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The Anthropocene can be read as being the era when the demand humanity makes on the biosphere’s goods and services—humanity’s ‘ecological footprint’—vastly exceeds its ability to supply it on a sustainable basis. Because the ‘ecological’ gap is met by a diminution of the biosphere, the inequality is increasing. We deploy estimates of the ecological gap, global GDP and its growth rates in recent years, and the rate at which natural capital has declined, to study three questions: (1) at what rate must efficiency at which Nature’s services are converted into GDP rise if the UN’s Sustainable Development Goals for year 2030 are to be sustainable; (2) what would a sustainable figure for world population be if global living standard is to be maintained at an acceptably high level? (3) What living standard could we aspire to if world population was to attain the UN’s near lower-end projection for 2100 of 9 billion? While we take a global perspective, the reasoning we deploy may also be applied on a smaller scale. The base year we adopt for our computations is the pre-pandemic 2019.

Externalities are the unaccounted-for consequences for others of actions taken by one or more persons. They are symptoms of institutional failure, which is why they cannot be eliminated without collective action. When externalities are adverse, the moral directives flowing from them can clash with the exercise of personal rights. In this paper we identify a class of environmental externalities in the contemporary world that accompany procreation. We also identify externalities that are allied to socially embedded preferences for family size. Those preferences can give rise to a heightened demand for children, which exacerbates the adverse environmental externalities present people impose on future generations. Crude but suggestive estimates of the demand humanity currently makes on the biosphere are used to show that adverse environmental externalities accompanying new births are significant. We use data on global economic demography to provide rough estimates of the size of the human population the Earth system can support at a good standard of living. Our analysis, which is designed only to raise questions that have been much neglected in economic demography, allows us to study the sensitivity of sustainable global population to the standard of living.

This paper presents an analysis of trends in sexual activity by marital status and age, and their associations with contraceptive use. Understanding levels of, and trends in, sexual activity is important for assessing the needs for family planning services and for analysing commonly used family planning indicators. Data were taken from 220 Demographic and Health Surveys (DHSs) and 62 Multiple Indicator Cluster Surveys (MICSs) to provide insights into sexual activity by marital status and age in a total of 94 countries in different regions of the world. The results show the sensitivity of the indicator with respect to the definition of currently sexually active, based on the timing of last sexual intercourse (during the last 4 weeks, 3 months, or 1 year). Substantial diversity in sexual activity by marital status and age was demonstrated across countries. The proportion of married women reporting recent sexual activity (sexual intercourse during the last 4 weeks) ranged from 50% to 90%. The proportion of unmarried women reporting recent sexual activity did not exceed 50% in any of the 94 countries with available data, but showed substantial regional differences: it appeared to be rare in Asia and extremely varied within Africa, Europe and Latin America and the Caribbean. Among married women, sexual activity did not vary much by age group, while for unmarried women, there was an inverted U-pattern by age, with the youngest age group (15–19 years old) having the lowest proportion sexually active. The proportion of women who reported currently using contraception and reported not being sexually active varied by the contraceptive method used and was overall much greater among unmarried women. The evidence presented in this paper can be used to improve family planning policies and programmes to serve the diverse needs, for example regarding method choice and service provision, of unmarried women.

Ce chapitre s’ouvre sur les objectifs du développement durable et rappelle les résultats des projections de population des Nations unies. Il traite ensuite des préférences sociales en matière de procréation et de l’évolution de la pratique de la contraception depuis les années 1950. la question cruciale des droits reproductifs est enfin analysée.

The COVID-19 crisis could leave significant numbers of women and couples without access to essential sexual and reproductive health care. This research note analyses differences in contraceptive method mix across Sustainable Development Goal regions and applies assumed method-specific declines in use (from 0 per cent to 20 per cent) to produce an illustrative scenario of the potential impact of COVID-19 on contraceptive use and on the proportion of the need for family planning satisfied by modern methods. Globally, it had been estimated that 77 per cent of women of reproductive age (15-49 years) would have their need for family planning satisfied with modern contraceptive methods in 2020. However, taking into account the potential impact of COVID-19 on method-specific use, this could fall to 71 per cent, resulting in around 60 million fewer users of modern contraception worldwide in 2020. Overall declines in contraceptive use will depend on the methods used by women and their partners and on the types of disruptions experienced. The analysis concludes with the recommendation that countries should include family planning and reproductive health services in the package of essential services and develop strategies to ensure that women and couples are able to exercise their reproductive rights during the COVID-19 crisis.

