Special Analysis: Contraceptive Method Mix
This special analysis is excerpted from the FP2020 Commitment to Action: Measurement Annex 2015.
In this section we present three analyses of contraceptive method mix.34
First, we analyze contraceptive prevalence for evidence of method skew, based on the latest available survey from each of the 69 FP2020 countries.
Next, for a subset of countries with sufficient data collected since 2012, we examine how method skew has changed over time.
Last, for the same subset of countries, we examine the most pronounced changes in the prevalence of specific types of contraceptive method.
The analyses presented here demonstrate that patterns of method mix are complex, and must be examined in the context of multiple factors. Examining method skew alone does not present a complete picture; but looking at it together with method diversity, traditional method use, and overall contraceptive prevalence can give us a better understanding of how “balanced” a country’s method mix actually is, and what implications this might have for women’s choice.
Download the full FP2020 Commitment to Action: Measurement Annex 2015
METHOD SKEW IN THE 69 FOCUS COUNTRIES
In this section we examine the prevalence of 10 types of contraceptive methods in a country’s overall method mix. Method prevalence is the proportion or “share” of use held by each contraceptive method type, with the sum of all types equaling 100%.
The method mix examined here is composed of 10 types: four long-acting and permanent methods (LAPMs), five short-term methods (STMs), and all traditional methods grouped together.
When the prevalence of a single method is 40% or greater, we refer to method skew. The range of 40% to 60% is considered a moderate level of method skew; 60% or greater is a high level of skew. The degree to which a method is disproportionately prevalent is referred to as method dominance.
Using each country’s most recent national survey,35 we analyzed the prevalence of 10 types of contraceptive methods and found method skew to exist in 40 out of the 69 FP2020 countries. Notably, of these 40 countries, “traditional” was the dominant method type in only four. LAPMs were the dominant method type in nine countries, while STMs were dominant in 27.
The presence of an unbalanced method mix or moderate level of skew is not necessarily negative. Method skew could be the result of user preference, or of the successful introduction of a new method. When method skew occurs hand-in-hand with increases in overall use, method skew might be indicative of a positive development: increased method availability and choice, and increased contraceptive prevalence.36 Examples are presented in the next section.
Further, “A totally balanced mix, with even shares for all methods, is never a program objective since it would mean, for example, that condom use would equal that of the implant and IUD use would equal that of male sterilization. Instead, the objective is to generally move away from an obviously distorted mix, without specifying precisely how fully balanced the mix should be, while enlarging access to a wider variety of method choices.”37
The figure below presents the countries where one method dominates the method mix, grouped by moderate or high skew, and showing the dominant method. Countries are sub-grouped by their CPR: low (0%-15%), moderate (15%-45%), and high (45% and greater), derived from the survey used to report method skew.
As shown in the figure, both moderate and high levels of method skew exist at all levels of CPR.
Method skew should be interpreted within the context of the country’s CPR; in a very low CPR country, the dominance of a particular method may be the result of early adopters of contraception sharing similar preferences, or the uptake of one method spurring growth in CPR. Method dominance in a high-CPR country may reflect women’s preferences, or, may be a reflection of the infrastructure for family planning service delivery in the country.
CHANGES IN METHOD SKEW OVER TIME
How has method skew changed over time in the FP2020 focus countries? To answer this question, we limited our analysis to the 38 countries with sufficient survey data from 2012 or later, which allows us to see how things have changed since the time of the London Summit.
Method skew was identified in 23 of the 38 countries, either in their most recent survey, in the survey it was compared to previously, or in both.38 We then categorized the countries as having moved into, or out of, either moderate skew (a single method is 40%-60% of prevalence) or high skew (a single method is ≥60% of prevalence).
We identified shifts (either into or out of skew, and between moderate and high levels of skew) in 13 countries.
- Four countries decreased from high to moderate skew (Djibouti, DR Congo, Egypt, and Kyrgyzstan).
- Three countries shifted away from having method skew altogether; in two of these countries, the shift was away from the dominance of traditional methods (Comoros, Togo); in the other country, injection became non-dominant. (Lesotho).
- Six countries who shifted from no skew to having moderate method skew; in all six, the newly dominant method was modern (injection: Gambia, Haiti, Liberia, Sierra Leone; pill: Niger; implant: Burkina Faso). All six countries have low CPR,39 ranging from 7.1% (Gambia, married or in-union women) to 23.6% (Haiti, all women).
- 10 countries had no change in their method skew; all continued to have either moderate or high level of skew, with dominance by a modern method.
