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AbstractCovert use of contraception is a common but underreported and understudied phenomenon where one partner uses contraception without the other's knowledge. We used Demographic and Health Survey couple data to examine the relationship between wives' perceptions of husbands' fertility preferences and type of contraceptive use (overt vs. covert) in Benin, Ethiopia, Kenya, Mali, Nigeria, Sierra Leone, Uganda, and Zambia using logistic regression. Wives who perceived that their husbands wanted more children than them had increased odds of using covertly, compared to those who perceived that husbands wanted the same number of children in all countries except Benin, and the strength of the relationships ranged from adjusted odds ratio (aOR) 2.89 (95 percent confidence interval (CI) 1.75–4.76) in Zambia to aOR 4.01 (95 percent CI 1.68–9.58) in Mali. Wives who reported not knowing their husbands' fertility preferences had increased odds of using covertly compared to wives who perceived that their husbands wanted the same number of children in all countries except Zambia, ranging from aOR 2.02 (95 percent CI 1.11–3.69) in Ethiopia to aOR 3.82 (95 percent CI 2.29–6.37) in Kenya. Our findings indicate that efforts to increase partner engagement to align couple's fertility preferences may encourage overt use.

AbstractFamily planning researchers have been studying the discontinuation of contraception—the prevalence and reasons for it—for decades, as it has implications for contraceptive prevalence, total fertility, and unintended fertility. However little is known about the reliability of contraceptive discontinuation reporting: only two studies have examined the reliability of reported discontinuation in low‐resource contexts. We use longitudinal and overlapping data from reproductive calendars to test the reliability of women's reporting of contraceptive discontinuation in Burkina Faso, Kenya, and Uganda. We test whether recent discontinuations reported at baseline are reported one year later, and if the same reason for discontinuation is reported. Results reveal moderate reliability at the aggregate level of reporting of the index discontinuation; however, reliability is low when the timing of discontinuation is considered. There is variability across the reliability of reasons for discontinuation; discontinuation due to desired pregnancy is reported reliably while other reasons are less reliably reported. Our findings have important implications for the field, particularly in how the data are used and interpreted; we urge caution around event‐level analyses of contraceptive discontinuation and reasons for discontinuation, given low reliability.

AbstractAlthough the reproductive calendar is the primary tool for measuring contraceptive dynamics in low‐income settings, the reliability of calendar data has seldom been evaluated, primarily due to the lack of longitudinal panel data. In this research, we evaluated the reproductive calendar using data from the Performance Monitoring for Action Project. We used population‐based longitudinal data from nine settings in seven countries: Burkina Faso, Nigeria (Kano and Lagos States), Democratic Republic of Congo (Kinshasa and Kongo Central Provinces), Kenya, Uganda, Cote d'Ivoire, and India. To evaluate reliability, we compared the baseline cross‐sectional report of contraceptive use (overall and by contraceptive method), nonuse, or pregnancy with the retrospective reproductive calendar entry for the corresponding month, measured at follow‐up. We use multivariable regressions to identify characteristics associated with reliability or reporting. Overall, we find that the reliability of the calendar is in the "moderate/substantial" range for nearly all geographies and tests (Kappa statistics between 0.58 and 0.81). Measures of the complexity of the calendar (number of contraceptive use episodes, using the long‐acting method at baseline) are associated with reliability. We also find that women who were using contraception without their partners/husband's knowledge (i.e., covertly) were less likely to report reliably in several countries.

AbstractContraceptive preferences are important for reproductive outcomes, such as contraceptive continuation and pregnancy. Current approaches to measuring reproductive preferences in population surveys are limited to exploring only fertility preferences and implicitly assume that contracepting people are using a method they want. We know that people change their fertility preferences over the life course as a response to life events, but there is no information about changes in contraceptive preferences, given the limited evidence about the measurement and distribution of contraceptive preferences. In this study, we examined the extent of change in women's contraceptive preferences over one year and identified characteristics associated with this change in Kenya using three rounds of nationally representative longitudinal data. Over one year, 18 percent of contraceptive users and 46 percent of contraceptive nonusers reported changes in their preferred contraceptive. Experiencing a pregnancy or birth and changes in marital status were associated with changes in contraceptive preferences for users and nonusers. We found that contraceptive preferences are dynamic, suggesting that family planning programs should ensure people's access to various methods to respond to women's changing circumstances and preferences.

