case study for family planning

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Family Planning Case Studies

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Cell Phone Hotline Spreads Family Planning Information in DR Congo Population Services International (PSI)

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• Research article
• Open access
• Published: 17 January 2019

Family planning among undergraduate university students: a CASE study of a public university in Ghana

• Fred Yao Gbagbo   ORCID: orcid.org/0000-0001-8441-6633 1 &
• Jacqueline Nkrumah 1  

BMC Women's Health volume  19 , Article number:  12 ( 2019 ) Cite this article

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Globally, the rate of unplanned pregnancies among students at institutions of higher education, continue to increase annually despite the universal awareness and availability of contraceptives to the general population. This study examined family planning among undergraduate university students focusing on their knowledge, use and attitudes towards contraception in the University of Education Winneba.

The study was a descriptive cross-sectional survey using a structured self-administered questionnaire. One hundred undergraduate students from the University of Education Winneba were selected using a multistage simple random sampling technique. A Likert scale was used to assess the attitude of the respondents towards family planning methods.

Findings show that the respondents had a positive attitude towards family planning with an average mean score of about 4.0 using a contraceptive attitude Likert scale. Knowledge of contraception, awareness and benefits however do not commensurate contraceptive use among undergraduate students since availability, accessibility and preference influence usage. Emergency Contraception (Lydia) was reported as easy to get contraceptive, hence the most frequently used contraceptive (31%) among young female students aged 21-24 years who appeared as the most vulnerable in accessing and using contraceptives due to perceived social stigma.

The observation that levels of Family Planning awareness levels do not commensurate knowledge and usage levels calls for more innovative strategies for contraceptive promotion, and Education on the various university campus. The study recommends that public Universities in Ghana should consider a possible curriculum restructuring to incorporate family planning updates. In this regard, a nationwide mixed method study targeting other tertiary institutions including colleges of education in Ghana is required to explore the topic further to inform policy and programme decisions.

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The global incidence of unplanned pregnancies amongst students at higher educational institutions every year continues to increase despite the high awareness and knowledge on regular modern contraceptives and emergency contraceptives among students in higher educational institutions [ 1 , 2 ]. Despite the immense contraceptive benefits for students in higher educational institutions [ 3 ], there is no direct positive correlation between the universal awareness, knowledge and use of contraceptives which challenges global health efforts. The poor utilisation of contraceptives in tertiary institutions is associated with many interrelated factors ranging from personal to institutional setbacks [ 4 ]. This eventually contributes to high unplanned pregnancy rates which is estimated to have contributed to about 8 to 30 million annual pregnancies worldwide [ 5 ]. Global estimates have also shown that about 210 million pregnancies occur annually across the world. 75 million (or about 36%) of the 210 are unplanned or unwanted pregnancies [ 6 ]. Students between 18 and 24 years report the highest rates of unplanned pregnancies in the world’s tertiary institutions [ 7 , 8 ]. A situation associated with multiple challenges across the world for countries, academic institutions and the individuals involved [ 9 ].

Studies in Africa, have generally documented low knowledge and awareness levels of effective contraceptive use amongst higher educational students [ 10 ]. Several factors including age, culture, ethnicity, religion, poor access to contraceptive services, peer pressure and lack of partner support were identified as contributing to the non-utilisation of contraceptives in tertiary institutions [ 11 ]. In a study amongst 15 to 24 year old South African women, it was estimated that only 52.2% of sexually experienced women are using contraceptives [ 12 ]. Because 80% of undergraduate students at higher educational institutions are sexually active, it is important that they have access to safe, accessible and adequate contraceptive services [ 13 ].

Although national surveys on family planning [ 14 ] have extensively looked at contraceptive uptake in Ghana, little is known about contraceptive up take among students in Ghanaian Universities. This study therefore examines family planning acceptance among students of the University of Education, Winneba in Ghana to compliment national data on family planning.

A descriptive cross-sectional study design using a quantitative approach of data collection was adopted. This design was chosen because it fits studies in natural setting, explains phenomena from the view point of persons being studied and produces descriptive data from the respondent own written or spoken words [ 15 ].

The study was conducted in the main campus of the University of Education, Winneba. The university was established in 1992 to train middle and top-level manpower for the educational sector of Ghana. It has four main satellite campuses, (Winneba and Ajumako in the Central Region of Ghana, Kumasi, and Mampong campuses in Ashanti Region of Ghana). The Winneba campus has three smaller campuses with five faculties (Faculty of social science education, Faculty of languages, Faculty of science education, Faculty of educational studies and School of creative Arts).

The study population comprised134 ‘non-resident’ undergraduate students of the University of Education Winneba, between ages 17–36 years in 2017 who were registered with an accommodation agent in Winneba that looks for accommodation for students who are unable to obtain university accommodation on campus. This population and age group was selected because anecdotal evidence shows that being a ‘non-resident’ student has the likelihood of making one vulnerable to sexual exploitations whilst seeking accommodation off campus. This age group was considered to be the reproductive age group of the undergraduate students. Because the University only guarantees on campus residential accommodation for only selected first year students, those who do not get the university’s residential accommodation are likely to be victims of sexual exploitations in the Effutu Municipality where the university is situated. This challenge is due to the scarcity of accommodation coupled with the high rent charges for rented accommodation. As per the estimated sample size calculated, a total of one hundred respondents comprising twenty from each of the five faculties were sampled at random to include both male and female students from the various course levels. This was done to ensure a true representation of the student population for the study.

A multistage sampling technique was used to select these respondents for the study. The first stage involved half day orientation of 2 field assistants (male and female) the estimation of the undergraduate students’ population who falls in this category during the period of the study. The second stage involved sample size calculation using an online Raosoft sample size calculator at 95% confidence interval, 5% margin of error and 50% response distribution [ 16 ]. In terms of the figures, the sample size n and margin of error E are given by:

Where N is the population size (134), R is the fraction of responses that the study is interested in, and Z(c/100) is the critical value for the confidence level c. The estimated number of respondents were then randomly sampled and contacted for participating in the in the third stage of the study. The fourth stage of the study involved distributing the developed questionnaires to consented students.

A Structured Questionnaire (See Additional file  1 ), designed by the authors was used to solicit responses from respondents. The questionnaire was exploratory in nature with both opened and closed ended questions to help respondents easily share their views. The questionnaire was pre-tested among 20 potential respondents from a different university. The Contraceptive Attitude Likert scales was used to measure attitudes by asking people to respond to series of statements about the topic, in terms of the extent to which they agree or disagree with them. Thus, tapping into the cognitive and affective components of attitudes [ 17 ]. The Contraceptive Attitude Scale presented positive and negative statements to elicit for responses that portray participants’ attitudes relating to contraception.

One hundred questionnaires were administered, and all the answers to a particular question were arranged, numbered and responses were coded. The responses were again listed and grouped, putting those with the same code together. Data analysis was done after data had been collected and checked for completeness and accuracy. The Statistical Package for Social Sciences (SPSS) software version 23 was used for data analysis. Frequencies, percentages and bar charts were used to describe the data in multivariable tables.

Ethics approval and consent to participate

An approval was obtained from the University prior to data collection. Written consent for participation and publication of findings were also obtained from respondents after the purpose, objectives and potential risk and benefits inherent in the study had been explained to them. Prior to the commencement of the study, the research protocol was presented at the bi-weekly academic research seminars of the Faculty of Science Education, University of Education, Winneba. The seminar brought together lectures of the Faculty (equivalent to an ethical review meeting) who critiqued and reviewed the study protocol for ethical suitability and sound methodology. All participants in the study were given the opportunity to ask questions about the study at any stage, and to withdraw from the study at any time. All data collected were kept confidential and data was analysed anonymously to ensure that results were not traceable to individual respondent.