Background Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. Monitoring progress towards these outcomes is well established for women of reproductive age (15–49 years) who are married or in a union (MWRA). For those who are not, limited data and variability in data sources and indicator definitions make monitoring challenging. To our knowledge, this study is the first to provide data and harmonised estimates that enable monitoring for all women of reproductive age (15–49 years) (WRA), including unmarried women (UWRA). We seek to quantify the gaps that remain in meeting family-planning needs among all WRA. Methods and findings In a systematic analysis, we compiled a comprehensive dataset of family-planning indicators among WRA from 1,247 nationally representative surveys. We used a Bayesian hierarchical model with country-specific time trends to estimate these indicators, with 95% uncertainty intervals (UIs), for 185 countries. We produced estimates from 1990 to 2019 and projections from 2019 to 2030 of contraceptive prevalence and unmet need for family planning among MWRA, UWRA, and all WRA, taking into account the changing proportions that were married or in a union. The model accounted for differences in the prevalence of sexual activity among UWRA across countries. Among 1.9 billion WRA in 2019, 1.11 billion (95% UI 1.07–1.16) have need for family planning; of those, 842 million (95% UI 800–893) use modern contraception, and 270 million (95% UI 246–301) have unmet need for modern methods. Globally, UWRA represented 15.7% (95% UI 13.4%–19.4%) of all modern contraceptive users and 16.0% (95% UI 12.9%–22.1%) of women with unmet need for modern methods in 2019. The proportion of the need for family planning satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 75.7% (95% UI 73.2%–78.0%) globally, yet less than half of the need for family planning was met in Middle and Western Africa. Projections to 2030 indicate an increase in the number of women with need for family planning to 1.19 billion (95% UI 1.13–1.26) and in the number of women using modern contraception to 918 million (95% UI 840–1,001). The main limitations of the study are as follows: (i) the uncertainty surrounding estimates for countries with little or no data is large; and (ii) although some adjustments were made, underreporting of contraceptive use and needs is likely, especially among UWRA. Conclusions In this study, we observed that large gaps remain in meeting family-planning needs. The projected increase in the number of women with need for family planning will create challenges to expand family-planning services fast enough to fulfil the growing need. Monitoring of family-planning indicators for all women, not just MWRA, is essential for accurately monitoring progress towards universal access to sexual and reproductive healthcare services—including family planning—by 2030 in the SDG era with its emphasis on ‘leaving no one behind.’, In a Bayesian hierarchical modelling study, Vladimira Kantorova and colleagues estimate progress towards meeting women’s contraceptive needs in 185 countries., Author summary Why was this study done? Increasing availability of modern contraception has permitted greater opportunities for individual choice and responsible decision-making in matters of reproduction. Global, regional, and national annual estimates of contraceptive prevalence, unmet need for family planning, and the proportion of need for family planning satisfied by modern methods have previously been available only for married or in-union women of reproductive age (15–49 years) (MWRA). We sought to provide estimates of these family-planning indicators for all women of reproductive age (15–49 years) (WRA), including unmarried women (UWRA), that could be used for global monitoring of the proportion of WRA who have their need for family planning satisfied with modern methods (Sustainable Development Goals [SDG] indicator 3.7.1.) What did the researchers do and find? We compiled data on contraceptive use and needs from 1,247 nationally representative surveys and produced harmonised annual estimates and projections that allow monitoring for all WRA, including UWRA. Among the 1.9 billion WRA worldwide in 2019, 1.1 billion have demand for family planning; of these, 842 million are using modern contraception, and 270 million have an unmet need for modern methods. UWRA account for an increasing share of users of modern contraceptive methods globally (15.7% in 2019 up from 12.1% in 2000), driven in part by an increase in contraceptive use among UWRA and an increase in the proportion of women who are unmarried. In 43 countries, of which 32 are low-income countries, less than half of the need for family planning is met by modern methods. What do these findings mean? Annual estimates of key family-planning indicators among all women and by marital status, including the degree of uncertainty around them, provide the global health and development community with better tools for monitoring progress in the era of the SDG and other family-planning initiatives. Although contraceptive use has increased, the progress has been uneven between countries, and large gaps remain in meeting family-planning needs. These gaps should be met by family-planning programmes that enable couples and individuals to decide freely and responsibly the number and spacing of their children, as well as have the information and means to do so.

Language and metaphors are central mechanisms of the human mind and thought processes, and allow us to draw on existing social or physical experiences to make sense of novel concepts. Metaphors are not simply linguistic tools; they are deeply rooted and structured in cultural backgrounds and can shape our understandings, perceptions and actions. Different cultures can have different views about the life-course, reproduction and preventing pregnancy,2 and these views are reflected in the use of language when talking about contraception. Our hypothesis is that the vernacular language used to refer to contraception in northern Malawi would not correspond to the English terms in content or tone, and that such mismatches in the language of public health initiatives could affect uptake. We propose that the discussion around English terms in reproductive health programming must understand and use the local vernacular in each setting, particularly when trying to promote family planning programmes, where cultural values will shape willingness to use contraception.

