Step UP Strengthening evidence for programming on unintended pregnancy


Collaborating to generate, communicate, and use policy-relevant evidence

STEP UP uses a strategic, holistic approach towards research. Each research strategy integrates a continuum of linked activities and outputs, which together contribute to STEP UP’s outcome of research uptake.

Each strategy thoughtfully engages in:

    • Evidence generation: Undertaking a coherent body of robust research to address STEP UP’s priority themes. (Click on the subtabs above to explore specific research activities)
    • Communication: Effectively sharing high-quality, policy- and programme-relevant evidence with multiple stakeholders using interactive and multi-directional processes.
    • Capacity building: Increasing the capacity of STEP UP partners and stakeholders to identify, generate, communicate, and use evidence for policy and programming.
    • Partnership: Strengthening alliances and networks to increase demand for and uptake of evidence.

The evidence gaps for reducing unmet needs for family planning and safe abortion are numerous. To identify its priority research themes, STEP UP met with key stakeholders in each focus country and globally to determine the critical evidence gaps of those engaged in policy and programming. As a result of this participatory priority-setting exercise, the following themes were identified. Research activities will reflect the specific context and needs of the countries in which they are implemented as well as contributing to the global evidence base.

STEP UP's priority research themes

    • Understanding the determinants and consequences of unintended pregnancy
    • Profiling unintended pregnancy to inform national policy and programming
    • Understanding and addressing unintended pregnancy among adolescents
    • Strengthening and integrating contraceptive services within national health systems
    • Increasing access to and use of medical abortion

Understanding the determinants and consequences of unintended pregnancy

Clearly understanding and defining the meaning and measurement of unintended pregnancy is central to designing and improving policies and programmes. Therefore, STEP UP is undertaking the following series of analyses to improve policy and programming so that unintended pregnancies can be prevented or more safely managed and adverse outcomes are reduced:

Unintended pregnancy: A conceptual framework

A unified conceptual framework for describing and explaining "unintended pregnancy," and for framing policy and programmatic responses, is being developed and validated through engagement with decision-makers and researchers and through analyses of existing data. The associated analyses stemming from this framework may stimulate and influence national and global thinking and decision-making on unintended pregnancy.

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Trends in pregnancy intentions and fertility preferences

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Use of contraception and unintended pregnancy: A complex relationship

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Understanding and addressing unmet need for contraception

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Profiling unintended pregnancy to inform national policy and programming

In this section: Bangladesh Country Profile; India Country Profile; Kenya Country Profile; Senegal Country Profile; Insights into Unmet Need reports

Country profiles

Four of STEP UP's focus countries (Bangladesh, India, Kenya, Senegal) identified the lack of a comprehensive analysis of the full range of factors associated with unintended pregnancy as a major evidence gap. Through a thorough and systematic desk review, secondary analyses of available datasets, and in-depth interviews with a wide range of key stakeholders, STEP UP partners compiled "country profiles" organized around six broad themes: (1) the legal, policy, and sociocultural context for sexual and reproductive health and rights; (2) trends and equity in family planning; (3) access to and quality of family planning and postabortion/safe abortion services; (4) financing and delivery mechanisms for service delivery; (5) outcomes of unintended pregnancies; and (6) policy and programmatic recommendations for reducing unmet need and unintended pregnancy.

Some key lessons learned from the Bangladesh Country Profile:

    1. The contraceptive prevalence rate in Bangladesh has increased sevenfold in the last forty years, yet from 1993–2007, the rate of unintended pregnancy barely decreased. A key reason for this is high rates of contraceptive discontinuation and a trend away from long-acting methods to shorter-acting methods.
    2. The unmet need for family planning nationwide lies at 13.5% and is higher among young women. Contraceptive discontinuation is a significant reason for unmet need; about 36% method users discontinue use within 1 year nationwide (primarily of short-acting methods), while only 14% of discontinuers switched to another method. This suggests a need for improved FP counseling and support.
    3. Discrimination against women in education, employment, marriage, and dowry has been identified as one of the prime reproductive health issues, and often results in violence.
    4. Central designed health policies inadequately address the needs of geographically-isolated populations.
    5. Abortion is illegal in Bangladesh; however, government-supported Menstrual Regulation (MR) programs have helped to reduce unsafe abortion-related deaths. However, only fifty-seven percent of facilities that are expected to provide MR actually do so.