AbstractContraceptive discontinuation for method‐related reasons, while presumably wanting to avoid pregnancy, is a common phenomenon and can contribute to high levels of unmet need and unplanned pregnancies. Some women discontinue contraceptive use and do not quickly resume a method ("stopping"), while others are able to quickly switch to another method to achieve their reproductive goal of avoiding pregnancy ("switching"). We use Demographic and Health Survey data from 48 countries to examine what differentiates women who were able to switch to another method versus those who ultimately stopped entirely, among women who discontinued contraception for method‐related reasons. Results show that wanting to limit births, having ever been married, and recent prior use are all associated with switching versus stopping. In addition, we find that women in West and Middle Africa were more likely to stop use compared to women in other regions. Addressing obstacles to contraceptive continuation, including effective method switching, among women who wish to delay or avoid pregnancy should be a priority for global and country initiatives aiming to deliver client‐centered care that supports women and couples to make their best family planning choices.

AbstractNorms and beliefs toward contraception, both positive and negative, motivate contraceptive use; however, they have seldom been explored longitudinally in low‐ and middle‐income countries, limiting our understanding of their influence on contraceptive dynamics. We used PMA2020 Uganda national longitudinal data of reproductive aged women in 2018 (baseline) and 2019 (follow‐up) to explore discontinuation and switching among modern contraceptive users at baseline (n = 688) and contraceptive use at follow‐up among nonusers at baseline (n = 1,377). Multivariable simple and multinomial logistic regressions assessed the association of individual and community‐level contraceptive beliefs with contraceptive uptake, discontinuation and switching. One‐quarter of nonusers at baseline were using contraception at follow‐up, while 37 percent of users at baseline had discontinued and 28 percent had switched methods at follow‐up. The odds of contraceptive uptake were lower among women who strongly agreed that contraception impacted future fertility or caused conflict within a couple, relative to those who strongly disagreed (adjusted odds ratio (aOR): 0.7 and aOR: 0.6, respectively), but higher among women who strongly agreed that contraception preserved beauty (aOR: 1.6). Women who strongly agreed that it was acceptable to use contraception before having children were less likely to discontinue their method than those who strongly disagreed (adjusted relative risk ratio (aRRR): 0.5), though living in a community where more women agreed with this statement was associated with higher discontinuation (aRRR: 6.0). Family planning programs that promote positive beliefs toward family planning could improve contraceptive uptake and continuation. More research is needed to understand how contraceptive beliefs shape contraceptive decisions across the life course.

OBJECTIVES: A more nuanced understanding of contributors to covert contraceptive use remains critical to protecting covert users and reducing its necessity. This study aimed to examine the overall prevalence of covert use, and sociodemographic characteristics associated with covert vs overt use across multiple geographies in sub-Saharan Africa and Asia. STUDY DESIGN: Performance Monitoring for Action (PMA) is one of the few nationally representative surveys that measures covert use across socially diverse contexts via a direct question. Utilizing PMA 2019–2020 phase 1 data from Burkina Faso, Côte D'Ivoire, Kenya, Democratic Republic of Congo (DRC; Kinshasa and Kongo Central regions), Uganda, Nigeria (Kano and Lagos), Niger, and Rajasthan, we estimated overall prevalence of covert use. We conducted bivariate analyses and multivariate logistic regressions for 6 sites, comparing the odds of covert use with overt use among users of contraception by sociodemographic characteristics. RESULTS: Covert use ranged from 1% in Rajasthan to 16% in Burkina Faso. Marital status was the only sociodemographic characteristic consistently associated with type of use across sites. Specifically, polygynous marriage (compared to monogamous) increased odds of using covertly, ranging from adjusted odds ratio (aOR) of 1.8 [95% confidence interval (CI) 1.2–2.7] in Burkina Faso to 6.2 [95% CI 2.9–13.3] in Kinshasa. Unmarried women with partners or boyfriends were also more likely to be using covertly compared with their monogamously married counterparts in all sites (aORs ranged from 2.2 [95% CI 1.0–4.7] in Uganda to 4.4 [95% CI 1.7–11.0] in Kinshasa). CONCLUSION: Understanding factors associated with covert use has programmatic and policy implications for women's reproductive autonomy. IMPLICATIONS: Covert use is a common phenomenon across most sites, representing a small but programmatically important contingent of users. Family planning providers and programs must protect access to and maintain privacy of reproductive services to this ...