Unidad de excelencia María de Maeztu CEX2019-000940-M We consider two aspects of the human enterprise that profoundly affect the global environment: population and consumption. We show that fertility and consumption behavior harbor a class of externalities that have not been much noted in the literature. Both are driven in part by attitudes and preferences that are not egoistic but socially embedded; that is, each household's decisions are influenced by the decisions made by others. In a famous paper, Garrett Hardin [G. Hardin, Science 162, 1243-1248 (1968)] drew attention to overpopulation and concluded that the solution lay in people "abandoning the freedom to breed." That human attitudes and practices are socially embedded suggests that it is possible for people to reduce their fertility rates and consumption demands without experiencing a loss in wellbeing. We focus on fertility in sub-Saharan Africa and consumption in the rich world and argue that bottom-up social mechanisms rather than top-down government interventions are better placed to bring about those ecologically desirable changes.

Five models estimate the impact of family planning on health outcomes, but the estimates previously have diverged because the models used different assumptions, inputs, and algorithms. After a collective harmonization process, the models now produce more similar estimates although they retain some minimal differences. These models assist in planning, resource allocation, and evaluation., Estimates of the potential impacts of contraceptive use on averting unintended pregnancies, total and unsafe abortions, maternal deaths, and newborn, infant, and child deaths provide evidence of the value of investments in family planning programs and thus are critically important for policy makers, donors, and advocates alike. Several research teams have independently developed mathematical models that estimate the number of adverse health outcomes averted due to contraceptive use. However, each modeling approach was designed for different purposes, and as such the methodological assumptions, data inputs, and mathematical algorithms initially used in each model differed; consequently, the models did not produce comparable estimates for the same outcome indicators. To address this, a series of expert group meetings took place in which 5 models—Adding it Up, Impact 2, ImpactNow, Reality Check, and FamPlan/Lives Saved Tool (LiST)—were reviewed and harmonized where possible. The group identified the main reasons for the inconsistencies in the estimates generated by the models for each of the adverse health outcome indicators. The group then worked together to align the methodologies for estimating numbers of unintended pregnancies, abortions, and maternal deaths averted due to contraceptive use, and reviewed the challenges with estimating the impact of contraceptive use on newborn, infant, and child deaths, including the lack of a conceptually clear pathway and rigorous evidence. The assumption that most influenced harmonization was the comparison pregnancy rate used by the models to estimate the counterfactual scenario—that is, if women who are currently using contraception were not using a method, how many would become pregnant? All the models now base this on the number of unintended pregnancies among women with unmet contraceptive need, bringing the estimates for unintended pregnancies, total and unsafe abortion, and maternal deaths much closer together. The agreed approaches have already been adopted by the Family Planning 2020 (FP2020) initiative and Track20, a project that supports FP2020. The experts will continue to update their models collaboratively to ensure that the most current estimation methodologies and data available are used. Valid and reliable methodologies for estimating these impacts from family planning are critically important, not only for advocacy to sustain resource allocation commitments but also to enable measurement and tracking of global development indicators. Conflicting estimates can be counterproductive to generating support for family planning programs, and this harmonization process has created a more unified voice for quantifying the benefits of family planning.

Between 2011 and 2014, the program provided more than 330,000 family planning services, mostly to rural women in the informal sector with little or no education. 70% of the voucher clients chose an implant and 25% an intrauterine device., From 2001 to 2011, modern contraceptive prevalence in Uganda increased from 18% to 26%. However, modern method use, in particular use of long-acting reversible contraceptives (LARCs) and permanent methods (PMs), remained low. In the 2011 Uganda Demographic and Health Survey, only 1 of 5 married women used a LARC or PM even though 34% indicated an unmet need for contraception. Between 2011 and 2014, a social franchise and family planning voucher program, supporting 400 private facilities to provide family planning counseling and broaden contraceptive choice by adding LARCs and PMs to the service mix, offered a voucher to enable poor women to access family planning services at franchised facilities. This study analyzes service trends and voucher client demographics and estimates the contribution of the program to increasing contraceptive prevalence in Uganda, using the Impact 2 model developed by Marie Stopes International. Between March 2011 and December 2014, 330,826 women received a family planning service using the voucher, of which 70% of voucher clients chose an implant and 25% chose an intrauterine device. The median age of voucher users was 28 years; 79% had no education or only a primary education; and 48% reported they were unemployed or a housewife. We estimated that by 2014, 280,000 of the approximately 8,600,000 women of reproductive age in Uganda were using a contraceptive method provided by the program and that 120,000 of the clients were “additional users” of contraception, contributing 1.4 percentage points to the national modern contraceptive prevalence rate. The combination of family planning vouchers and a franchise-based quality improvement initiative can leverage existing private health infrastructure to substantially expand family planning access and choice for disadvantaged populations and potentially improve contraceptive prevalence when scaled nationally.