The overall response rate for the study was 100%. Table 1 presents the background characteristics of respondents. A large number of the respondents were within the age categories of 21 to 24 years and 25 to 28 years. Most of the respondents were single (86.0%) and have no children (86.0%).

Table 2 present results of students’ knowledge, information sources and reasons for accepting or not accepting family planning. Family planning awareness and knowledge among students was a key consideration in the study.

About 94% of respondents answered yes to whether they have ever heard about family planning. Although majority (61%) of the respondents believed FP is helpful, about (67.0%) knew that one could get pregnant by relying on the withdrawal method. It appears most students would be committed to family planning uptake if services are made available. This is evident by 69% of them responding in the affirmative when asked whether they will encourage their family or friends to use family planning services in the University.

Having knowledge of family planning does not necessarily translate into utilization since the respondents had varied reasons for and against using family planning. Respondents who were of the view that FP was not helpful (25.0%) had either not used any family planning method before (28.0%) or had ever suffered unpleasant negative side effects (20.0%) following family planning usage or believed the bible is against family planning (2.0%).

Figure 1 presents respondents’ attitudes towards family planning as estimated using the Contraceptive Attitude Scale. The overall population surveyed had a positive attitude towards family planning (average mean attitude score was about 4.0 out of 5.0).

Attitude towards Family Planning

There were however some divergent responses to the questions relating to contraceptive use. Some of these include:

‘I will not have sexual intercourse if no contraceptive method was available’

‘I will use contraceptives even if my partner does not want me to use it’

‘I will not use contraceptives because they encourage promiscuity’

When the respondents were asked if they have ever used any FP method before, the majority of the respondents (67.0%) mentioned that they had never used any FP method. Regarding availability of family planning service when needed, about 64.0% of the respondents indicated that family planning services are always available in chemical shops and from colleges on campus when needed. About 58% will use FP methods in the future. Regarding information on source of family planning services if required, most of the respondents (85%) knew where to get family planning services in their communities (Table  3 ). Young Female students aged 21-24 years were the most vulnerable in accessing and using contraceptives due to perceived social stigma relating to a female student buying a contraceptive.

Table  4 documents the various family planning choices and reasons for the choices. About 65.0% of respondents reported that they primarily use contraceptives to prevent pregnancy and usually use a contraceptive before sexual intercourse (34.0%). When asked to select the primary methods of contraception frequently used, Emergency Contraception was the most reported frequently used (51%) contraceptive followed by male condoms (34.0%). Various side effects associated with some FP methods were also reported. Some respondents were of the view that there should be education for students on the risk and benefits of FP methods for effective use. Others believed FP should not be tolerated among students because it can be abused leading to major health problems that could affect studies. Knowledge of contraception, awareness and benefits however do not commensurate contraceptive use among undergraduate students since availability, accessibility, preference and cost of contraceptives hinders use.

This study examined family planning among undergraduate university students focusing on their knowledge, use and attitudes towards family planning in the University of Education Winneba. The study was a descriptive cross-sectional survey using a structured self-administered questionnaire for data collection. Various findings obtained from the study had reproductive health programme and policy implications. Informal sources of family planning information such as friends, peers and relatives were common information sources for young people [ 18 ] but yet prone to misconceptions, distortions and half-truths. Other studies ranked the family (parents, brothers and sisters) as the lowest source of information on sexuality [ 19 , 20 , 21 ]. These findings are similar to those reported in the current study that high level of awareness (94.0%) of contraceptives is noted among university students.

An observation that a large number of the respondents were within the age categories of 21 to 24 years and 25 to 28 years of which most (86.0%) were single and have no children (86.0%), is an indication that current university students are relatively young and unmarried. A situation that predisposes them to sexual exploitations and requires knowledge on family planning methods to enable them make informed decision and choices regarding their reproductive intentions. Family planning awareness and knowledge among students was a key consideration in the study. The majority (94%) of respondents indicating that they have ever heard about family planning shows a near universal awareness of family planning methods. This is in line with national reports on family planning awareness in Ghana and a significant departure from many other studies which tended to focus on awareness alone or translate awareness to knowledge [ 22 , 23 ]. Understanding the methods and benefits of contraception are critical to having motivated users. It has also been noted that motivation is one of the important factors in minimizing failure rates in the utilization of contraception [ 24 ]. From previous research findings [ 25 , 26 , 27 ] it was established that the most commonly used Family Planning methods among students were short term methods predominantly, condoms, oral contraceptives and withdrawal methods. This confirms finding of other studies that students had little knowledge about effective contraceptive methods [ 28 ]. In the current study, a remarkable percentage (25%) did not know that pregnancy could occur when one relying solely on withdrawal method. Also about 21.0% of respondents did not know what oral contraceptive pills do, and some 3% also said oral contraceptive pill prevents Sexually Transmitted Infections (STIs). It was surprising to note in this era of increasing STIs that about 2% of respondents’ from a tertiary institution belief a single condom can be reused many times if washed and dried.

At the tertiary level, one would have expected that all respondents would have known the implications of unprotected sexual intercourse. However the study finding that about (61%) of the respondents believed family planning is helpful implies that there are some other students who don’t belief in family planning hence having unprotected sexual intercourse. Although accessibility to family planning methods on campus in this study was very high (66.0%), results from other similar studies were to the contrary [ 29 , 30 ]. This therefore suggests that if students know the benefits and how to use contraceptives, they will not experience unwanted pregnancies and its associated consequences of unsafe abortion complications, disruption in academic work and possible death. Contraceptive education is a component of sex education and is one of the proven approaches to prevent risky sexual behaviour and must be introduced on university campuses to guide students’ family planning choices.

Additionally, findings also shows that there are some students about (67.0%) at the university who knew that one could get pregnant by relying on the withdrawal method yet that is their preferred family planning methods. Various studies [ 31 , 32 ] have explained this observation further by indicating that some adolescents girls feel that a partner’s use of condom suggest that they (the girls) might be classified as unclean, likened to commercial sex workers or seen as engaging in extra-relationship sexual activities if they negotiate for condom use during sexual intercourse. The perception of ‘ I trust my partner so no need for condom use’ further explains the frequency of withdrawal methods being a regular family planning method on campus.

Generally, it appears most students were committed to family planning uptake if services are made available as evident by about 69% of them responding in affirmative when asked whether they will encourage their family or friends to use family planning services in the University. This observation is positive for enhanced family planning service delivery on university campuses to meet the needs of students. Contrary to this observation are those of similar studies which reported that Student frown on invasive family planning methods [ 33 , 34 ]. The distinction between invasive and non-invasive methods bothers on factors such as availability of method, ease of use and adherence to instructions of a health professional to use the method.

Respondents outlined various sources of family planning information of which television adverts constituted the most reported (31%) source of information. This observation is quite worrying since anecdotal evidence from university campuses shows that majority of student rarely have and watch televisions whist on the various campuses. It will therefore be very important and useful to devise innovative ways of educating students on family planning methods whilst on campus.

A finding that having knowledge of family planning does not necessarily translate into usage is very revealing and of public health importance. As it would have been expected, using a method is the surest way of explaining its relevance. However in this study, respondents who were of the view that family planning was not helpful had never used any family planning method before (28.0%). It is there important to use of family planning satisfied client for contraceptive education and promotion on University campuses to ensure the desired positive results. These are students who are likely to positively influence their sexually active peers on contraceptive use since they are likely to say: ‘ I will not have sexual intercourse if no contraceptive method was available’ or ‘I will use contraceptives even if my partner does not want me to use it’ as reported in the study.

