Nome do Projeto
Data inicial - Data final
28/10/2020 - 28/02/2023
Unidade de Origem
Coordenador Atual
Área CNPq
Ciências da Saúde
Family planning can be defined as the capability of women, men, and couples to determine responsibly the number and spacing of their children, without any form of discrimination or coercion. Universal access to sexual and reproductive health is fundamental to better quality of life and sustained development and is on two of the Sustainable Development Goals, as part of goal 3, of good health and well-being, and goal 5, of gender equality. During the last decades, most countries presented progress in increasing coverage, however, at different levels in different settings. Despite the increase in modern contraceptive use in the last decades, it is still low in several countries, especially those from low-income regions, and in several others, a high share of total modern contraceptive use is due to permanent methods of contraception. High use of sterilization hinders a correct view of family planning coverage through its association with some kind of coercion and through an overestimation of family planning access and use where the highest share of modern contraception is achieved with sterilization among women in the end of their reproductive lifespan, being a large proportion of younger women left without meeting their need for family planning. An outlining of pathways to increase family planning coverage among women with different characteristics and different needs could provide relevant information to better design programs and policies. The main aim of this research project is to identify barriers, limitations, and helpers to universal coverage of family planning practices in low- and middle-income countries. Considering it, we propose three original articles. The first article aims to identify where demand for family planning is highly satisfied by female sterilization and the presence of inequalities according to wealth, age, number of living children, and considering the intersectionality between age and number of living children. Using PMA2020 data and a multilevel approach, the second article will analyze the role of health facilities in demand for family planning satisfied in selected geographies. The last article will use an ecological approach to investigate which social and cultural characteristics changed along the increase in demand for family planning satisfied by modern methods. Countries will be included according to their progress in the last decades, the availability of data for multiple times and their location, to guarantee global representativeness. To address this aim, we will promote partnerships with reproductive health experts from success countries and carried out standardized analysis using publicly available data from Demographic Health Surveys, Multiple Indicator Cluster Surveys, Reproductive Health Surveys, Performance Monitoring and Accountability 2020 surveys, and other national health surveys.

Objetivo Geral

Identify patterns of contraceptive use as related to health facility characteristics and overuse of sterilization and explore pathways to universal access to reproductive health care in selected LMICs, through national health surveys.


Universal health coverage (UHC) means that all people have access to the health interventions and services they need, without discrimination. It has been extensively recognized as fundamental to better quality of life, sustained socioeconomic development and global peace and security (WHO, 2010). However, in several countries the aim of delivery UHC is far from being achieved (Horton and Das, 2015). Problems in provision and access of health services are important and easily-fixable barriers to universal coverage. These problems include availability of resources, requirement of direct payments at the time people need care, and inefficient and inequitable use of resources (WHO, 2010). The basic right of individuals and families to have information and means to decide the number, spacing, and timing of their children freely and responsible is a well-recognized human right (UNFPA, 2009). Several keys to effective and sustainable family planning policies are already known, such as legislation, political commitment, adequate funding, availability of a range of methods, support from upper classes and community leaders (Cleland et al., 2006). Based on it, new approaches to address the barriers to family planning coverage have been implemented in LMICs in the last years, increasing contraceptive use trough promotion of self-administration injection and implants among vulnerable women living in remote areas, and through peer education to reduce contraception stigma among adolescents (IPPF, 2015). Despite the progress made (Hellwig et al., 2019), important socio-demographic inequalities still being identified in family planning indicators (Blumenberg et al., 2020; Ewerling et al., 2018; Hellwig et al., 2019), being them among the largest observed in health (UNFPA, 2009). In addition, making a wider range of methods available is fundamental to achieve universal coverage of family planning. In many countries, permanent methods of contraception account for a high share of modern contraceptive use. In several cases,
permanent contraception is associated with coercive practices on women in different moments of their reproductive lifespan, especially among poor and unempowered women (Bertrand et al., 2014; Patel, 2017; Singh et al., 2012).
There are several ways to deliver and promote family planning services. Among those, some can be more powerful or more consistent with the principals of humanity, justice, and equity than other ones. The need for more evidence to assist decision making in what are the best approaches to deliver UHC has been requested in the literature (Horton and Das, 2015), along with a better understanding of what is holding some subgroups behind regarding family planning coverage. An outlining of favorable pathways to increase family planning coverage in low- and middle-income settings could provide important information to help governments and international agencies to design and implement more efficient and equitable policies.



The main outcome, common to the three planned papers, is demand for family planning satisfied by modern methods (mDFPS). mDFPS is defined as the proportion of women of reproductive age (15-49 years old) in need of contraception that are currently using a modern contraceptive method. Women were considered in need of contraception if they are fecund and do not want to become pregnant within the next two years or are unsure if or when they want to become pregnant. Those who were pregnant at the time of the survey and declared the pregnancy as unintended were also considered in need of contraception. Women were classified as infecund if they were menopausal; had had a hysterectomy; had never menstruated; had had their last period more than six months ago and were not postpartum amenorrhoeic; said they cannot get pregnant; or if they had been married for at least five years, had never used contraception and not become pregnant in the previous five years (Bradley and Casterline, 2014).
Modern contraceptive methods are defined here as a technological product or a medical procedure that prevents natural reproduction (Hubacher and Trussell, 2015). Considering this definition, the methods classified as modern were:
- male and female condom
- diaphragms and cervical caps
- vaginal rings
- spermicidal agents
- contraceptive pills
- injectables
- patch contraception
- emergency contraceptive pill
- intrauterine devices (IUD)
- implants
- male and female sterilization
Withdrawal, lactational amenorrhea, and methods based on calendar (such as rhythm method, Standard Day Method, Basal Body Temperature Method, TwoDay Method, and Sympto-thermal Method) will not be considered as modern methods for the purpose of our analyses.

Indicadores, Metas e Resultados


Article 1- Female sterilization in LMICs

- We expect a high variability on the share of sterilization, both within and between regions. We also expected a higher prevalence of use among women who are older and who have three or more children.
- According to wealth, we expect a higher share of female sterilization among the poorest in countries where this procedure is offered in the public sector while it will be higher among the richest otherwise. Further, in those settings we expect that female sterilization will be unjustifiably higher among the more vulnerable women.

Article 2

Family planning services characteristics and demand for family planning satisfied
- We expect a higher contraceptive use prevalence in areas with facilities who provide contraceptives free of charge and those who work with community health workers.
- We also expect that offer of a wider range of contraceptives in nearby facilities will be associated with higher contraceptive use.

Article 3

Pathways to universal access of reproductive health care
- Countries with higher use of contraceptives will have a wider range of contraceptive methods available, being the short-acting reversible ones the most used. According to the social context, we expect those geographies to have a higher proportion of women with high levels of education, higher levels of women’s empowerment, with more tolerant social norms.
- Geographies who managed to succeed in increase family planning coverage in the last years are the ones that made national investments in family planning services, in addition to donor funding.
- Success in increasing contraceptive use are likely to be associated with investments in youth-friendly reproductive health services, integration of family planning services with other health programs, and advocacy through community leaders.

Equipe do Projeto

NomeCH SemanalData inicialData final

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