In July 2012, the London Summit on Family Planning reenergized the reproductive health field by establishing a new commitment to bring modern contraception to women and girls with an unmet need for family planning—those who say they do not want a child soon or at all but are not currently using contraception. At that time, it was estimated that 222 million women in the developing world had an unmet need for modern contraception.1 Most of these women were concentrated in the world's 69 poorest countries.2 The family planning community committed at the Summit to enabling an additional 120 million women in these 69 countries to use modern contraception by 2020.2–4 The community felt that designating a single number would help rally the community and push forward a renewed focus on family planning.3 Nearly 5 years later, the widely recognized “120 by 20” goal supported by the Family Planning 2020 (FP2020) global partnership can be credited for galvanizing renewed commitment to family planning. However, the new metric of “additional users”—an aggregate metric that estimates how many more modern contraceptive users there are now compared with the estimated 2012 baseline number—has created confusion about the definition and meaning of several other related family planning metrics, including “new users,” “acceptors,” “first-time users,” and “adopters.” It has also raised the question of how service-level metrics collected by programs can be linked to the aggregate concept of “additional users” to assess progress of individual programs toward population changes in contraceptive use at the country level. In this article, which follows from a panel discussion among the 4 coauthors held during the 2016 International Conference on Family Planning, we outline several of the metrics currently used to measure family planning program progress and propose a preferred set of service-level metrics to inform contributions to the FP2020 aggregate-level goal of reaching “additional users.” We also describe 2 approaches—Track20's Family Planning Estimation Tool (FPET) and Marie Stopes International's Impact 2 model—for bridging the gap between service-level measures available in programs' routine service statistics and the aggregate metric of additional users. Finally, we draw attention to the need for more robust data collection systems that allow for the collection of harmonized routine longitudinal metrics rather than focusing solely on visit-based service statistics or cross-sectional household surveys.

Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. To quantify the gaps that remain in meeting needs among adolescents, this study provides a harmonised data set and global estimates and projections of family planning indicators for adolescents aged 15–19 years. We compiled a comprehensive dataset of family-planning indicators among women aged 15–19 from 754 nationally representative surveys. We used a Bayesian hierarchical model with country-specific annual trends to estimate contraceptive prevalence and unmet need for family planning, with 95% uncertainty intervals (UIs), for 185 countries, taking into account changes in proportions married or in a union and differences in sexual activity among unmarried women across countries. Among 300 million women aged 15–19 years in 2019, 29.8 million (95% UI 24.6–41.7) use any contraception, and 15.0 million (95% UI 12.1–29.2) have unmet need for family planning. Population growth and the postponement of marriage influence trends in the absolute number of adolescents using contraception or experiencing unmet need. Large gaps remain in meeting family-planning needs among adolescents. The proportion of the need satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 59.2% (95% UI 44.8–67.2) globally among adolescents, lower compared to 75.7% (95% UI 73.2%–78.0%) among all women age 15–49 years. It was less than one half of adolescents in need in Western Asia and Northern Africa (38.7%, 95%UI = 20.9–56.5), Central and Southern Asia (43.5%, 95%UI = 36.6–52.3), and sub-Saharan Africa (45.6%, 95%UI = 42.2–49.0). The main limitations of the study are: (i) the uncertainty surrounding estimates for countries with limited or biased data is large; and (ii) underreporting of contraceptive use and needs is likely, especially among unmarried adolescents.