Notably, in countries with low CPR, the increased use of a modern method, while moving the country into method skew, may actually be contributing to an overall increase in CPR as a result of users choosing a method that had not previously been available.40
A case in point is Liberia, where injections have come to dominate the method mix in their 2013 DHS survey, and where the CPR (for all women) in the same year is 21.7%, as compared to a CPR of 13.3% in their 2007 DHS survey.
This example, combined with the finding that all five countries whose method mix profiles have demonstrated shifts into method skew are countries with lower CPRs (below 25%), points to the importance of examining method mix in the context of overall contraceptive prevalence.
SHIFTS IN USE OF METHOD TYPES
Which methods have increased the most in use? Of the 69 FP2020 focus countries, 29 have sufficient data collected since the time of the London Summit to support this analysis. We compared these countries’ most recent surveys with data from their previous survey of the same type (that is, we compared a country’s most recent DHS survey to its previous DHS survey; or its most recent PMA2020 survey to its previous PMA2020 survey, and so on).41
The average duration between surveys was six years, ranging from one to 16 years apart. For each method, the average annual change in method prevalence (e.g., percentage of women using the method) was considered.
“It has long been recognized that the availability of only 1 or 2 contraceptive methods in a country constrains total contraceptive use and limits the options that women and couples have to manage their pregnancies. Conversely, adding methods expands choice for women and men and increases contraceptive use.”
- ROSS ET AL 2015
Overall, two methods stood out as experiencing the most frequent, and largest increases: injections and implants. The graphs below show, for each method, the five countries with the largest average annual increase between their two surveys.42
In three countries, increases in these methods were coupled with declines in use of other methods. The countries are Ethiopia (injections), Zambia (LAM), and Zimbabwe (pill). In the remaining countries, all methods experienced growth in use.
The growth in the prevalence of injections is consistent with the findings of our analysis of method skew. The increased prevalence of implants, however, has not translated to changes in method skew, since in many countries baseline levels of implant use were very low. However, implants were shown to increase the diversity of modern methods in the method mix.
34. The estimates in this section differ from those we present for Core Indicator 9, modern contraceptive method mix, because these analyses include traditional methods as a method type.
35. Note that only 38 of the 69 FP2020 focus countries had adequate national survey data from 2012 or later to support these analyses. Where all women surveys were unavailable, married/in-union women surveys were used.
36. Ross J, Stover J. Use of modern contraception increases when more methods become available: analysis of evidence from 1982–2009. Glob Health Sci Pract. 2013;1(2):203-212. http://dx.doi.org/10.9745/GHSP-D-13-00010.
37. Ross J, Keesbury J, Hardee K. Trends in contraceptive method mix in low- and middle-in come countries: analysis using a new “average deviation” measure. Glob Health Sci Pract. 2015;3(1):34-55. http://dx.doi.org/10.9745/GHSP-D-14-00199.
38. The previous survey was chosen based on whether it had method mix data for the same population (all women or married or in-union women) as the newer survey. In two countries (Gambia and Tajikistan), the new survey data for all women could not be used in the analysis, as these countries have no previous surveys with all women data; thus we cannot do a comparison. Therefore, values for married women from the most recent survey were used in the comparative analysis.
39. CPR is shown from the newest survey, to match the method mix values shown.
40. Ross J, Keesbury J, Hardee K. Trends in the contraceptive method mix in low- and middle-in come countries: analysis using a new ‘‘average deviation’’ measure. Glob Health Sci Pract. 2015;3(1):34-55. http://dx.doi.org/10.9745/GHSP-D-14-00199.
41. Because of differences in methodology between DHS, MICS, PMA2020, and other surveys it is best to compare changes in specific methods prevalence from two data points that come from the same type of survey. Therefore, in some cases an older survey was used for comparison if the previous survey was of a different type. This also meant excluding countries with recent surveys that did not have a previous survey of the same type. The following countries were excluded from this analysis: Benin, Burkina Faso, Burundi, Djibouti, Gambia, India, Mongolia, Nepal, Tajikistan, Uganda, and Vietnam.
42. Sources: Ethiopia (AW): PMA2020 2014 R2 and PMA2020 2014 R1; Kenya (MW): pDHS 2014 and DHS 2008-9; Lesotho (MW): pDHS 2014 and DHS 2009; Liberia (AW): DHS 2013 and DHS 2007; Malawi (MW): MICS 2014 and MICS 2006; Senegal (AW): DHS 2014 and DHS 2012-2013; Sierra Leone (AW): DHS 2013 and DHS 2008; Zambia (AW): DHS 2013-2014 and DHS 2007; Zimbabwe (MW): MICS 2014 & MIMS (MICS) 2009.