Inequities in Effective Coverage of Family Planning Services in Low-and Middle-Income Countries: Linking Households and Facility Surveys
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Background
Despite decades of family planning (FP) program successes in low-and middle-income countries (LIMCs), unmet need for contraceptives persists with inequalities in coverage. Including elements of service readiness in family planning intervention coverage measures will better inform population-level program performance.
Methods
Five LMICs countries were identified with a health facility and household survey conducted within five years of one another within the last 10 years: Bangladesh, Haiti, Malawi, Nepal and Tanzania, with time trend data available for Nepal. We used ecological linking methods to develop quality readiness adjusted FP coverage measures by linking health facility assessments (readiness) and household surveys (intervention coverage). Linking units were defined by facility type, managing authority and geographic location using women’s reported source of contraceptives. Intervention coverage was defined as the percentage of women 15-49 years of age in need of contraceptive services who were using a modern method and we used the average FP readiness score in each linking unit to calculate readiness-adjusted intervention coverage. We used a coverage cascade model to understand gaps in health service readiness and access, and performed a health equity analysis for wealth, locality and age.
Findings
We found large gaps in FP intervention coverage and readiness in all settings. Facility readiness scores ranged from 0.60 and 0.75 with gaps in coverage and readiness-adjusted coverage ranging from 49 percentage points (pp) in Bangladesh to 34pp in Malawi. Urban, wealthier and adolescent women had lower readiness-adjusted coverage since they also obtained their contraceptives outside of health facilities. We found little change in the coverage cascades for Nepal from 2015 to 2021.
Conclusions
This analysis demonstrates calculating readiness-adjusted FP coverage using a cascade model in five geographically diverse countries with time trends in one country. As previous studies have shown, we found large gaps in intervention and readiness-adjusted coverage with related inequalities.