Regarding information on source of family planning services if required, most of the respondents (85%) knew where to get family planning services in their communities. For availability of family planning services when needed, about 64.0% of the respondents indicated that family planning services are always available in chemical shops and from colleges on campus when needed. The obvious indicated sources of contraceptives on campus (i.e., chemical shops and peers) do not provide varying choice of services there by limiting students to short term and less effective family planning methods. It is encouraging noting that about 58% of respondents will use FP methods in future. This is an indication of them understanding the importance of family planning to studies as about 65.0% of respondents reported primarily using contraceptives to prevent pregnancy and usually use a method before sexual intercourse (34.0%) despite the various side effects associated with some FP methods reported.

Knowledge of contraception, awareness and benefits however do not commensurate contraceptive use among undergraduate students since availability, accessibility and preference influence usage. Emergency Contraception (Lydia) was reported as easy to get contraceptive, hence the most frequently used contraceptive (31%) among young female students aged 21-24 years who appeared as the most vulnerable in accessing and using contraceptives due to perceived social stigma. This observation shows that Students always have a unique view on issues especially those in youthful ages. It is therefore important to incorporate their views in family planning programming. The observation that some respondents were of the view that there should be education for students on the risk and benefits of family planning methods for effective use is in the right direction and worth exploring. There are also concerns of values clarification as observed by the findings that some respondents believed family planning should not be tolerated among students because it can be abused leading students to becoming promiscuous or suffering major health problems that will affect their studies.

The following recommendations are therefore being suggested to chart a way forward:

Public Universities in Ghana should consider a possible curriculum restructuring to incorporate family planning lessons in the academic programme for students to acquire current knowledge in this area. The reproductive health education programs should include the importance of using dual contraceptive methods as a means to prevent HIV transmission and pregnancy, as well as information on how to make an informed decision relating to contraceptive choices.

The Winneba Municipal Health Directorate should incorporate family planning education on campuses into their public health programs.

The university health service should also create friendly environment for student to access family planning services and also collaborate with the student body to organise programmes to educate the students on family planning methods.

The student representative council (SRC) should also make family planning education a part of their programs and in collaboration with the university health services organise free STI testing and family planning counselling at least once yearly.

A nationwide mixed method study targeting other tertiary institutions particularly colleges of education in Ghana is required to explore the topic further for a national decision on contraceptive security in tertiary institutions in Ghana.

Conclusions

Findings of this study showed that the awareness of family planning among the students was high. However, levels of contraceptive usage were low and restricted to the short term, Emergency Contraceptives and redrawal methods. The perception by a cross-section of respondents (although by a small group) that condoms can be reused more than once confirms the gross ignorance of contraception practices and the potential risk to STIs and Pregnancy. Additionally, Emergency Contraception (Lydia) being reported as easy to get contraceptive, hence the most frequently used contraceptive (31%) among young female students aged 21-24 years, is an indication that this student population appeared as the most vulnerable in accessing and using contraceptives due to perceived social stigma and must therefore be the prime focus of contraception education and services on the University. The University of Education being a tertiary institution mandated to train teachers, is expected to ensure that its students have accurate and current information on family planning methods relevant to educate others. This is an obvious gap that requires policy decisions at all levels and FP education interventions at the tertiary level of education in Ghana.

Abbreviations

• Family planning

Statistical Package for Social Sciences

Sexually Transmitted Infections

University of Education Winneba

World Health Organization (WHO). (2013): Family planning fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs351/en / United Nations. (2011). The millennium development goals report. Retrieved from www.un.org/millenniumgoals/11_MDG%20Report_EN.pdf

Maja TMM, Ehlers VJ. Contraceptive practices in northern Tshwane, Gauteng Province. Health SA Gesondheid. 2004;9(4):42–52 https://doi.org/10.4102/hsag.v9i4.179 .

Article   Google Scholar  

Ersek, J.L., Brunner Huber, L.R., Thompson, M.E. & Warren-Findlow, J., (2011):‘Satisfaction and discontinuation of contraception by contraceptive method among university women’, Matern Child Health J 15, 497–506. PMID: 20428934, https://doi.org/10.1007/s10995-010-0610-y

Hubacher, D., Ifigeneia, M. & McGinn, E., (2008): ‘Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it’, Contraception 78, 73–78. PMID: 18555821, https://doi.org/10.1016/j.contraception.2008.03.002

Adhikari, R., (2009): ‘Factors affecting awareness of emergency contraception among college students in Kathmandu, Nepal’, BMC Women’s Health 9, 27. PMID: 19761598, https://doi.org/10.1186/1472-6874-9-27

Singh, S., Sedgh, G., & Hussain, R. (2010) “Unintended pregnancy: worldwide levels, trends, and outcomes”Studies in family planning 41, no. 4:241–250.

Esere MO. Effect of sex education programme on at-risk sexual behaviour of school going adolescents in Ilorin, Nigeria. Africa health science. June. 2008;8(2):120–5.

Google Scholar  

Trieu, S.l., Shenoy, D.P., Bratton, S. & Marshak, H.H., (2011): ‘Provision of emergency contraception at student health centers in California community colleges’, Womens Health Issues 21(6), 431–437. PMID: 21703870, https://doi.org/10.1016/j.whi.2011.04.011

Vermaas, L., (2010). ‘Dealing with unplanned pregnancies and abortions amongst tertiary students’, paper presented at the 6th African Conference on Psychotherapy in Uganda, Kampala, Uganda, 14–16 December, viewed 13 February 2013, from http://www.tut.ac.za/News/Pages/pregnancies.aspx .

Ahmed, F.A., Moussa, K.M., Petterson, K.O. & Asamoah, B.O., (2012), ‘Assessing knowledge, attitude, and practice of emergency contraception: A cross sectional study among Ethiopian undergraduate female students’, BMC Public Health, 12, 110, viewed 06 March 2015, from http://biomedcentral.com/1471 –2458/12/110 Page 7 of Original Research http://www.curationis.org.za doi: https://doi.org/10.4102/curationis.v38i2.1535 .

Golbasi Z, Tugut N, Erenel AS. Knowledge and opinions of Turkish University students about contraceptive methods and emergency contraception. Sex Disabil. 2012;30:77–87 https://doi.org/10.1007/s11195-011-9227-3 .

MacPhail, C., Pettifor, A.E., Pascoe, S. & Rees, H.V., (2007): ‘Contraception use and pregnancy among 15–24 year old south African women: a nationally representative cross-sectional survey’, BMC Med 5, 31. PMID: 17963521, https://doi.org/10.1186/1741-17015/5/31

Bryant, K.D., (2009): ‘Contraceptive use and attitudes among female college students’, Journal of ABNF 20(1), 12–16. PMID: 19278182.

Ghana Statistical Service (2014). Ghana Demographic and Health Survey Report.

Akintade OL, Pengpid S, Peltzer K. Awareness and use of and barriers to family planning services among female university students in Lesotho’, south African journal of Gynaecology 17(3), 72–78.McNab C, (2009): what social media offers to health professionals and citizens. Bull World Health Organ. 2011;87:566.

Raosoft Sample Size Calculator Accessed on 2 nd July, 2012 from http://www.raosoft.com/samplesize.html

Tilahun D, Assefa T, Belachew T. Knowledge, attitude and practice of emergency contraceptives among Adama University female students. Ethiopia Journal of Health Sciences November. 2010;20(3):195–202.

Sigereda G., (2004): Barriers to use contraceptive among adolescents in the city of Addis Ababa. Master’s theses.