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Some key lessons learned from the India Country Profile:

    1. Despite six decades of large investments in family planning programming, the contraceptive prevalence rate (CPR) remains low in the North Indian states of Bihar, Madhya Pradesh and Odisha. The technical medical and counseling skills of community health providers must be reinforced and supported to improve the reach and quality of FP counselling and increase CPR.
    2. Although abortion was made legal in 1971, sex-selective abortion was made illegal in 1994, contributing to confusion among women and providers about the legality of abortion. Unsafe abortion is accordingly high, accounting for an estimated 9 to 20 percent of all maternal deaths. To correct misconceptions and reduce the level of consequent unsafe abortions, community awareness must be raised, abortion fees must be standardised, and reporting and monitoring procedures must be simplified.
    3. In all three states, infrastructural and staff shortcomings were enormous. Efforts to address the staffing gaps—such as the ASHA and ANM programs—are hampered by poor supply chains leading to unavailability in contraceptive supplies. Public-private partnerships can assist public health systems in many of these regards, although strong replicable examples are few and bear further study.

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Some key lessons learned from the Kenya Country Profile:

    1. In Kenya sexual and reproductive health (SRH) is recognized as a key human right and several measures have been taken to ensure these rights are upheld, including provisions in the new Constitution. The SRH rights of certain populations nevertheless continue to be violated—especially those of people infected or affected by HIV/AIDS, orphans and vulnerable children, refugees and internally displaced persons, and adolescents. Policies and programs should make particular efforts to reach these groups.
    2. The SRH needs of adolescent girls are shifting. Both age at sexual initiation and age at marriage among Kenyan women increased between the survey years, but the mean difference between these ages widened, indicating an increase in premarital sexual activity and the risk of pregnancy before marriage. National and regional health departments should push the implementation of the policies and guidelines to reach youth with comprehensive SRH information and services.
    3. Access to medical abortion using Mifepristone and Misoprostol is problematic as these drugs are not widely used by either practitioners or providers nor known by the women needing these services. The Ministry of Health, and national health networks should improve awareness and access to quality post-abortion care services (including reducing financial barriers to accessing care), and improve the quality of post-abortion care in both public and private health facilities.

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Some key lessons learned from the Senegal Country Profile:

    1. Senegal has a high fertility rate of 5 children per woman, possibly due to the early age of marriage and first pregnancy, and the low rate of contraceptive use (as of 2011, only 9.6% of women were using contraception; of those, only 8.9% used a modern method).
    2. The vast majority of women who seek family planning services do so at public facilities (85%). This may suggest that focusing policy efforts at public health programs could have a significant impact on levels of unmet need for FP.
    3. Abortion is illegal in Senegal. Because of this, little data exists as to the magnitude of existing abortion, but the Senegal Ministry of Health estimates that unsafe abortion accounts for 20% of maternal morbidity.
    4. If unmet need for family planning were met, the maternal mortality rate could be decreased by 20–30%.

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Insights into unmet need

Unintended pregnancies stem primarily from unmet need for effective contraception. Many factors may contribute to unmet need. This series of studies sought to establish the relative influence of two often-cited factors: lack of access (defined as awareness of the two most widely used contraceptive methods in the country and awareness of at least one supply source); and intention to use family planning in the future. Analyses were undertaken using DHS datasets, disaggregated by different population strata, for STEP UP's three focus countries in sub-Saharan Africa: Ghana, Kenya, and Senegal.

Some key lessons learned:

    • In Ghana, 42% percent of the women had unmet need for family planning, with significant inequality across population strata; unmet need was over 50% among women with no education, or those in the poorest quintile. Yet even among wealthier women, use of modern methods has declined and use of traditional methods is more common. (Research Report: Insights into unmet need in Ghana)
    • In Kenya, most women with unmet need were aware of the two main contraceptive methods (pills and injectables) and a supplier, but the poorest, least educated women and those living in North Eastern Province had significantly less knowledge and access. The imbalanced method mix (in which pills and injectables are used by the majority of modern-method users) leads to high rates of discontinuation with low rates of switching, due to there being few options for non-hormonal methods. (Research Report: Insights into unmet need in Kenya)
    • In Senegal, over half of women having unmet need for family planning did not intend to use FP in the future; this finding was consistent across all population strata. (Research Report: Insights into unmet need in Senegal; en français)