To investigate a method of using patient-held records to collect contraception data in Malawi, that could be used to explore contraceptive discontinuation and method switching.In 2012, all 7393 women aged 15 to 49 years living in the area covered by the Karonga demographic surveillance site were offered a family planning card, which was attached to the woman's health passport - a patient-held medical record. Health-care providers were trained to use the cards to record details of contraception given to women. During the study, providers underwent refresher training sessions and received motivational text messages to improve data completeness. After one year, the family planning cards were collected for analysis.Of the 7393 eligible women, 6861 (92.8%) received a family planning card and 4678 (63.3%) returned it after one year. Details of 87.3% (2725/3122) of contacts between health-care providers and the women had been recorded by health-care providers on either family planning cards or health passports. Lower-level health-care providers were more diligent at recording data on the family planning cards than higher-level providers.The use of family planning cards was an effective way of recording details of contraception provided by family planning providers. The involvement of health-care providers was key to the success of this approach. Data collected in this way should prove helpful in producing accurate estimates of method switching and the continuity of contraceptive use by women.Examiner une méthode consistant à utiliser les dossiers tenus par les patients pour recueillir des données sur la contraception au Malawi qui pourraient permettre d'analyser les interruptions et les changements de méthodes de contraception.En 2012, l'ensemble des 7393 femmes âgées de 15 à 49 ans de la région couverte par le système de surveillance démographique de Karonga s'est vu proposer une carte de planification familiale, attachée à leur carnet de santé – un dossier médical tenu par les patients. Les professionnels de santé ont été formés à utiliser ces cartes pour noter les renseignements sur la contraception prescrite aux femmes. Au cours de l'étude, ils ont assisté à des séances de remise à niveau et ont reçu des SMS d'incitation en vue d’améliorer l'exhaustivité des renseignements inscrits. Au bout d'un an, les cartes de planification familiale ont été recueillies pour analyse.Sur les 7393 femmes éligibles, 6861 (92,8%) ont reçu une carte de planification familiale et 4678 (63,3%) l'ont restituée au bout d'un an. Des renseignements sur 87,3% (2725/3122) des contacts entre les professionnels de santé et les femmes avaient été consignés par les professionnels de santé sur les cartes de planification familiale ou les carnets de santé. Les professionnels de santé de niveau inférieur étaient plus appliqués à inscrire les renseignements sur les cartes de planification familiale que ceux de niveau plus élevé.L'utilisation de cartes de planification familiale s'est révélée un moyen efficace de consigner les renseignements sur la contraception prescrite par les prestataires de services de planification familiale. L'implication des professionnels de santé était indispensable à la réussite de cette démarche. Les données recueillies de cette manière devraient permettre de faire des estimations précises des changements de méthodes et de la continuité du recours aux contraceptifs par les femmes.Investigar un método para hacer uso de las historias clínicas de los pacientes para recopilar datos sobre los anticonceptivos en Malawi, los cuales podrían utilizarse para estudiar la eliminación de los anticonceptivos y los cambios de métodos.En 2012, se ofreció a todas las 7.393 mujeres de entre 15 y 49 años que vivían en la zona cubierta por los puestos de vigilancia demográfica de Karonga una cartilla de planificación familiar, que se adjuntaba a su pasaporte sanitario (la historia clínica del paciente). Se enseñó a los profesionales sanitarios a hacer uso de las historias para documentar detalles sobre los anticonceptivos administrados a las mujeres. A lo largo del estudio, los profesionales se sometieron a sesiones formativas de actualización y recibieron mensajes de texto motivacionales para mejorar el cumplimiento total de los datos. Después de un año, se recogieron las cartillas de planificación familiar para analizarlas.De las 7.393 mujeres que cumplían los requisitos, 6.861 (92,8%) recibieron una cartilla de planificación familiar y 4.678 (63,3%) la devolvieron al cabo de un año. Los detalles del 87,3% (2.725/3.122) de las visitas entre los profesionales sanitarios y las mujeres fueron documentados por los primeros en las cartillas de planificación familiar o bien en los pasaportes sanitarios. Los proveedores de atención sanitaria de bajo rango fueron más minuciosos a la hora de documentar los datos en las cartillas de planificación familiar que los de alto rango.El uso de las cartillas de planificación familiar fue una forma efectiva de registrar los detalles de los anticonceptivos administrados por los proveedores de planificación familiar. La implicación de los proveedores de atención sanitaria fue clave para el éxito de este enfoque. La información recopilada de esta forma deberá ser de ayuda a la hora de producir estimaciones rigurosas sobre si existen cambios de métodos y continuidad en el uso de anticonceptivos por parte de las mujeres.إجراء استقصاء لتحديد طريقة لاستخدام السجلات التي يملكها المرضى لجمع البيانات المتعلقة بمنع الحمل في ملاوي، حيث يمكن الاستعانة بهذه الطريقة في استكشاف معلومات عن التوقف عن استعمال موانع الحمل والتحول لاستخدام طرق بديلة.تم تقديم بطاقة تنظيم الأسرة إلى جميع النساء اللاتي تتراوح أعمارهن بين 15 و49 عامًا والبالغ عددهن 7393 ممن يقيمون بالمنطقة التي تشملها خدمة موقع الترصد الديموغرافي في كارونجا، وذلك في عام 2012، حيث تُرفق بالبطاقة الصحية الخاصة بالمرأة – والتي تمثل سجلًا طبيًا يملكه المريض. وقد تلقى مقدمي خدمات الرعاية الصحية تدريبًا على استخدام هذه البطاقات التي تم إعطاؤها للنساء لتسجيل تفاصيل منع الحمل. وأثناء الدراسة حضر مقدمو هذه الخدمات جلسات تدريبية لتجديد المعلومات، كما تلقوا رسائل نصية تحفيزية لرفع مستوى اكتمال البيانات. وبعد مرور عام واحد، تم جمع بطاقات تنظيم الأسرة لتحليلها.حصلت 6861 (92.8%) امرأة من بين 7393 امرأة تنطبق عليها الشروط، على بطاقة تنظيم الأسرة، بينما أرجعت 4678 (63.3%) منهن البطاقة بعد مرور عام واحد. وسجّل مقدمو خدمات الرعاية الصحية تفاصيل 87.3% (2725/3122) من مرات التواصل بينهم وبين النساء فيما يتعلق إما ببطاقات تنظيم الأسرة أو البطاقات الصحية. وتحلى مقدمو خدمات الرعاية الصحية في المستويات الأقل بهذا المجال بمزيد من الجدية في تسجيل البيانات المتعلقة ببطاقات تنظيم الأسرة مقارنةً بمقدمي خدمات الرعاية الصحية في المستويات الأعلى بهذا المجال. ا旨在调查利用患者保存的记录来收集马拉维境内避孕数据的方法，该方法可以用来探索避孕药具的停用和方法转换。.2012 年，居住在卡龙加县人口监测站点覆盖范围内的所有 15 至 49 岁女性（共 7393 名）都收到了计划生育卡，该卡附在女性的医疗记录册——患者保存的医疗记录内。 医疗服务提供者接受了培训，使用该卡记录女性使用避孕药具的详细情况。在研究过程中，提供者接受了进修培训课，并且收到了激励性的短信，以提高数据完整性。 一年之后，收集计划生育卡进行分析。.在 7393 名符合条件的女性中，有 6861 (92.8%) 名收到了计划生育卡，4678 (63.3%) 名在一年后返还了计划生育卡。 医疗服务提供者在计划生育卡或医疗手册上记录了医疗服务提供者与 87.3% (2725/3122) 女性之间的联系详情。 低级别的医疗服务提供者比高级别的更加勤于在计划生育卡上记录数据。.计划生育卡的使用是记录计划生育提供者所提供避孕详情的一种有效方法。 医疗服务提供者的参与是该方法成功的关键。 用这种方法收集的数据对准确评估方法转换和女性使用避孕药的持续性颇有助益.Изучить метод ведения пациентами записей с целью сбора информации о методах контрацепции, принятых в Малави. Получить информацию для исследования прекращения применения контрацептивных средств и перехода от одного метода контрацепции к другому.В 2012 году жительницам региона, который находится в ведении участка демографических наблюдений Каронга, предложили так называемые карты планирования семьи. В исследовании приняли участие 7393 женщины в возрасте от 15 до 49 лет. Карты планирования семьи прилагались к «паспорту здоровья женщины» — медицинской карте, которую ведет сама пациентка. Медицинских работников обучили использованию этих карт для фиксации подробной информации о том, какие контрацептивные средства они предлагали женщинам. Во время исследования медицинские работники проходили повторное обучение и получали мотивационные текстовые сообщения с целью добиться большей полноты данных. Спустя год карты планирования семьи были собраны для анализа.Из 7393 женщин, которые смогли принять участие в исследовании, 6861 получила карту планирования семьи (92,8%) и 4678 (63,3%) женщин вернули эти карты врачам спустя год. 87,3% (2725 из 3122 человек) пациентов располагали подробными сведениями о посещении врачей. Данные сведения были внесены самими врачами в карту планирования семьи или паспорт здоровья женщины. Следует отметить, что медицинские работники низшего звена были более прилежны в том, что касается внесения данных в карты планирования семьи, нежели медработники более высокого уровня.Использование карт планирования семьи оказалось эффективным методом фиксации подробных сведений о том, какого рода противозачаточные средства предлагались женщине ее врачами. В этом исследовании участие и заинтересованность самих медицинских работников играли ключевую роль. Собранные таким образом данные полезны для точных оценок необходимости продолжения использования женщиной противозачаточных средств или перехода с одного метода контрацепции на другой.