Abiodun MO, Olayinka PB. Sexual activity and contraceptive use among female students of tertiary educational institutions in Illorin. Nigeria Contraception. 2009;79(2):146–9.

Mehra, D., Agardh, A., Petterson, K.O. & Ostergren, P.O., (2012): ‘Non-use of contraception: determinants among Ugandan university students’, Glob Health Action 5, 18599. PMID: 23058273, https://doi.org/10.3402/gha.v5i0.18599

Tayo A, Akinola O, Babatunde A, Adewunmi A, (2011): Contraceptive knowledge and usage among female school students in Lagos, south-West Nigeria. Journal of public health and epidemiology January, 3 (1), pg. 34–37.

Bafana T. Factures influencing contraceptive use and unplanned pregnancy in a South African population. MA thesis: Witwatersrand University; 2010.

Egarter C, Grimm C, Ahrendt KNH-J, Bitzer J, Ehlers VJ, Zvavemwe Z. Experiences of a community based contraceptive programme. Int J Nurs Stud. 2009;46(3):302–9.

World Health Organization, WHO. Programming for adolescent health and development: report of a WHO/UNFPA/UNICEF study group on programming for adolescent health. Technical report. Geneva: WHO; 1999. p. 886.

Cadmus E, Owoaje E. Patterns of contraceptive use among female undergraduates in the University of Ibadan, Nigeria. The Internet Journal of Health. 2009;10(2).

John, H. Contraceptive Knowledge, Perceptions and use among adolescents journal of Sociol Res 2012; 3(2):170–180. 25–34.

Appiah-Agyekum, N.N. & Kayi, E.A. (2013). Students’ Perceptions of Contraceptives in University of Ghana, 7(1): 39–44. Beware of AIDS (BAWA), Offinso-Ashanti, Ghana International Conference on AIDS. International Conference of AIDS 12: 1005 (abstract number 60018).

Roberts, C., Moodley, J. & Esterhuizen, T., (2004): Emergency contraception: knowledge and practices of tertiary students in Durban, South Africa’, Journal of Obstetrics and Gynaecology 24(4), 441–445. PMID: 15203588, https://doi.org/10.1080/0144361040001685619

Canadian Statistics, (2010): Trends in the Age Composition of College and University Students and Graduates www. Statcan.gc.ca Accessed 1/4/14.

Dreyer G. Contraception: a south African perspective. Pretoria: Van Schaik Publishers; 2012.

Adegoke AA. Adolescents in Africa: Revealing the problems of teenagers in contemporary African society. Ibadan, Hadassah Publishing; 2003.

Omo-Aghoja LO, Omo-Aghoja VW, Aghoja CO, Okonofua FE, Aghedo O, Umueri C, Otayohwo R, Feyi-Waboso P, Onowhakpor EA, Inikori KA. Factors associated with the knowledge, practice and perceptions of contraception in rural southern Nigeria. Ghana Med J. 2009;43(3):115–21.

CAS   PubMed   PubMed Central   Google Scholar  

McMahon S, Hansen L, Mann J, Sevigny C, Wong T, Roache M. Contraception. BMC Womens Health. 2004;4(Suppl1):S25.

Clements S, Madise N. Who is being served least by family planning providers? A study of modern contraceptives use in Ghana, Tanzania and Zimbabwe. Afr J Reprod Health. 2004;8:124.

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Acknowledgements

The authors are grateful to the University of Education Winneba, Faculty of Science Education for the valuable inputs in shaping the manuscript. Many thanks also to the respondents for their corporation during data collection.

The entire study was jointly funded by the authors.

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The raw data and any material related to the study is available upon reasonable request from the corresponding author.

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FYG conceptualized and designed the study. JN supervised the data collection, analysis and drafted the initial report. Both authors discussed the report, edited it together and approved the manuscript for final submission.

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Correspondence to Fred Yao Gbagbo .

Ethics declarations

The research protocol was first presented at the Faculty of Science Education, University of Education, Winneba periodic academic seminars for review and approval for methodology and ethical suitability. This seminar, brings together senior members and research fellows of the University to review research protocols and papers meant for publication and conferences. Approval for data collection and publication were subsequently granted following the full incorporation of comments received from the seminar presentation.

Prior to data collection, verbal and written permissions were sought from the respondents to participate in the study. The permission was granted after the objectives and nature of the study were satisfactorily explained to the respondents.

Consent for publication

The respondents consented for the study to be published but assured of anonymity before administering the questionnaire. The respondents were also given the opportunity to ask questions about the study at any stage, and to withdraw from the study at any time.

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The authors declare that they have no competing interests in this study.

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Additional file

Additional file 1:.

Appendix I-Questionaire. The appendix I contains the structured question developed by the authors and used for data collection in the study. (DOCX 23 kb)

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Gbagbo, F.Y., Nkrumah, J. Family planning among undergraduate university students: a CASE study of a public university in Ghana. BMC Women's Health 19 , 12 (2019). https://doi.org/10.1186/s12905-019-0708-3

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Received : 01 August 2017

Accepted : 02 January 2019

Published : 17 January 2019

DOI : https://doi.org/10.1186/s12905-019-0708-3

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Medicaid Family Planning Programs: Case Studies of Six States After ACA Implementation

Jocelyn Guyer, Elizabeth Osius, Sharon Woda, Jacqueline Marks, Usha Ranji , and Alina Salganicoff Published: Apr 27, 2017

• Executive Summary
• Introduction

The passage of the Affordable Care Act (ACA) in 2010 made changes to the Medicaid program that have had considerable implications for family planning coverage and services available to low-income women. Prior to the ACA, over 3 million low income women received family planning services through stand alone, limited Medicaid benefit family planning programs. 1 The ACA enabled many low and modest-income women who were previously only eligible for family planning coverage to obtain full-scope insurance through Medicaid or the Marketplaces for the first time. These changes have altered the role of family planning programs within many states and created a more complex environment for family planning providers.

While still responding to coverage changes created by the ACA, family planning programs and providers are also facing new, emerging changes brought about by other industry trends. The ACA’s delivery system reform provisions sparked changes in how care is paid for and delivered. Family planning programs traditionally operated through specialty “stand alone” providers with direct contracts with the state. These providers are now grappling with how to integrate into the broader delivery system and, in states that have expanded Medicaid, how to work with Medicaid managed care organizations (MCOs) and the transition from uninsured or limited family planning benefit packages to comprehensive Medicaid coverage. These changes are impacting how family planning providers interact and contract with Medicaid MCOs and other payers, how they are reimbursed for care, the scope of services they provide and how they form and value relationships with other providers. Besides ACA changes, Congressional and federal efforts to “defund” Planned Parenthood through limits on Medicaid and Title X funding would limit access to family planning services for women living in certain communities across the country. This study addresses the shifting landscape in which family planning services are being provided, including routes to coverage; eligibility and enrollment; benefits; access; impact on providers of changes; and delivery system reform. Based on case studies in six states and interviews with national experts, providers, advocates and government officials, it describes major trends in how women secure Medicaid family planning coverage and services and the implications of ACA-related changes for family planning providers and the role of family planning more broadly in Medicaid delivery system reform initiatives.

This study was conducted in the summer of 2016 before the November election changed the outlook for the ACA and Medicaid. The Trump Administration has signaled that they intend to give states considerably more flexibility to reshape their Medicaid programs and to block federal funding to Planned Parenthood, a leading source of family planning care for low-income women. With Medicaid reform under debate at the federal and state levels, it is important to understand the role of family planning programs and how they could be affected by Medicaid restructuring.

