Method Choice

 

Welcome to the programmatic area on family planning (FP) method choice within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. Method choice is one of the subareas found in the family planning (FP) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications.  Method choice is an essential element of FP programs that seek to meet country development goals and provide high-quality information, counseling, and services to women and couples of reproductive age. Method choice is client-centered, includes informed counseling by providers, ensures that women and couples make informed and voluntary decisions about FP use, and provides a full mix of modern contraceptive methods to support increased and continuous use. Indicators presented here can be used to assess programmatic efforts to expand contraceptive choice through the provision of long-acting and permanent methods. Key indicators to monitor and evaluate method choice can be found in the links at left.

Percent of service delivery points prepared to provide a specific service that have actively provided this service within the last month

Definition:

This indicator measures the preparedness of service delivery points (SDPs) to offer a specific service, as identified by the program, where the SDP has actively provided this service within the past month. “Preparedness” is measured by the following: (1) all essential equipment needed for that specific service are present, functioning, and located in the service delivery area or in reasonable proximity for use; (2) all essential medications and supplies needed for that specific service are present; and (3) at least one staff member assigned to the facility has either professional or in-service training to provide the service following standard procedures. 

This indicator is calculated as:

(Number of SDPs prepared to provide a specific service that have actively provided this service within the past month/Total number of SDPs prepared to provide a specific service) x 100

Data Requirements:

Data for this indicator may be obtained through a Service Provision Assessment (SPA) or a Service Availability and Readiness Assessment (SARA), which may be repeated every three to five years, to measure changes over time. This indicator can be disaggregated by SDP type and location (i.e., poor/not poor, rural/urban, and geographic region).

Data Sources:

SPA or SARA

Purpose:

This is an important indicator for monitoring health system strengthening in developing countries.  A SPA survey is a health facility assessment that provides a comprehensive overview of a country’s health service delivery.  They collect information on the overall availability of different facility-based health services in a country and their readiness to provide those services (DHS Program, 2018).  Key services and topics assessed in a SPA survey are:

The SARA is designed as a systematic survey to generate a set of core indicators of services, which can be used to measure progress in health system strengthening over time.  The SARA core indicators are incorporated into the inventory component of the SPA survey as well.  The SARA focuses on service availability, general service readiness, and service-specific readiness.

Percent of service delivery points offering a mixture of short-acting modern contraceptive and long-acting reversible contraceptive methods

Definition:

In a specified timeframe (e.g., in the past month or in the past three, six, or twelve months), the percent of service delivery points (SDPs) offering at least two modern temporary methods of contraception (male or female condoms, pills, injections, and spermicides) and offering at least one long-acting reversible contraceptives (LARC) method (intrauterine device [IUD] or implant) on site. This indicator can be disaggregated by SDP type and location (i.e., poor/not poor, rural/urban, and geographic region).

This indicator is calculated as:

(Number of SDPs offering at least two temporary contraceptive methods and at least one LARC method/Total number of surveyed SDPs eligible to offer temporary methods and at least one LARC method on site) x 100.

Data Requirements:

Responses to a facility survey question asking whether or not a facility is eligible to offer the methods/service and if the facility currently provides the methods/service.

The question should specify that the service must be provided onsite rather than as client referrals. Data should be collected for each method provided. Evaluators may also want to ask follow up questions about referrals and the number of days that a method is offered to provide more detail about service provision. Example questions for LARCs are below. For IUD services consider specifying responses by type of IUD service (e.g. interval IUD, postpartum IUD, transcesarean IUD, and IUD after postabortion care) if this is helpful to the design or evaluation of the program.

Main questions:

Optional follow-up questions:

Because of the differences in the type of services offered at particular levels of facilities, evaluators should also tabulate the indicator by facility type to identify policy and program implications at various service delivery levels.

If targeting and/or linking to inequity, classify service delivery points by location (poor/not poor) and disaggregate by location.

Data Sources:

Facility survey

Purpose:

This indicator determines the extent to which facilities are eligible to provide and are currently providing a range of family planning (FP) methods to clients. It is also a long-term indication of whether or not a national FP policy that includes LARCs is being implemented.