Understanding and addressing unintended pregnancy among the urban, adolescent poor

Some of the highest levels of unintended pregnancy globally are experienced by adolescents, both married and unmarried. Their age and marginalized social status mean that they also experience more severe adverse outcomes from an unintended pregnancy, including unsafe abortion, high-risk pregnancy, and delivery leading to morbidity and mortality, unwanted childbearing, and sustained economic and social deprivation. With rapid urbanization characterising population growth in all of STEP UP's focus countries, adolescents living in, or moving into, urban informal settlements are particularly vulnerable.

STEP UP is undertaking a series of studies that explore the lives and reproductive health needs of urban poor adolescents by examining how these vary between adolescents living in various situations, including married, unmarried, older and younger, in and out of school or employment, and those living with HIV. Evidence from these studies is being used to inform the design and testing of innovative approaches to increasing access to appropriate information and services for addressing these needs.

Prevalence of unintended pregnancy and family planning needs among married adolescent girls in urban slums of Dhaka

Key lessons learned:

    • There are high levels of unintended pregnancy among married adolescent girls in urban slums; more than half of the pregnancies (53%) were unintended. This was largely due to improper use or non-use of FP. The most common reasons were: inconsistent use, cost, lack of awareness of available methods, fear of side effects, and pressure from their spouses or families to have children. There were also high levels of method discontinuation. Counseling on FP must be improved for both girls and their spouses in order to clear some of these barriers to correct method use and to ensure appropriate timing and consistent use of FP method. The support of families and community leaders must also be marshalled to support FP services for these girls.
    • Ensuring that FP services are affordable for married adolescent girls and their spouses (for instance, through a standard demand-side financing mechanism for the very poor) is also key.
    • Targeting key groups with FP services could have a significant impact on reducing unintended pregnancy (such as those who are newly married, want to postpone their pregnancy at a later age, or want to space births or have reached their ideal family size). Spouses of the adolescent girls should also be targeted to elicit their support and participation in such programs.

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Sexual and reproductive health needs of adolescents living in urban slums in Kenya

Some key lessons learned:

    • Poor knowledge of the menstrual cycle and fertility among both men and women.
    • Universal knowledge of HIV/AIDS: Nearly 100% of male and female adolescents across all age clusters reported that they had heard of HIV/AIDS.
    • Substantial age and gender differences in HIV testing experiences: The proportion of adolescents that has ever been tested for HIV increased with age and education. Married adolescents were more likely to have ever been tested for HIV, with females more likely to have been tested than males.
    • Early initiation of sexual activity: Sexual debut before the age of 15 was reported by 11% of males and 8% of females.
    • Disconnect between adolescents’ sexual and reproductive health attitudes and their behavior: Respondents tended to place a high value on abstinence before marriage, yet many still reported engaging in premarital sexual activity.
    • High burden of unwanted and mistimed pregnancies: Thirty-six percent of females’ most recent pregnancies were unplanned, with the burden substantially higher among certain subgroups of females.

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Understanding the reproductive health needs of adolescents in selected slums in Ghana

  • The inadequacy of RH information provided in the school system is shown by the fact that the majority (80%) of adolescents indicated that they want more classes on RH in school. A majority of parents (97%) also indicate that the school system should provide that service. There is the need for the incorporation of comprehensive sexuality education appropriate for each educational level into schools. Teachers with specialized skills in imparting this information should be trained and appropriate curriculum methodologies and materials developed.
  • Given that almost one in five (19%) of adolescents have ever been fondled against their will and 15% have ever been physically forced to have sex, a conscious effort should be made to integrate interventions to address sexual violence into reproductive health programs. Interventions that empower the adolescent to know what coercion and signs of violence as well as where to seek services should be tested.
  • Overall, the findings from this study suggest that two-thirds (66%) of parents who did discuss sexual related issues with their wards indicated that they needed more information to have meaningful discussions. In order to enhance family-based sex education, parent-oriented programs and community workshops are therefore needed to allay fears and misconceptions surrounding adolescent SRH, to enhance parents’ SRH knowledge, and to build their capacity and skills to provide information to adolescents.