Background and Context

Prior to the ACA’s passage, Medicaid was already the single most important payer of publicly-funded family planning services in the United States, financing more than 75% of all publicly-funded family planning services. 2 Family planning services long have had a special role within Medicaid, reflecting recognition by policymakers that there are significant social and economic consequences to unintended pregnancies, including greater poverty and reliance on public benefit programs. 3 Family planning services have been a mandatory benefit in Medicaid since 1972 and are reimbursed by the federal government at a 90% matching rate. Federal law also requires that family planning services be exempt from cost-sharing and that beneficiaries have the right to secure the services from the providers of their choice, a provision known as the “freedom-of-choice” requirement.

Until the 1990s, however, many women simply did not qualify for Medicaid family planning services because they did not meet categorical eligibility rules that limited Medicaid eligibility to adults who were pregnant, parents/caretaker relatives, disabled or elderly. Then, with California in the lead, a number of states sought and secured Medicaid 1115 waivers to establish family planning programs that could serve low-income women, and sometimes men, beyond Medicaid categorical eligibility rules. By 2009, the year prior to passage of the ACA, at least 24 states had family planning waivers, 4 and over 3 million women had gained coverage for family planning services through these programs. California’s program, FamilyPACT, was the largest, with 2.5 million enrollees, while there were approximately 942,000 enrollees in all other programs combined. 5

Impacts of ACA Coverage Changes on Medicaid Family Planning

While family planning was not the primary focus of the Affordable Care Act (ACA), the law has had sizable implications for how many women receive family planning services and for family planning providers. The ACA extended eligibility for full-scope Medicaid to adults under 138% FPL and also created new Marketplaces that offer subsidized coverage up to 400% FPL. Although Medicaid expansion now is optional as a result of the 2012 Supreme Court decision on the ACA, the District of Columbia and 31 states have elected to expand Medicaid. In these states, many women who previously qualified only for a Medicaid family planning program have been able to secure coverage that offers a comprehensive benefit package (i.e., “full-scope” Medicaid).

The ACA also gives states the option to establish family planning programs through a simpler mechanism than a complex and lengthy waiver application process that needed to be renewed and evaluated periodically. By enacting a state plan amendment (SPA), states could base eligibility solely on income, while waivers may limit eligibility by other criteria such as age and sex. States using the SPA option must also set the eligibility threshold for their family planning program at or below the income threshold for pregnant women in the state. Fourteen states have transitioned to or have newly established a SPA family planning program since the option became available. 6 , 7

Finally, the ACA established integrated, modernized and streamlined standards for eligibility and enrollment processes that are used to evaluate eligibility for Medicaid, Marketplace coverage and related subsidies, and the Children’s Health Insurance Program (CHIP). Medicaid agencies and Marketplaces are required to use a “single, streamlined application,” to ensure individuals end up enrolled in whichever program for which they are eligible regardless of whether they submit their application to a Medicaid agency or a Marketplace. As a result, many more people are finding their way to coverage by applying through Marketplaces, raising the importance of understanding how Marketplace web sites and related eligibility and enrollment procedures work for women who qualify for full-scope Medicaid or family planning programs.

Other Developments

Family planning is garnering more attention than ever before at both state and national levels. In the political realm, highly controversial videos on the role of Planned Parenthood staff in disposing of fetal tissues have generated heated debate over the role of Planned Parenthood affiliates in Medicaid family planning programs. Some states have sought to ban Planned Parenthood providers from receiving any Medicaid funds while other states have ongoing inquiries into the role of clinics that offer abortion services within family planning programs. For example, Oklahoma’s Medicaid agency announced it was terminating its contracts with Planned Parenthood until, two months later, the agency reversed course and entered into “conditional one-year Provider Agreements” with the two Planned Parenthood affiliates in the State. 8 In Missouri, the Legislature passed a fiscal year 2017 budget that effectively converts the Medicaid family planning program (supported by a combination of federal and State funds) into a fully State-funded program and excludes providers who offer abortion services.

In the past few years, CMS has issued a number of regulations and informational bulletins aimed at strengthening access to family planning services. In April 2016, CMS released a final Medicaid managed care rules that includes several provisions directly relevant to family planning services. 9 As described in more detail later in the report, these include: new requirements for Medicaid MCOs to inform beneficiaries of the freedom-of-choice provision; stronger network adequacy standards for family planning providers; and, a reiteration of the importance of ensuring that beneficiaries can elect the family planning method of their choice. CMS also released three informational bulletins in 2016 on family planning: (1) reminding states that they cannot exclude family planning providers from Medicaid unless they are unfit to provide a covered service; 10 (2) encouraging best practices for promoting access to long-acting reversible contraception (LARC); 11 and (3) highlighting that states cannot employ utilization controls, such as step therapy, that would interfere with a beneficiary’s right to choose her preferred method of family planning, regardless of whether a state operates a managed care or fee-for-service program. 12

Methodology

This study is based largely on interviews with state officials, providers and consumer advocates in Alabama, California, Connecticut, Illinois, Missouri and Virginia. 13 The in-depth state case studies were supplemented by interviews with national experts, family planning provider organizations and federal policymakers with expertise on Medicaid and family planning services, quality metrics, eligibility and enrollment issues, and waivers. Using a standardized questionnaire, interviewees were asked about their perspective on a range of issues, including: the implications of the ACA for how low-income women secure family planning services; family planning benefits and access to care; the role of family planning issues in broader delivery system reform; and impacts on family planning providers. A full list of interviewees is attached as Appendix C.

These six states were selected to represent a cross-section in terms of geography, Medicaid expansion status, implementation of a Medicaid family planning program and whether that program was established via a waiver or a SPA. Table 1 displays the characteristics of the states included in the analysis. Three of the selected states expanded Medicaid (California, Connecticut, and Illinois); two converted Medicaid family planning waivers to the state plan option (California and Virginia); one newly established a Medicaid family planning program post ACA enactment (Connecticut); two continued existing Medicaid family planning programs operated under waivers (Alabama, Missouri); and one terminated its program after expanding Medicaid (Illinois).

• Affordable Care Act
• Women's Health Policy
• Family Planning
• Reproductive Health
• Access to Care

Also of Interest

• Medicaid Family Planning and Maternity Care Services: The Current Landscape

Family planning among undergraduate university students: a CASE study of a public university in Ghana

Affiliations.

• 1 Department of Health Administration and Education, University of Education Winneba, Faculty of Science Education, P.O. Box 25, Winneba, Ghana. [email protected].
• 2 Department of Health Administration and Education, University of Education Winneba, Faculty of Science Education, P.O. Box 25, Winneba, Ghana.
• PMID: 30654787
• PMCID: PMC6337791
• DOI: 10.1186/s12905-019-0708-3

Background: Globally, the rate of unplanned pregnancies among students at institutions of higher education, continue to increase annually despite the universal awareness and availability of contraceptives to the general population. This study examined family planning among undergraduate university students focusing on their knowledge, use and attitudes towards contraception in the University of Education Winneba.

Methods: The study was a descriptive cross-sectional survey using a structured self-administered questionnaire. One hundred undergraduate students from the University of Education Winneba were selected using a multistage simple random sampling technique. A Likert scale was used to assess the attitude of the respondents towards family planning methods.

Results: Findings show that the respondents had a positive attitude towards family planning with an average mean score of about 4.0 using a contraceptive attitude Likert scale. Knowledge of contraception, awareness and benefits however do not commensurate contraceptive use among undergraduate students since availability, accessibility and preference influence usage. Emergency Contraception (Lydia) was reported as easy to get contraceptive, hence the most frequently used contraceptive (31%) among young female students aged 21-24 years who appeared as the most vulnerable in accessing and using contraceptives due to perceived social stigma.

