morbidity and mortality. Although integrating family planning into child immunization services may increase access to information and services and postpartum contraceptive use, evidence on how integration affects service delivery and health outcomes is scarce. One limitation of previous studies is the use of binary integration measures. To address this limitation, this study applied Provider and Facility Integration Index scores to estimate associations between integration and contraceptive use, receipt of family planning information, and knowledge of family planning services availability. This study leveraged pooled cross-sectional health facility client exit interview data collected from 2,535 women in Nigeria. Provider and Facility Integration Index scores were calculated (0-10, 0 = low, 10 = high) for each facility (N = 94). The Provider Integration Index score measures provider skills and practices that support integrated service delivery; the Facility Integration Index score measures facility norms that support integrated service delivery. Logistic regression models identified associations between Provider and Facility Integration Index scores and (a) contraceptive use among postpartum women, (b) receipt of family planning information during immunization visits, and (c) correct identification of family planning service availability. Overall, 46% of women were using any method of contraception, 51% received family planning information during the immunization appointment, and 83% correctly identified family planning service availability at the facility. Mean Provider and Facility Integration Index scores were 6.46 (SD = 0.21) and 7.27 (SD = 0.18), respectively. Provider and Facility Integration Index scores were not significantly associated with postpartum contraceptive use. Facility Integration Index scores were negatively associated with receipt of family planning information. Provider Integration Index scores were positively associated with correct identification of family planning service availability. Our results challenge the position that integration provides a clear path to improved outcomes. The presence of facility and provider attributes that support integration may not result in the delivery of integrated care.

OBJECTIVE:Bangladesh achieved the fourth Millennium Development Goal well ahead of schedule, with a significant reduction in under-5 mortality between 1990 and 2015. However, the reduction in neonatal mortality has been stagnant in recent years. The purpose of this study is to explore the association between place of delivery and newborn care with early neonatal mortality (ENNM), which represents more than 80% of total neonatal mortality in Bangladesh.METHODS:In this study, 2014 Bangladesh Demographic and Health Survey data were used to assess early neonatal survival in children born in the three years preceding the survey. The roles of place of the delivery and newborn care in ENNM were examined using multivariable logistic regression models adjusted for clustering and relevant socio-economic, pregnancy, and newborn characteristics.RESULTS:Between 2012 and 2014, there were 4,624 deliveries in 17,863 sampled households, 39% of which were delivered at health facilities. The estimated early neonatal mortality rate during this period was 15 deaths per 1,000 live births. We found that newborns who had received at least 3 components of essential newborn care (ENC) were 56% less likely to die during the first seven days of their lives compared to their counterparts who received 0-2 components of ENC (aOR: 0.44; 95% CI: 0.24-0.81). In addition, newborns who had received any postnatal care (PNC) were 68% less likely to die in the early neonatal period than those who had not received any PNC (aOR: 0.32; 95% CI: 0.16-0.64). Facility delivery was not significantly associated with the risk of early newborn death in any of the models.CONCLUSION:Our study findings highlight the importance of newborn and postnatal care in preventing early neonatal deaths. Further, findings suggest that increasing the proportion of women who give birth in a healthcare facility is not sufficient to reduce ENNM by itself; to realize the theoretical potential of facility delivery to avert neonatal deaths, we must also ensure quality of care during delivery, guarantee all components of ENC, and provide high-quality early PNC. Therefore, sustained efforts to expand access to high-quality ENC and PNC are needed in health facilities, particularly in facilities serving low-income populations.

Background Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality. Objective The objective is to inform on potential options for measuring maternal mortality. Methods This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS). Results For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003. Conclusions Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches. Contribution Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

Background Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities. Methods This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high). Results Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high. Conclusion Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

Background Unmet need for postpartum contraception is high. Integration of family planning with routine child immunization services may help to satisfy unmet need. However, evidence about the determinants and effects of integration has been inconsistent, and more evidence is required to ascertain whether and how to invest in integration. In this study, facility-level family planning and immunization integration index scores are used to: (1) determine whether integration changes over time and (2) identify whether facility-level characteristics, including exposure to the Nigerian Urban Reproductive Health Initiative (NURHI), are associated with integration across facilities in six urban areas of Nigeria. Methods This study utilizes health facility data collected at baseline ( n = 400) and endline ( n = 385) for the NURHI impact evaluation. Difference-in-differences models estimate the associations between facility-level characteristics, including exposure to NURHI, and Provider and Facility Integration Index scores. The two outcome measures, Provider and Facility Integration Index scores, reflect attributes that support integrated service delivery. These indexes, which range from 0 (low) to 10 (high), were constructed using principal component analysis. Scores were calculated for each facility. Independent variables are (1) time period, (2) whether the facility received the NURHI intervention, and (3) additional facility-level characteristics. Results Within intervention facilities, mean Provider Integration Index scores were 6.46 at baseline and 6.79 at endline; mean Facility Integration Index scores were 7.16 (baseline) and 7.36 (endline). Within non-intervention facilities, mean Provider Integration Index scores were 5.01 at baseline and 6.25 at endline; mean Facility Integration Index scores were 5.83 (baseline) and 6.12 (endline). Provider Integration Index scores increased significantly ( p = 0.00) among non-intervention facilities. Facility Integration Index scores did not increase significantly in either group. Results identify facility-level characteristics associated with higher levels of integration, including smaller family planning client load, family planning training among providers, and public facility ownership. Exposure to NURHI was not associated with integration index scores. Conclusion Programs aiming to increase integration of family planning and immunization services should monitor and provide targeted support for the implementation of a well-defined integration strategy that considers the influence of facility characteristics and concurrent initiatives.