To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.Comparer les politiques nationales de lutte contre le virus de l'immunodéficience humaine (VIH) qui influencent l'accès aux services de dépistage et de traitement du VIH dans six pays d'Afrique subsaharienne.Nous avons examiné les politiques de lutte contre le VIH dans le cadre d'une étude multi-pays sur la mortalité des adultes en Afrique subsaharienne. Un outil d'extraction de données a été mis au point et utilisé afin d'examiner les documents et les directives des politiques nationales de lutte contre le VIH publiés en Afrique du Sud, au Kenya, au Malawi, en Ouganda, en République-Unie de Tanzanie et au Zimbabwe entre 2003 et 2013. Des entretiens avec des informateurs clés ont permis de combler les carences de ces résultats. Les politiques nationales ont été classées suivant leur degré de correspondance, explicite ou implicite, avec 54 indicateurs relatifs aux politiques, déterminés d'après des analyses documentaires et des examens d'experts. Nous avons également comparé les politiques nationales avec les recommandations de l'Organisation mondiale de la Santé (OMS).Nous avons observé de grandes différences entre les politiques de ces pays ; chaque pays était avancé dans certains domaines et pas dans d'autres. Le Malawi l'était particulièrement en matière de promotion du démarrage rapide du traitement antirétroviral. Cependant, aucun pays n'avait un contexte politique pouvant systématiquement permettre d'augmenter l'accès aux soins et d'éviter l'arrêt du traitement. Dans certains domaines, les pays allaient plus loin que les recommandations de l'OMS et les informateurs ont indiqué que la pratique dépassait souvent le cadre des politiques.Évaluer l'impact des différentes politiques sur l'accès aux soins et les résultats en termes de santé des personnes qui vivent avec le VIH n'est pas chose simple. Certaines politiques exercent une influence plus forte que d'autres et les politiques officielles ne sont pas toujours mises en œuvre. Des recherches ultérieures devraient évaluer le degré de mise en œuvre des politiques et mettre en lien leurs conclusions avec les résultats de la lutte contre le VIH.Comparar las políticas nacionales relativas al virus de la inmunodeficiencia humana (VIH) que influencian el acceso a las pruebas del VIH y a los tratamientos en seis países sub-saharianos.Se revisaron las políticas relativas al VIH como parte de un estudio multinacional sobre la mortalidad de adultos en África Subsahariana. Se desarrolló una herramienta de extracción de políticas y se utilizó para revisar los documentos y guías de las políticas nacionales relativas al VIH publicadas en Kenia, Malawi, República Unida de Tanzania, Sudáfrica, Uganda y Zimbabue entre 2003 y 2013. Se hicieron entrevistas a informantes claves que ayudaron a llenar los vacíos en los resultados. Las políticas nacionales se clasificaron según si se adhirieron explícita o implícitamente a 54 indicadores de políticas, identificados mediante bibliografía y opiniones de expertos. Asimismo, se compararon las políticas nacionales con las directrices de la Organización Mundial de la Salud (OMS).Se descubrió que había una amplia variedad entre las políticas de los países. Cada país estaba más avanzado en algunas áreas que en otras. Malawi estaba especialmente avanzado en la promoción de empezar rápidamente la terapia antirretroviral. Sin embargo, ningún país tenía un contexto de introducción de políticas consistente que incrementara el acceso a la atención primaria y evitara la deserción. Algunos países iban más allá de las orientaciones de la OMS en algunas áreas e informantes clave informaron de que la práctica a menudo superaba la política.Evaluar el impacto de las diferencias en las políticas relativas en el acceso a la atención primaria y los resultados en la salud entre aquellas personas con VIH es un reto. Algunas políticas ejercerán más influencia que otras y las políticas oficiales no siempre se aplican. Las investigaciones futuras deberían evaluar el grado de aplicación de las políticas y vincular estos resultados con los resultados del VIH.الغرض旨在对比在撒哈拉沙漠以南的六个非洲国家中能够影响艾滋病病毒测试和治疗服务的国家艾滋病病毒 (HIV) 政策。.在撒哈拉沙漠以南的非洲国家中进行有关成人死亡率的多国研究期间,我们评审了艾滋病病毒政策。 当时开发了一种政策提取工具并将其用于评审津巴布韦、肯尼亚、马拉维、南非、坦桑尼亚联合共和国以及乌干达在 2003 年和 2013 年期间出版的国家艾滋病病毒政策文件和指南。关键知情人访谈帮助我们弥补了调查结果中的不足之处。 我们依据国家政策是否以明确或隐含的方式遵循 54 项政策指标来对其进行分类,并且通过文献和专家评审加以确认。 同时,我们还对比了国家政策和世界卫生组织 (WHO) 指南。.各国的政策差异很大;每个国家都在一些方面达到先进水平,而在另一些方面却没有达到先进水平。 马拉维在推动抗逆转录病毒疗法的快速启动方面尤为先进。 然而,没有一个国家能够终保持一贯有利的政策环境,难以按预期提高护理普及率和预防消耗。 各国在某些方面超出了世界卫生组织指南的范围,并且据关键知情人报告,实际情况往往超越政策范围。.评估政策差异对艾滋病病毒患者的护理普及率和医疗效果的影响具有挑战性。 某些政策会比其他政策产生更大的影响,并且官方政策并不总是能够得到落实。 今后的研究应评估政策实施的程度,并将这些调查结果与艾滋病病毒的医疗效果联系起来。.Сравнить политику в отношении вируса иммунодефицита человека (ВИЧ) в шести странах Африки к югу от Сахары. Оценивается доступность анализа на ВИЧ и услуг по лечению.Политики в отношении ВИЧ были рассмотрены в рамках многонационального исследования смертности взрослого населения в странах Африки к югу от Сахары. Для анализа политик был разработан специальный инструмент, который использовался для проверки официальных документов и рекомендаций, связанных с государственной политикой в отношении ВИЧ, опубликованных в Кении, Малави, Южной Африке, Уганде, Объединенной Республике Танзания и Зимбабве в период между 2003 и 2013 гг. Неясные моменты уточнялись благодаря ключевым информаторам. Национальные политики распределялись по категориям в зависимости от того, придерживались ли они явным или косвенным образом 54 показателей, выявленных в ходе оценки публикаций и отчетов специалистов. Было также проведено сравнение национальных политик с рекомендациями Всемирной организации здравоохранения (ВОЗ).Политики в разных странах отличались друг от друга; в каждой из стран отмечался прогресс в одних областях и отставание в других. В частности, Малави значительно выделялась продвижением раннего начала антиретровирусной терапии. Тем не менее ни в одной стране не была реализована эффективная политика, которая облегчала бы доступ к медицинской помощи и препятствовала бы оттоку персонала. В некоторых областях страны пошли дальше рекомендаций ВОЗ и основные информаторы сообщили, что практика часто опережала политику.Оценить, насколько отличия в государственной политике влияют на доступ к лечению и результаты мероприятий по охране здоровья для лиц, живущих с ВИЧ, довольно сложно. Некоторые из политик имеют сравнительно больший эффект, и официальная политика не всегда выполняется. В будущих исследованиях необходимо оценить степень выполнения политик и связать полученные данные с результатами лечения ВИЧ.