Strengthening and integrating contraceptive services within national health systems

As sources of supply for contraceptive information and services increase and diversify and the commercial and not-for-profit sectors play increasingly important roles in most developing countries, contraception is gradually being integrated and mainstreamed into a wider variety of health care programmes within national health systems. While such strategies appear to make good sense from both client and provider perspectives, numerous implementation and financing challenges face policymakers and programme managers striving to increase access to contraception through integration.

STEP UP is supporting a series of studies to better understand these challenges and to generate evidence that can inform efforts to strengthen health systems that seek to deliver integrated services. Some key activities and lessons learned are:

Integrating contraceptive and safe abortion services with post-rape care

    • Policies, programmes, and country experiences in sub-Saharan Africa: Based on a study on how pregnancy prevention and management services feature within post-rape care services in sub-Saharan Africa, it was observed that pregnancy management and safe abortion for survivors do not feature prominently in national sexual violence guidelines in the region, with only a few exceptions. Existing provisions for pregnancy management and abortion also tend to lack detailed guidance or country-specific information that would facilitate access to these services. Furthermore, of the eight national protocols reviewed, only three treat safe abortion as an essential element of care to be provided for rape survivors, with clear guidance on its provision.

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Integrating contraceptive services with maternal health services

    • Postpartum Family Planning in Burkina Faso. There are substantial shortfalls in the availability of quality postpartum family planning. Individual counselling and the quality of information provided are often inadequate and occasions to advise women on family planning are wasted, resulting in low uptake of contraception during routine postnatal care. Furthermore, cultural traditions and practices and high desired family size limit the demand for modern contraception, which is not well understood or acceptable to many people. Yet the study indicated that there may be a margin for the expansion of demand, and improving quality of care could play a role in taking advantage of this.

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Integrating contraceptive services with HIV/STI services

    • Symposium on SRH-HIV service integration: In response to the programmatic and policy issues arising from the conflicting evidence concerning interactions between hormonal contraception and HIV acquisition, STEP UP convened a 2011 symposium to review and discuss the critical and emerging issues around integrating SRH and HIV/AIDS services to enable dual protection. Key recommendations included: (1) For key populations, manage the provision and correct, consistent use of condoms; (2) As one of a series of studies reporting the relationship between hormonal contraception and HIV acquisition, the Heffron et al. study must be put into context given the conflicting findings; and (3) Explore the possibility of solving complex issues surrounding counseling by using social marketing, media, and information dissemination.

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Increasing access to and use of medical abortion

Increasing access to safe and effective medical abortion services (where legal) is an essential component of comprehensive sexual and reproductive health care. It also provides an important opportunity for counselling and delivery of contraceptive services to prevent repeat abortions. Despite rapid improvements in the availability of medical abortion (MA) commodities, many women have limited access to safe procedures, even when permissive policies exist. To enable women to have access to a wider range of providers who are qualified to deliver safe and effective services, STEP UP is undertaking a series of studies to better understand the challenges to providing MA in various settings and to test interventions that will contribute to increasing the availability of MA.

Key activities and lessons learned include:

Medical Abortion in Bangladesh

    • Introducing menstrual regulation with medication (MRM) in Bangladesh: This study tested the feasibility of introducing MRM in Bangladesh and assessed the accessibility of providing the combination regimen of Mifepristone and Misoprostol in urban and rural health facilities. It was clear from the findings that it is feasible to introduce MRM services in Bangladesh and that women who received the service were satisfied with the overall quality of care provided at the health facilities.

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Medical Abortion in Kenya

    • Availability, use, and quality of care of medical abortion services in Kenya: Little is known about the provision of MA services in Kenya, the acceptability of MA among service providers and clients, and the content and quality of care offered. This study observed that while availability of MA services is growing and attitudes towards abortion are changing, negative attitudes and beliefs towards abortion are still prevalent among health workers, the judiciary, police, and the general public. Most pharmacies are poorly equipped to provide MA services. Further, of the clients who did seek MA services, very few were given family planning counseling, indicating a critical missed opportunity to prevent repeat abortions.