The reproductive calendar is a data collection tool that collects month-by-month retrospective histories of contraceptive use. This survey instrument is implemented in large-scale demographic surveys, but its reliability is not well-understood. Our analysis helps to address this research gap, using longitudinal panel data with overlapping calendars from urban Kenya. Our findings indicate calendar data collected in 2014 underestimated 2012 reports of current use by 5 percentage points. And while the overall percentage of women reporting at least one episode of contraceptive use was similar across the two calendars (67 percent vs. 70 percent), there was notable disagreement in contraceptive behavior when comparing the histories of individual women; less than 20 percent of women with any contraceptive use reported the exact same pattern of use in both calendars. Low calendar reliability was especially apparent for younger women and those with complicated contraceptive histories. Individual-level discordance resulted in a small difference in 12-month discontinuation rates for the period of calendar overlap; when surveyed in 2014, women reported a 12-month discontinuation rate of 39 percent, compared to a rate of 34 percent reported in 2012. When using retrospective calendar data, attention must be paid to the potential for individual reporting errors.

CONTEXT Women's concerns about contraceptive-induced menstrual changes can lead to method discontinuation and nonuse, contributing to unmet need for contraception. Research on women's perceptions of amenorrhea related to longer acting methods and in low-income countries is limited. METHODS Data were from nationally representative household surveys and focus group discussions with women of reproductive age conducted in Burkina Faso and Uganda in 2016-2017. Bivariate cross-tabulations and multivariate logistic regression analyses were used to examine sociodemographic and reproductive characteristics associated with women's attitudes about contraceptive-induced amenorrhea (n=2,673 for Burkina Faso and 2,281 for Uganda); menstrual health determinants were also examined for Burkina Faso. Qualitative data from focus group discussions were analyzed to understand reasons behind women's attitudes and how they influence contraceptive decision making. RESULTS Sixty-five percent of women in Burkina Faso and 40% in Uganda reported they would choose a method that caused amenorrhea during use. In Burkina Faso, the predicted probability of accepting amenorrhea was higher for women aged 15-19 (compared with older women), living in rural areas, married and cohabiting (compared with never married), currently using a contraceptive method (compared with never users) and from Mossi households (compared with Gourmantché); menstrual health practices were not associated with amenorrhea acceptability. In Uganda, the least wealthy women had the highest predicted probability of accepting amenorrhea (51%). Qualitative analysis revealed a variety of reasons for women's attitudes about amenorrhea and differences by country, but the relationship between these attitudes and contraceptive decision making was similar across countries. CONCLUSIONS Addressing misconceptions about contraception and menstruation may result in more informed method decision making.

AbstractInformal fees are payments made by patients to their health care provider that are over and above the official cost of services. Payments may be motivated by a combination of factors such as low supervision, weak sanctions, and inadequate provider salaries. The practice of soliciting informal fees from patients may result in restricted access to medical care and reduced care‐seeking behavior among vulnerable populations. The objective of this study is to examine nuanced health care provider perspectives on informal fee payments solicited from reproductive health patients in Kenya. We conducted in‐depth semistructured interviews in 2015–2016 among a sample of 20 public and private‐sector Kenyan health care workers. Interviews were coded and analyzed using an iterative thematic approach. More than half of participants reported that solicitation of informal fees is common practice in health care facilities. Providers reported low public‐sector wages were a primary driver of informal fee solicitation coupled with collusion among senior staff. Additionally, patients may be unaware that they are being asked to pay more than the official cost of services. Strategies for reducing this behavior include more adequate and timely remuneration within the public sector, educating patient populations of free or low‐cost services, and evidence‐based methods to increase provider motivation.

Informal fees are payments made by patients to their health care provider that are over and above the official cost of services. Payments may be motivated by a combination of factors such as low supervision, weak sanctions, and inadequate provider salaries. The practice of soliciting informal fees from patients may result in restricted access to medical care and reduced care-seeking behavior among vulnerable populations. The objective of this study is to examine nuanced health care provider perspectives on informal fee payments solicited from reproductive health patients in Kenya. We conducted in-depth semistructured interviews in 2015-2016 among a sample of 20 public and private-sector Kenyan health care workers. Interviews were coded and analyzed using an iterative thematic approach. More than half of participants reported that solicitation of informal fees is common practice in health care facilities. Providers reported low public-sector wages were a primary driver of informal fee solicitation coupled with collusion among senior staff. Additionally, patients may be unaware that they are being asked to pay more than the official cost of services. Strategies for reducing this behavior include more adequate and timely remuneration within the public sector, educating patient populations of free or low-cost services, and evidence-based methods to increase provider motivation.

Informal fees are payments made by patients to their health care provider that are over and above the official cost of services. Payments may be motivated by a combination of factors such as low supervision, weak sanctions, and inadequate provider salaries. The practice of soliciting informal fees from patients may result in restricted access to medical care and reduced care-seeking behavior among vulnerable populations. The objective of this study is to examine nuanced health care provider perspectives on informal fee payments solicited from reproductive health patients in Kenya. We conducted in-depth semistructured interviews in 2015-2016 among a sample of 20 public and private-sector Kenyan health care workers. Interviews were coded and analyzed using an iterative thematic approach. More than half of participants reported that solicitation of informal fees is common practice in health care facilities. Providers reported low public-sector wages were a primary driver of informal fee solicitation coupled with collusion among senior staff. Additionally, patients may be unaware that they are being asked to pay more than the official cost of services. Strategies for reducing this behavior include more adequate and timely remuneration within the public sector, educating patient populations of free or low-cost services, and evidence-based methods to increase provider motivation.