Malawi is a global leader in the design and implementation of progressive HIV policies. However, there continues to be substantial attrition of people living with HIV across the “cascade” of HIV services from diagnosis to treatment, and program outcomes could improve further. Ability to successfully implement national HIV policy, especially in rural areas, may have an impact on consistency of service uptake. We reviewed Malawian policies and guidelines published between 2003 and 2013 relating to accessibility of adult HIV testing, prevention of mother-to-child transmission and HIV care and treatment services using a policy extraction tool, with gaps completed through key informant interviews. A health facility survey was conducted in six facilities serving the population of a demographic surveillance site in rural northern Malawi to investigate service-level policy implementation. Survey data were analyzed using descriptive statistics. Policy implementation was assessed by comparing policy content and facility practice using pre-defined indicators covering service access: quality of care, service coordination and patient tracking, patient support, and medical management. ART was rolled out in Malawi in 2004 and became available in the study area in 2005. In most areas, practices in the surveyed health facilities complied with or exceeded national policy, including those designed to promote rapid initiation onto treatment, such as free services and task-shifting for treatment initiation. However, policy and/or practice were/was lacking in certain areas, in particular those strategies to promote retention in HIV care (e.g., adherence monitoring and home-based care). In some instances, though, facilities implemented alternative progressive practices aimed at improving quality of care and encouraging adherence. While Malawi has formulated a range of progressive policies aiming to promote rapid initiation onto ART, increased investment in policy implementation strategies and quality service delivery, in particular to promote long-term retention on treatment may improve outcomes further.