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Global assessments of Medical Abortion

    • MA provision by doctors versus midlevel providers in the US, Nepal, South Africa, Vietnam, and India: Training midlevel providers (MLPs) to conduct surgical abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion. This paper reviews the evidence that compares the effectiveness and safety of abortion procedures administered by MLPs versus doctors. It concluded that there were no statistical differences in incomplete abortion and complications for first trimester surgical and medical abortion up to 9 weeks performed by MLPs compared with physicians, indicating that access to MA could be improved by incorporating MLPs into service provision in countries where this is not currently the case. Further studies are required to establish more precise effect estimates.

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What's New

New Research Uptake Case Study: STEP UP is proud to release a new Research Uptake Case Study: Bangladesh: Using strong evidence and strategic collaboration to increase access to menstrual regulation with medication. The case study highlights successful research uptake resulting from STEP UP’s collaboration on increasing women’s access to MRM in Bangladesh, including approval of MRM service introduction into the national family planning program and plans for STEP UP assistance in the scale up of MRM to nearly 4,000 health facilities.

Journal Article: Estimates of the potential impacts of contraceptive use on averting unintended pregnancies, total and unsafe abortions, maternal deaths, and newborn, infant, and child deaths are critically important for policy makers, donors, and advocates investing in family planning programmes. There are five mathematical models that estimate the impact of family planning on health outcomes, but each modeling approach was designed for different purposes, and consequently do not produce comparable estimates for the same outcome indicators. This article, Harmonizing Methods for Estimating the Impact of Contraceptive Use on Unintended Pregnancy, Abortion, and Maternal Health explores a collective harmonization process undertaken to address this. The models now produce more similar estimates (although they retain some minimal differences) and may assist in planning, resource allocation, and evaluation, and offer a more unified voice for quantifying the benefits of family planning.

Dissemination event in Nigeria: STEP UP findings from a study evaluating whether community health extension workers (CHEWs) can insert contraceptive implants to the same quality standards as nurses and midwives were shared at a dissemination meeting in Abuja last month. Over 100 participants attended, including high-level state and federal representatives, CHEWs & nurses, donors, and implementing partners. The plenary session was chaired by Dr. Kayode Afolabi (Director of reproductive health, FMOH) with support from Dr. Tony Udoh (FMOH).

The session yielded insight into key aspects of implant service provision, upon which the FMOH proposed that it review and extend the accreditation period to enhance service quality. The event also prompted commitments to be made by State officials to better support trained staff retention in training facilities, and by MSI Nigeria to provide technical support to States on scaling up this task shifting. See links for Nigerian media coverage of the event in the Daily Post, Premium Times, and Vanguard.

Journal article: In 2015, the Government of Bangladesh approved the use of the mifepristone-misoptostol drug combination to be administered up to 9 weeks from a woman’s last menstrual period by trained service providers for menstrual regulation with medication (MRM). This journal article, Provision of menstrual regulation with medication among pharmacies in three municipal districts of Bangladesh: A situation analysis, explores a STEP UP study which assessed the provision of MRM in randomly selected urban pharmacies in Bangladesh. The study revealed knowledge gaps among pharmacy workers regarding recommended dosage for MRM and inconsistent practice in informing women on effectiveness, follow-up visits, possible complications and provision of post-MRM contraceptives. Pharmacy workers need additional training and a strong monitoring and regulatory system for pharmacy provision of MRM in pharmacies should be established.

Activity update: The STEP UP team investigating reasons for unmet need for family planning (with particular attention to measurement of unintended pregnancy) in Matlab, Bangladesh has completed the second round of data collection. Over 2,300 women were interviewed. Follow-ups are also being completed with women in Nairobi and Homa Bay, Kenya.

STEP UP at the Brookings Institute: STEP UP researcher Chi-Chi Undie was invited to the Brookings Institution in Washington DC to participate in a panel at the Girls’ Education Research and Policy Symposium hosted by the Institute’s Center for Universal Education (CUE). CUE convenes policymakers, practitioners, and stakeholders in the girls’ education arena to discuss the most pressing issues as identified by the Echidna Global Scholars, a group of global leaders in girls’ education. Please click here to view video recording of the session in which Chi-Chi discusses STEP UP’s work with the Ministry of Education on school re-entry for girls in Kenya.