Issue(s):

This is an overview indicator that does not address the availability of specific methods. It is important to note the distinction between whether a site offers a given service (in other words that the service is defined to be part of the site’s constellation of services) and whether a site has the resources it needs to actually carry out a given service at an adequate level of quality. The latter is explored more fully in other indicators in this section related to availability of infrastructure, supplies, and equipment; provider training; infection prevention systems; and counseling. A relatively large proportion of interviewees may report that LARC services are offered, however a significant proportion of these sites may not be currently offering the services because they do not have a provider who has been trained in the provision of that service in the past three years or the site may not have all the appropriate supplies and instruments.

Percent of facilities offering a permanent method of family planning

Definition:

In a specific timeframe (e.g., in the past month or the past three, six, or twelve months), the percent of facilities offering female sterilization/tubal ligation, and/or male sterilization/vasectomy services on site or through periodic visits by a visiting provider. 

This indicator is calculated as:

(Number of facilities currently offering a permanent method of family planning [FP] on site/Total number of surveyed facilities eligible to offer permanent methods on site) x 100

Data Requirements:

Responses to a facility survey question asking whether or not a facility offers permanent FP services.

The question or questionnaire should specify that the service must be provided onsite rather than as client referrals. Data should be collected separately by method. Evaluators may also want to ask follow up questions about referrals and the number of days that a method is offered to provide more detail about service provision. Example questions are below. For female sterilization consider differentiating between minilap and tubal ligation and/or specify responses by type (e.g. interval, postpartum (<7 days) and, transcesarean). For vasectomy services consider differentiating between vasectomy and no-scalpel vasectomy (NSV).

Main question: Does this facility currently offer _______ services here?

Optional follow-up questions:

If targeting and/or linking to inequity, classify service delivery points by location (poor/not poor) and disaggregate by location.

Data Sources:

Facility survey

Purpose:

This indicator determines the extent to which facilities are providing permanent FP methods to clients. Assessed along with other indicators, it helps programs assess the extent of contraceptive choice. It is also a long-term indication of whether or not a national FP policy which includes long-acting permanent methods (LAPMs) is being implemented.

Issue(s):

It is important to note the distinction between whether a site offers a given service (in other words that the service is defined to be part of the site’s constellation of services) and whether a site has the resources it needs to actually carry out a given service at an adequate level of quality. The latter is explored more fully in other LAPM indicators related to availability of infrastructure, supplies, and equipment; provider training; and counseling. A relatively large proportion of interviewees may report that LAPM services are offered, however a significant proportion of these sites may not be currently offering the services because they do not have a provider who has been trained in the provision of that service in the past three years or the site may not have all the appropriate supplies and instruments.

Percent of clients referred to other family planning services

Definition:

Percent of clients who sought family planning (FP) services from a service delivery point (SDP) and received a referral for another FP service during a defined period (e.g., in the past three, six, or twelve months). A referral occurs if the client is advised where he or she can go to find their preferred or recommended FP method not provided at the original SDP, and the referral is documented at the referral source as proof that a referral was made. 

This indicator is calculated as:

(Number of FP clients who received a referral for an FP service during the reference period/Total number of FP clients served at the SDP during the reference period) x 100

Data Requirements:

The number of clients seeking FP services at an SDP during a given period (e.g., annually) and confirmation of how many were referred for FP services. 

This indicator can be disaggregated by type of SDP or type of referral provided, as well as by client characteristics (e.g., age, sex, geographic location, and rural/urban status).

Data Sources:

Service delivery statistics

Purpose:

The focus of this indicator is to monitor FP service delivery. This indicator aims to measure access to FP services and meeting client's FP needs.

Issue(s):

This indicator similarly assumes that screening for FP need and FP counseling have occurred prior to referral.

Tracking referrals remains a challenge in many countries. Maintaining a system of recording referrals may be difficult until coordination among SDPs improves.

Method mix

Definition:

he percent distribution of contraceptive users (or alternatively, of first-time users) by method in a defined period (e.g., in the past 12 months). 