Conclusion: The observation that levels of Family Planning awareness levels do not commensurate knowledge and usage levels calls for more innovative strategies for contraceptive promotion, and Education on the various university campus. The study recommends that public Universities in Ghana should consider a possible curriculum restructuring to incorporate family planning updates. In this regard, a nationwide mixed method study targeting other tertiary institutions including colleges of education in Ghana is required to explore the topic further to inform policy and programme decisions.

Keywords: Family planning; Ghana; Undergraduate students; University of Education; Winneba.

• Contraception Behavior / psychology
• Contraception Behavior / statistics & numerical data*
• Contraception, Postcoital
• Contraceptive Agents / therapeutic use
• Contraceptives, Oral, Combined / therapeutic use*
• Contraceptives, Postcoital / therapeutic use*
• Cross-Sectional Studies
• Family Planning Services / organization & administration
• Health Knowledge, Attitudes, Practice*
• Students / psychology
• Students / statistics & numerical data
• Universities
• Young Adult
• Contraceptive Agents
• Contraceptives, Oral, Combined
• Contraceptives, Postcoital

CASE STUDY 08 Family Planning for People and Planet

Executive Summary

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Family planning in India: The way forward

Poonam muttreja.

Population Foundation of India, New Delhi, India

Sanghamitra Singh

Given the magnitude of the family planning programme in India, there is a need to strengthen the coordination of all its aspects, focusing on planning, programmes, monitoring, training and procurement. The quality of care in family planning must be a major focus area to ensure the success of family planning programmes. Despite serious efforts and progress, India has yet to achieve its family planning goals. Furthermore, there is a need for greater male participation both as enablers and beneficiaries and also address the sexual and reproductive needs of the youth. It is imperative for the government to ensure the prioritization of family planning in the national development agenda. Family planning is crucial for the achievement of the sustainable development goals, and subsequent efforts need to be made to improve access and strengthen quality of family planning services.

Introduction

Over the years, social scientists have argued the relationship between demographic change and economic outcomes, and it is now well established that improving literacy and economic conditions for individuals lowers birth rates, while low fertility in turn plays a positive role in economic growth. Family planning (FP) programmes impact women's health by providing universal access to sexual and reproductive healthcare services and counselling information. FP also has far-reaching benefits which go beyond health, impacting all 17 sustainable development goals (SDGs) 1 ; however, the focus is on goals 1, 3, 5, 8 and 10. FP has been recognized as one of the most cost-effective solutions for achieving gender equality and equity (goal 5) by empowering women with knowledge and agency to control their bodies and reproductive choices by accessing contraceptive methods 1 . A women's access to her chosen family planning method strongly aligns with gender equality. Birth spacing can have great implications on health, for instance, reduction in malnutrition (goal 2) and long-term good health (goal 3) for the mother and the child 1 . Access to contraceptives helps in delaying, spacing and limiting pregnancies; lowers healthcare costs and ensures that more girls complete their education, enter and stay in the workforce, eventually creating gender parity at workplace.

Today, the demographic dividend is in India's favour and FP can and should be used to leverage it. Longer lives and smaller families lead to more working-age people supporting fewer dependents. This reduces costs and increases the country's wealth, economic growth (goal 8) and productivity of the people. Ultimately, these result in reduction in poverty (goal 1) and inequalities (goal 10) leading to the achievement of the SDGs through a multiplier effect.

Research shows that adequate attention to family planning in countries with high birth rates can not only reduce poverty and hunger but also avert 32 per cent of maternal and nearly 10 per cent of childhood deaths, respectively 2 . There would be additional significant contributions to women's empowerment, access to education and long-term environmental sustainability 2 . The United States Agency for International Development (USAID) estimates that ‘every dollar invested in family planning saves four dollars in other health and development areas, including maternal health, immunization, malaria, education, water and sanitation’ 3 , 4 . Thus, investing in family planning is the most intelligent step that a nation like India can take to improve the overall socio-economic fabric of the society and reap high returns on investments and drive the country's growth.

With over half of its population in the reproductive age group and 68.84 per cent of India's population residing in villages, opportunities are plenty but so are the challenges 5 . It is still an unrealized dream of the healthcare system to be able to reach the last mile, especially women belonging to scheduled castes and tribes (SC and ST) in distant and remote parts of the country. As a result, the mortality among these groups is high. Scheduled tribes in India have the highest total fertility rate (3.12), followed by SC (2.92), other backward class (OBC) (2.75) and other social groups (2.35) 6 . Contraceptive use is the lowest among women from ST (48%) followed by OBC (54%) and SC (55%) while female sterilization is the highest among women from OBC (40%) followed by SC (38%), ST (35%) and other social groups (61.8%) 6 . There is an urgent need for universal and equitable access to quality health services including contraceptive methods.

Favourable policy environment to meet high unmet need for contraception

An estimate done by the Ministry of Health and Family Welfare (MoHFW), Government of India, states that if the current unmet need for family planning is met over the next five years, India could avert 35000 maternal deaths and 12 lakh infant deaths 7 . If safe abortion services could be ensured along with increase in family planning, the nation could save approximately USD 65000 million 7 . Yet, the fourth National Family Health Survey (NFHS-4) 8 states that almost 13 per cent of women have an unmet need for family planning including a six per cent unmet need for spacing methods 9 . The consistency in these numbers since the NFHS-3 in 2005-2006 6 suggests that despite increasing efforts to create awareness on the subject, there is an existing gap between a woman's desired fertility and her ability to access family planning methods and services.

There is a direct correlation between the number of contraceptive options available and the willingness of people to use them. As shown in Fig. 1A , it has been estimated that the addition of one method available to at least half of the population correlates to an increase in use of modern contraceptives by 4-8 percentage points. Fig. 1A shows a projection of the rise of modern contraceptive prevalence rate (mCPR) in India, based on the trends observed by Ross and Stover 10 and using the current mCPR of 47.8 for India (from NFHS 4) 8 as the base value.

Effect of number of contraceptive methods on modern contraceptive prevalence rate (mCPR). (A) The graphic is a projection of the rise in modern contraceptive prevalence rate (mCPR) in India with every additional contraceptive method. This estimation is based on the mCPR of 47.8 from the National Family Health Survey 4 (NFHS-4). Source : Refs 8 , 10 . (B) Evidence on contraceptive method mix in developing countries South/South-East Asia. The mCPR has been represented on a scale of 100 percentage points to depict the distribution of contraceptive method mix for each country. Source : Refs 8 , 13 , 14 .

Expanding the basket of contraceptive choices led to an increase in overall contraceptive prevalence in Matlab, Bangladesh, where household provision of injectable contraceptives in 1977 led to an increase in contraceptive prevalence from 7 to 20 per cent 11 , 12 . As of 2015, injectable and pills together accounted for about 73 per cent of the modern contraceptive usage in Bangladesh, which has an mCPR of 55.6 per cent 13 . In addition to Bangladesh, Fig. 1B shows the mCPR of other neighbouring South East Asian countries such as Bhutan, Indonesia, Nepal and Sri Lanka where the availability of seven (or more) contraceptive methods corresponds with a higher mCPR. India, with five available methods of contraception (as of 2015), recorded the lowest mCPR among these countries ( Fig. 1B ) 8 , 13 , 14 .

In India, efforts have been made over the years by the government to create a favourable policy environment for family planning, in the form of several important policy and programmatic decisions. At the London Summit on Family Planning held in 2012, the Government of India made a global commitment to provide family planning services to an additional 48 million new users by 2020 14 . According to the FP 2020 country action plan 2016 14 , the government aims at focusing on mCPR, keeping in mind the current annual mCPR increase rate of one per cent as compared to the 2.35 per cent annual increase required to reach the FP2020 goals for India 14 . As a signatory of the SDGs in 2015, India has committed itself to achieving good health and well-being (goal 3) as well as gender equality (goal 5) by 2030 15 .