This paper argues that poverty assessments that use standard money-metric indicators of poverty overlook the welfare of communities highly vulnerable to weather-related extremes, and that an assessment of vulnerability to climate change should be an integral part of poverty assessment. Using Ghana as a case study, this paper evaluates to what extent the standard money-metric measures of poverty represent the welfare of those households vulnerable to weather-related extremes. In addition, the paper illustrates the importance of mainstreaming climate change into development strategies, highlights the importance of integrating vulnerability assessments and stresses the need for developing adaptation strategies for poverty alleviation. Copyright (C) 2010 John Wiley & Sons, Ltd.

CONTEXT: Increased use of contraceptives in Malawi has not translated into a commensurate reduction in fertility, but the reason is unknown. Insight into contraceptive switching and discontinuation may shed light on this conundrum and on whether the commonly used modern contraceptive prevalence rate (mCPR) is the best indicator of family planning program performance. METHODS: A one-year prospective longitudinal data set was created from patient-held family planning cards of 4,678 reproductive-age women living in a demographic surveillance site in rural northern Malawi. Contraceptive service data recorded on the women's cards by providers were linked to their socioeconomic, demographic and health data. Contraceptive point prevalence estimates calculated from these data were compared with mCPR estimates from cross-sectional surveys. Survival analyses examined contraceptive adherence. RESULTS: The contraceptive point prevalence of 35% was slightly lower than comparable cross-sectional estimates of mCPR. Only 51% of users of the injectable-the most widely used modern method-received their first reinjection on time, and just 15% adhered to the method for 12 months. Although various study variables were associated with contraceptive use, none were associated with adherence. CONCLUSIONS: Gaps in and discontinuation of use of the injectable may play a role in the discrepancy between mCPR and fertility. Interventions to help women adhere to injectable use and to promote long-acting methods should be strengthened.