For each method, this indicator is calculated as:

(Number of users of a specific method/Total number of contraceptive users) x 100

Data Requirements:

Number of users (or acceptors) by method

Data Sources:

Service statistics (program-based) or DHS-type surveys (population-based)

Purpose:

The method mix provides a profile of the relative level of use of different contraceptive methods. A broad method mix suggests that the population has access to a range of different contraceptive methods. Conversely, method mix can signal: (1) provider bias in the system, if one method is strongly favored to the exclusion of others; (2) user preferences; or (3) both.

Regarding what constitutes a desirable method mix, practitioners generally feel that a program should respond to the changing needs of the population at different stages in the reproductive life cycle, and offer reversible methods for those who desire to space pregnancies and permanent methods for those who have completed their desired family size. Thus, programs offering no permanent methods or overemphasizing permanent methods are subject to criticism. Yet within the category of reversible methods, the distribution of acceptors by type of contraceptive will vary by availability of specific methods, costs, local preferences, and other factors, and thus make it difficult to generalize regarding desirable method mix.

Issue(s):

Method mix often changes in response to the introduction of a new method in-country, to non-availability of methods due to stockout, to increased need for a method that also protects against sexually transmitted infections (i.e., condoms), and to user preferences. Data on method mix can signal these changes, but do not provide insight into the reasons for the change. Evaluators can use qualitative methods to better understand the clients' motivations for switching methods.

Because of the problems of monitoring the number of current users based on service statistics, method mix is generally based on acceptors, not on current users, when measured at the program level. The two yield different distributions, since user data reflects the accumulation of long-acting methods from previous years.

Similarly, one expects some discrepancy on method mix calculated from program statistics versus surveys, even in programs with reliable data. (The reason is that program- based statistics reflect activity in the calendar year under study, whereas the survey results include continuing users of long-acting methods who adopted them in previous years and have not needed or chosen to return to the clinic in the calendar year under study). In addition, survey data may include folk methods, non- program methods (e.g., withdrawal), and program methods also available from non-program sources (e.g., pills from pharmacies).

In the case of method mix, the question is not which source of data is better: program- versus population- based. Both are used in forecasting the future contraceptive needs of a country. Many evaluators consider survey data more reliable for assessing preferences for specific methods, because they include clients from both the public and private sector, in addition to those using a non-program method such as withdrawal. However, one must be mindful that in survey data (e.g., the DHS or RHS) the coefficient of variation may be large, and thus affect the stability of the estimate, especially where the percentage using a specific method is very low. Finally, survey data and service statistics sometimes differ, a situation that can arise from inflated service statistics, wastage in the system, or the sale of products outside the intended area for the program (e.g., across borders).

Gender Implications:

Contraceptive method mix can be one indication of gender balance in contraceptive responsibility within a country or program. Globally, vasectomy, though safer and less costly, is much less widely available and used than female sterilization is. Nearly a third of all contraceptive users rely on female sterilization, while only seven percent rely on vasectomy. In India, the ratio of 35 female sterilizations to 1 vasectomy suggests that the program is heavily biased towards female responsibility for contraception. In many parts of sub-Saharan Africa, vasectomy remains virtually unknown. The condom, rhythm, and withdrawal also require male participation or responsibility. Family planning programs have historically been poor at involving men in programs, interventions, and discussions.  Encouraging greater gender equity in contraceptive practice is one goal of the efforts to involve men as partners in family planning and reproductive health.

Furthermore, varying gender constraints (e.g. domestic, child/elder care responsibilities, masculine gender roles that inhibit positive health seeking behaviors) and opportunities in-country affect men and women’s ability to access specific family planning methods and/or distribution points and may have significant implications on the actual method mix available to clients in the public sector.      

Method information index

Definition:

This indicator is an index that summarizes whether service providers supply adequate information to women when receiving family planning (FP) services. It measures the extent to which specific information is provided to help women to make informed choices. The index consists of three questions: Were you informed about other methods? Were you informed about side effects? Were you told what to do if you experienced side effects? The reported value is the percentage of women who responded “yes” to all three questions. Data can be disaggregated by method.

Data Sources:

PMA2020 Survey in select year

Purpose:

This is an FP2020 core indicator. It provides information on the level of access women have to information and counseling on FP and can be used to compare and track trends in  counseling services provided.

Issue(s):

This indicator does not  capture the quality of the FP counseling services. Where the indicator is primarily based on self-report, clients may not remember or know for certain whether their provider asked them all three questions.

Source of supply

Definition:

The percent distribution of the types of service-delivery points cited by users as the source of their current contraceptive method (if more than one source, then the most recent one)

Data Requirements:

If the focus is on the source of contraceptive supply, and which sectors or service delivery types are providing which methods, the indicator is calculated as:

(Number of respondents currently using contraception and the most recent source of supply of their method / Total number of respondents currently using contraception) x 100

If the focus is on the contraceptive method, and the distribution of where each method is sourced, the indicator is calculated as:

(Number of respondents currently using a particular contraceptive method and the most recent source of supply for that method / Total number of respondents currently using that particular contraceptive method) x 100

Source of supply can be disaggregated by sector (public or private), type of service delivery point (e.g., hospital, family planning [FP] clinic, pharmacy, or community health worker) and/or location (i.e., poor/not poor, rural/urban, and geographic region).

Both types of calculations should be disaggregated by method.

Data Sources:

Population-based surveys

Purpose:

This indicator is useful to FP program officials because it shows where contraceptive users obtain their supplies and thus allows programs to evaluate their effectiveness and to forecast procurement needs. It is particularly appropriate to countries trying to shift the burden for FP services from the public to the private sector. For example, the DHS-type surveys yield information on the percentage of modern method prevalence accounted for by the private sector.

In most countries, the source of supply will vary substantially by type of method. Permanent methods, IUDs, and implants require a clinic-based facility (including mobile clinics). Pills are available through clinics in addition to commercial and community-based distributor (CBD) outlets. DepoProvera, once a clinic-based method, has been introduced into CBD programs and is available in pharmacies in some countries. Condoms and spermicides can be dispensed from any type of facility. Thus, data on source of supply are particularly useful when classified by method.

"Source of supply" yields two types of information: type of facility and type of sector (public/private). Type of facility generally includes hospital, health center, FP clinic, mobile clinic, pharmacy, field worker, private doctor, and shop, among others. Sector distinguishes between governmental programs and those in the private sector (including the local FP association, commercial retailers, private physicians, and other private providers). Ideally, data on source of supply should yield the percentage of contraceptive use attributable to the government program, the private FP association, the private sector (pharmacies, private doctors), and other relevant sources.

Issue(s):

The distinction between public and private is often difficult to make, especially in countries with multiple sources of contraception. The respondent may incorrectly identify a given clinic as a government clinic, when in fact it is private (or she simply may not know if it is public or private). A private physician may in fact be participating in a subsidized program to offer low cost services to specific groups. In response to this problem, the DHS questionnaire provides a line for entering the actual name of the facility. Subsequent to the interview, a member of the research team codes the place mentioned according to the correct classification, based on master lists of service delivery points. To classify those not on the list, researchers can later contact key informants from the area.

Percent of women whose demand is satisfied for a modern method of contraception

Definition:

Percent of women of reproductive age (WRA) (15–49 years), or their partners, who desire no child, no additional children, or to postpone the next pregnancy and who are currently using a modern contraceptive method at a point in time. Women using a traditional method are assumed to have an unmet need for modern contraception. This measure applies only to women who are married or in union. 

This indicator is calculated as:

(Modern contraceptive prevalence rate [mCPR]/Total demand for modern methods of contraception) x 100, where mCPR is calculated as (Number of women of reproductive age using a modern method of contraception/Total number of women of reproductive age) x 100 and where total demand for modern methods is calculated as mCPR + unmet need for modern methods 

Data Requirements:

The total number of women of reproductive age, by marital status; and of these, the number that are currently using a contraceptive method.

This indicator can be disaggregated by method as well as by age, geographic region, and rural/urban status. 

Data Sources:

Estimated using data from surveys such as the DHS, MICS, PMA2020, RHS and other nationally representative surveys; modeling using surveys and service statistics

Purpose:

This indicator provides a measure of population coverage of contraceptive use, taking into account all sources of supply and modern contraceptive methods. It provide a useful summary measure of the overall effectiveness of family planning program services in enabling clients to sustain contraceptive use. 

Issue(s):

Although a woman may report that she is currently using a modern contraceptive method, this indicator is unable to determine if the method is being used consistently and correctly. Furthermore, because the data source for this indicator is only WRA who are married or in union, it is not capturing sexually active women who are unmarried or not in union whose demand for modern contraception is not satisfied.

Percent of women who obtained contraceptive method of choice

Definition:

Percent of women women of reproductive age (WRA) (15-49) currently using a modern contraceptive method who report that they obtained their contraceptive method of choice, at a particular point in time. 

This indicator is calculated as:

(Number of WRA currently using a modern method of contraception who report that they obtained their contraceptive method of choice/Total number of WRA currently using a modern method of contraception who were surveyed) x 100

Data Requirements:

Number of WRA who are using modern contraception and if their contraceptive method was what they had chosen

This indicator can be disaggregated by age, geographic region, and rural/urban status. 

Data Sources:

PMA2020 questionnaire, DHS

Purpose:

This indicator addresses the issue of choice and women being able to obtain the contraceptive method that best suits their reproductive needs and preferences. Most countries offer only a limited choice of contraceptive methods. Substantial evidence indicates that a restricted choice of contraceptive methods constrains the opportunity of individual couples to obtain a method that suits their needs, resulting in lower levels of contraceptive prevalence (Ross, Hardee, Mumford and Eid, 2001).

This indicator can be used to track access to a range of different contraceptive methods. 

Issue(s):

This indicator does not address client treatment or barrier to contraceptive access not having to do with supply of contraceptive stock, such as lack of training or biases among program staff regarding certain methods, excessive medical barriers, unneeded eligibility criteria, and family opposition.

References:

John Ross, Karen Hardee, Elizabeth Mumford and Sherrine Eid. "Contraceptive Method Choice in Developing Countries," International Family Planning Perspectives, 2001, 28(1):32-40.

Percent of women who chose their contraceptive method individually or jointly

Definition:

Percent of women of reproductive age (WRA) (15-49) currently using a modern contraceptive method who report that they chose the method themselves or jointly with a partner or provider at a particular point in time. 

This indicator is calculated as:

(Number of WRA currently using a modern contraceptive method who report that they either chose their method themselves or jointly with a partner/Total number of WRA currently using a modern contraceptive method who were surveyed) x 100

Data Requirements:

Number of women using a modern contraceptive method and how they came to the decision to use that method

This indicator can be disaggregated by age, geographic region, rural/urban status, and whether the method was chosen individually or jointly (with either a partner or service provider).

Data Sources:

PMA2020 questionnaire, DHS

Purpose:

This indicator can be used to measure couples' communication and male engagement in family planning (FP). Couples' joint decision-making is a stronger determinant of the use of contraceptive methods than women-only decision-making (Hameed et al, 2014). Interventions that promote couples' discussion of fertility preferences and FP can use this indicator to track progress with engaging men in FP decision-making and increasing communication about FP within the couple.

This indicator can also be used to track client-provider communication. A woman who has chosen her contraceptive method jointly with her provider may be indicative of positive client-provider communication and effective FP counselling.

Issue(s):

A significant problem with this indicator is that it captures neither the quality nor the quantity of communication the woman may have had with her partner or provider.  A woman and her partner may have engaged in a supportive, in-depth conversation about their fertility preferences and reproductive needs and chosen together what contraceptive method was best suited to them.  Or there may have been no conversation at all with the man dictating to the woman what contraceptive method she was going to use.  In both situations, the women would report affirmatively that they chose their contraceptive method jointly with their partner, despite the latter scenario not reflecting the change programmers would hope to see.

References:

Waqas Hameed, Syed Khurram Azmat, Moazzam Ali, Muhammad Ishaque Sheik, Ghazunfer Abbas, Marleen Temmerman, and Bilal Iqbal Avan. "Women's Empowerment and Contraceptive Use: The Role of Independent versus Couples' Decision-Making, from a Lower Middle Income Country Perspective," PLoS One. 2014; 9(8): e104633.