In 2015, the announcement of the introduction of three new contraceptive methods - injectable contraceptive, centchroman and progestin only pills by the government of India 16 indicated a much-needed shift from the terminal method of female sterilization, which accounted for two-thirds of contraceptive use in India until 2015-2016, to more modern limiting methods of contraception 9 . Introduction of new contraceptive methods has always been marred by controversies surrounding their efficacy, side effects and safety. Consistent efforts need to be made to educate not just the users but also the service providers in every aspect surrounding a newly introduced method so that their capacities are strengthened. The users will also benefit from the strengthening of service providers; they will have better, more accurate access to information surrounding various contraceptive options, enabling them to make more informed choices. The third and equally important partner is the media. Greater efforts need to be made by both the government and civil society organizations to educate media to promote unbiased reporting and avoid creating panic on introduction of new methods.

Like any medical solution, contraceptive methods can also have side effects but it is imperative to note that the ability to access the available range of contraceptive choices is every woman's reproductive right. Implementation of pilot programmes is of utmost significance and relevance to generate further evidence on the efficacy of various contraceptives in different contexts. This enables a better understanding of the impediments in introduction as well as sustained usage of new contraceptives. To prevent early discontinuation and also dispel-related myths and misconceptions, women will need proper counselling on the usage and side effects of contraceptives.

Empowering community health workers to ensure better quality of care

India has close to 900,000 Accredited Social Health Activists (ASHAs) who are the access point for meeting the health needs and demands of the remotest sections of the population, especially women and children 17 . In addition to the ASHAs, other community health workers such as the auxiliary nurse midwife (ANM), reproductive, maternal, new born, child and adolescent health (RMNCH) counsellors and adolescent health counsellors are crucial in covering for the shortage of specialized healthcare providers in the country. Capacity building of community health workers can be of significance in reaching the last mile. The training of frontline workers has to be technical and beyond; there needs to be greater emphasis on trainings around community mobilization and counselling for contraceptive technologies, addressing myths and misconceptions prevailing in the communities regarding modern methods of contraception.

Quality of care (QoC), consisting of its crucial components such as access to contraceptive choices, quality counselling services, information and follow ups, can ensure that the unmet need of millions of women across the country is met, and there is an accelerated reduction in fertility. Efficient responsiveness to users not only creates demand but also ensures return of the clients, ensuring long-term effectiveness and sustainability of the programme. To ensure that quality services reach the last mile, services need to be geographically convenient. And finally, quality services cannot be provided in the absence of adequate infrastructure and competent and unbiased service providers and frontline workers.

The landmark verdict in the Devika Biswas versus Union of India case in 2016 made a number of recommendations to ensure a diligent functioning of the Quality Assurance Committees at the State and district levels 18 . The judgment took cognizance of “The Robbed of Choice and Dignity” report of the multiorganizational fact-finding mission led by Population Foundation of India (PFI) on the sterilization deaths in Bilaspur, Chhattisgarh in November 2014 19 . It also directed the State and Union government to move away from a fixed target-based approach for family planning. And finally, it made specific recommendations to the government to improve the quality of services being provided under the family planning programme. This was a significant move to advance women's reproductive rights and choices in the last several decades and ensures a promising way forward for family planning in India.

Recognizing family planning as a human rights issue

Women's health goes beyond providing technical solutions or increasing the availability of contraceptive methods. Of tremendous significance is a woman's agency, choice and access to quality reproductive services. Access to quality family planning is not only a human right; it is extremely important for individual and societal well-being, and for the nation's development as a whole.

Addressing critical indicators such as child marriage and early pregnancy

Child marriage violates the basic rights of children and especially the right to enjoy a free and joyful childhood. India is among the countries with the highest number of girls married before the age of 18 20 . Early marriage is typically followed by immediate childbearing. A systematic review of 23 programmes from Africa, Bangladesh, Nepal and India conducted by PFI showed that social pressure to prove fertility, insufficient knowledge on contraceptives and limited decision-making power among women were the main reasons for the high levels of early pregnancy 21 . The country needs policies in place that empower women, rather than those that restrict access to contraception.

According to NFHS-4, eight per cent women between 15 and 19 yr of age were either already mothers or pregnant 8 . NFHS-4 data also reveals that between 2005-2006 and 2015-2016, the percentage of women (between 20 and 24 yr) married before 18 yr of age dropped by 21 per cent, while there was a 12 per cent decrease in the percentage of men married before the age of 21 8 . While these figures depict a positive trend, one cannot ignore the fact that over one out of four (27% of girls) were married before the age of 18.

The government and civil society organizations should continue to work on the issue of child marriage by adopting different strategies including, but not limited to, raising awareness, behaviour change communication (BCC), community participation, conducting empowerment programmes for adolescents and not merely offering cash incentives.

Easy access to safe abortion services for women

The World Health Organization has stated that ‘every eight minutes a woman in a developing nation will die of complications arising from an unsafe abortion’ 22 . An estimated 15.6 million abortions occur annually in India 23 . Only five per cent of abortions in India occur in public health facilities, which are the primary access point for healthcare for poor and rural women 23 . Unsafe abortions account for 14.5 per cent of all maternal deaths globally 24 and are most common in developing countries in Africa, Latin America and South and Southeast Asia, with restrictive abortion laws, while the unmet need continues to be high. Such abortions are preventable by ensuring access to quality family planning, safe abortion and counselling services as well as by providing comprehensive sex education 25 .

The social stigma surrounding abortion compels women to resort to unsafe abortion methods at the hands of unqualified service providers. In the Indian context, a study conducted in Bihar and Jharkhand found that abortion providers in both the public and private sectors favoured offering abortion and counselling services to married rather than unmarried women 26 . The same study pointed out that only 31 per cent of all participating providers agreed that all women regardless of marital status should receive information on contraception on request 26 . This act of restricting abortion services to women based on their marital status highlights the prejudice of providers against unmarried women and leads to high instances of unsafe abortions in the country.

The Medical Termination of Pregnancy Act (MTP), 1971 intends to provide safe and easily accessible abortion services to women with unwanted pregnancies on the approval of a medical practitioner, provided the pregnancy is within 20 wk gestation 27 . In India, unsafe abortion is routinely performed by unregistered medical practitioners without any medical training as well as by women who prefer to self-medicate themselves. Such practices often lead to severe health complications. According to International Centre for Research on Women, 59 per cent of women in Madhya Pradesh surveyed revealed that they had an abortion because they did not want any more children. In addition, 22 per cent confessed using abortion as a proxy to contraception and as a means of birth spacing 28 .

To improve access to safe abortion services, a draft amendment bill to the MTP Act, 2014 has been proposed by the Ministry of Health and Welfare, which allows abortion between 20 and 24 wk if the pregnancy involves risk to the mother and child or has been caused by rape 29 . It would also allow Ayurveda and Unani practitioners to carry out medical abortions. While increasing the time limit is in line with the technological advancements and would give the couple adequate time to decide, it can also lead to an increase in sex-selective abortions in the country.

Finally, there is a paradox when it comes to men's attitude towards abortion which needs to be acknowledged and addressed. Men need to be more involved in every dimension of sexual and reproductive health and family planning, right from being users of contraception to being supportive partners to their significant other as she makes a crucial decision about abortion.

Enhanced male engagement in family planning

In many parts of the world including India, family planning is largely viewed as a women's issue. A disproportionate burden for the use of contraception falls on Indian women. Female sterilization accounts for more than 75 per cent of the overall modern contraceptive use in India ( Fig. 1B ). In contrast, India's neighbouring countries such as Bangladesh, Bhutan, Indonesia, Nepal and Sri Lanka exhibit a more balanced method mix scenario which subsequently translates into a higher mCPR ( Fig. 1B ).

As per NFHS-4 data, the two methods of contraception available to men - vasectomy and condoms - cumulatively account for about 12 per cent of the overall mCPR suggesting that women are the driving force behind the family planning vehicle in India 8 , and 40.2 per cent men think it is a woman's responsibility to avoid getting pregnant 30 . Most family planning programmes focus on women as primary contraceptive users while men are viewed as supportive partners, despite evidence depicting interest from male users to existing programming 31 . There needs to be greater recognition of the fact that decision-making on contraceptive use is the shared responsibility of men and women and programmes should cater to men as FP users. Family planning initiatives should address beliefs, myths and misconceptions surrounding contraceptive services as well as other barriers that refrain active male participation 32 . The family planning programmes should restructure their communication methods and strategies in a manner that includes men as both enablers and beneficiaries, hence making them responsible partners.

It is also important to reach men and adolescent boys as users not just in family planning programmes but also in government policies and guidelines as well as in research to create more male contraceptive options 31 .

Addressing the sexual and reproductive needs of the youth

Youth (15-34 yr) account for 34.8 per cent of the total Indian population, of which an enormous number still do not have access to contraceptives 33 .

According to a 2006-2007 subnational youth survey in India, while most youth had heard of contraception and HIV/AIDS, there was lack of detailed information and awareness 34 . While 95 per cent of youth had heard of at least one modern method of contraception, accurate knowledge of even one non-terminal method was considerably low among young women, with only 49 per cent reporting positive knowledge 34 . Likewise, while 91 per cent of young men and 73 per cent of young women reported having heard about HIV/AIDS, only 45 per cent of young men and 28 per cent of young women had comprehensive awareness of HIV 34 . The recently released findings of the UDAYA study in the States of Uttar Pradesh and Bihar by the Population Council revealed low levels of knowledge regarding sexual and reproductive health across all adolescents 35 , 36 . In both States, among older adolescents (15-19 yr), slightly less than a quarter of unmarried boys and girls and one in two married girls knew that a girl could become pregnant even when she had sex for the first time 35 , 36 . Correct knowledge of oral and emergency contraceptives was considerably low across all adolescent groups in both States which indicated an urgent need to improve awareness, strengthen service deliveries and evaluate outreach strategies 35 , 36 .

In its 2016 report, the Lancet Commission acknowledged the ‘triple dividend’ of investing in adolescents: ‘for adolescents now, for their future adult lives, and for their children’ 37 . According to an estimate by the Guttmacher Institute, 38 million of the 252 million adolescent girls aged 15 to 19 years in developing countries are sexually active and do not wish to be pregnant over the next two years 38 . These adolescents include a staggering 23 million with an unmet need for modern contraception 38 . It is more important now than ever to make a shift from one-size-fits-all approaches and cater to the needs of married and unmarried adolescents.

Increased investment in family planning

The National Health Policy 2017 talks of increasing public spending to 2.5 per cent of the GDP, which is a welcome sign 39 . However, much higher health allocations are necessary to take forward the nation's family planning agenda in favour of reproductive health and rights. The Government's newly launched Mission Parivar Vikas Programme focuses on improving access to contraceptives and family planning services in 145 high fertility districts in seven States 40 . In addition to higher health allocations, the government needs to ensure efficient and complete utilization of funds already allocated to family planning activities.

India spent 85 per cent of its total expenditure on family planning on female sterilization with 95.7 per cent of this money going towards compensation, 1.45 per cent on spacing methods and 13 per cent on family planning-related activities such as procurement of equipment, transportation, Information Education and Communication (IEC) and staff expenses in 2016-17 41 . According to our analysis of the National Health Mission (NHM) Financial Management Report 41 , the total budget available for family planning activities under the NHM was ₹12220 million in India during 2016-2017. Of the total money for family planning, 64 per cent was directed for providing terminal or limiting methods, nine per cent towards ASHA incentives for FP activities, 5.3 per cent for training, 5.5 per cent for procurement of equipment, 3.7 per cent for spacing methods and 3.6 per cent towards BCC/IEC activities for family planning ( Fig. 2 ) 41 . The total spending was ₹7415 million indicating that only 60.7 per cent of the total money available for family planning activities was spent during 2016-2017. Of the total expenditure for FP activities, 68 per cent was spent on terminal or limiting methods of which compensation for female sterilization constituted 92.7 per cent; 13.3 per cent was incurred for ASHA incentives, 3.7 per cent was incurred for spacing methods of which incentives to providers for post partum intrauterine contraceptive device (PPIUCD) insertion constituted 73.2 per cent and compensation for intrauterine contraceptive device (IUCD) insertion at health facilities constituted 14.2 per cent, 2.8 per cent on interpersonal communication (IPC)/BCC activities and two per cent was spent for training ( Fig. 2 ).

Allocation, expenditure and utilization of FP budget 2016-2017. POL, petroleum oil and lubricants; RMNCH, reproductive, maternal, newborn, child, health; FP, family planning; bcc, behaviour change communication; IEC, Information, Education and Communication; IUCD, intrauterine contraceptive device. Source : Ref. 41 .

Investing in behaviour change communication (BCC)

The above mentioned numbers suggest that although family planning programmes in India have made significant progress, the budgetary spending and allocation is still skewed towards terminal methods, with inadequate emphasis on training of service providers and investment in BCC/IPC. The issues surrounding family planning and sexual and reproductive health emerge from deep-seated social norms, which cannot be uprooted overnight. It is imperative to strategize effectively to work with communities to influence social norms.

Social and Behaviour Change Communication (SBCC) can address sociocultural norms such as sex selection, early marriage, unwanted pregnancies, domestic violence and gender inequality. PFI's transmedia edutainment intervention, Main Kuch Bhi Kar Sakti Hoon - I , (A Woman, Can Achieve Anything, MKBKSH) is one such example 42 . PFI's experience with MKBKSH Season 1 and 2 shows that entertainment education (EE) initiatives have tremendous reach and potential to change the knowledge, perception and behaviour among viewers.

In addition to SBCC, interpersonal/spousal communication has the potential to significantly improve family planning use and continuation. In countries with high fertility rates and unmet need, men have often been considered unsupportive partners as far as family planning is considered 32 suggesting lack of adequate spousal communication. SBCC is a key avenue in the existing communication within the family planning programme in a country like India where frontline workers reach populations where other media cannot reach. It is the time to not just increase investments in health and family planning but to fully utilize the currently available budget and rearrange the existing allocations in favour of reversible contraceptive methods and SBCC to challenge and change existing sociocultural norms.

The success of India's family planning programme is shouldered by researchers, policymakers, service providers and users, who will need to do their part to ensure equitable access to quality family planning services. The praxis of family planning is simple and the availability of a basket of contraceptive choices can play a crucial role in stabilizing population growth. An effective and successful family planning programme requires a shared vision among key stakeholders, which include the government, civil society organizations and private providers. These stakeholders should ensure that the sexual and reproductive needs of youth and adolescents in the country are fulfilled. In addition, greater male participation as active partners and responsibility bearers can certainly ensure increased use of contraception. The time to act is now. And this should begin with a concerted effort from everyone to empower women, expand family planning choices and strive for greater gender equality so that every individual can lead a dignified life.

Financial support & sponsorship:

The study was supported by Bill and Melinda Gates Foundation.

Conflicts of Interest: