Our findings show that living closer to an SDP is not a determinant of modern contraceptive use or having unmet need for FP services. This result was observed with data collected from all rounds of surveying. Associations between distance to SDPs and changes in level of modern contraceptive use were insignificant.
Our analysis shows that, with increased distance to an SDP, the proportion of women using any modern contraceptive method does not decrease significantly. However, data collected from some rounds of surveying, illustrated a decrease in the percentage of women using a modern contraceptive method with an increase in distance from some SDPs. For example, in round 2 of PMA2020 in Kinshasa, the proportion of modern contraceptive users decreased from 21% to 16.3 %, when distance from an SDP that offered free services increased from 250m to 1000m. Additionally, in round three of data, the proportion of modern contraceptive users decreased from 23.1% to 18.4%, when distance from an SDP that provided at least 5 modern contraceptive methods was increased from 250m to 1000m. However, as stated previously, these decreases in modern contraceptive use were not statistically significant.
Similarly, our findings present no significant difference between the proportion of women with unmet need for family planning and distances of250m, 500m, and 1000m from an SDP that offers free services, or 5 or more modern contraceptive methods. We expected to find a higher proportion of women with unmet need for family planning in buffer zones further away from SDPs with preferable characteristics. Analysis of data collected in round 3 of PMA2020 shows that the proportion of women with unmet need for family planning increased from 15.0% in buffer zones 250m from an SDP that provided at least five methods, to 18.2% in buffer zones 1000m from an SDPs that provided at least five methods.
We evaluated several additional FP metrics and SDP characteristics to verify if any additional factors could be a determinant for modern contraceptive methods use women.
SDPs that had at least three or more methods in stock or five or more methods in stock were used to measure the availability of reliable FP services. The percentage of women that used modern contraceptives that lived within each buffer zone of and SDP that offered at least three or five methods did not significantly change. This suggests that living closer to a facility that has a larger range of available methods may not affect the likelihood of using family planning services.
PMA2020 results show that there is a growing tendency among women in the DRC to use long-acting reversible contraceptive (LARC) methods (specifically, the implant method) (PMA2020, 2018). We, therefore, used frequency and percentage of SDPs that had at least one long-acting reversible contraceptive (LARC) method as an indicator. Although the percentage of women using a modern contraceptive decreased with an increase in distance from an SDP with LARC methods in all rounds, this decline was not statistically significant. For instance, in round 2, the proportion of women using modern contraceptives varied from 19.3% in areas 250m from an SDP that provided LARC methods, to 18.4% in areas 1km from an SDP that provided LARC methods. In Rounds 3 to 5, the proportion of modern contraceptive users varied from 19.3%, 23.3%, and 22.0%in areas 250m from an SDP to 17.9%, 22.4%, and 20.3% in areas 1km from the same SDPs, respectively (Tables 1-4).
Table 1. Distribution of women living 250, 500, and 1000 meters from an SDP and corresponding contraceptive use and unmet need for FP services, PMA2020 survey round 2
|
N
|
% of women using a modern contraceptive method
|
P-value*
|
% of women experiencing an unmet need for FP services
|
P-value**
|
In 250m radius of SDP that offers FP services
|
1188
|
18.8%
|
|
18.0%
|
|
In 500m radius of SDP that offers FP services
|
2078
|
18.4%
|
1.000
|
18.3%
|
1.000
|
In 1KM radius of SDP that offers FP services
|
2453
|
18.5%
|
1.000
|
18.6%
|
1.000
|
In 250m radius of SDP that has >3 methods
|
596
|
20.0%
|
|
20.0%
|
|
In 500m radius of SDP that has >3 methods
|
1493
|
19.2%
|
1.000
|
19.0%
|
1.000
|
in 1KM radius of SDP that has >3 methods
|
2138
|
18.3%
|
1.000
|
18.8%
|
1.000
|
In 250m radius of SDP that has >5 methods
|
271
|
20.7%
|
|
14.8%
|
|
In 500m radius of SDP that that has >5 methods
|
796
|
20.9%
|
1.000
|
15.5%
|
1.000
|
In 1KM radius of SDP that that has >5 methods
|
1497
|
19.2%
|
1.000
|
16.4%
|
1.000
|
In 250m radius of SDP with LARC methods
|
750
|
19.3%
|
|
19.7%
|
|
In 500m radius of SDP with LARC methods
|
1662
|
18.6%
|
1.000
|
19.0%
|
1.000
|
In 1KM radius of SDP with LARC methods
|
2190
|
18.4%
|
1.000
|
18.5%
|
1.000
|
In 250m radius of SDP open >6 days
|
964
|
17.7%
|
|
18.6%
|
|
In 500m radius of SDP open >6 days
|
1826
|
17.7%
|
1.000
|
18.7%
|
1.000
|
In 1KM radius of SDP open >6 days
|
2394
|
18.5%
|
1.000
|
18.9%
|
1.000
|
In 250m radius of SDP without stockout
|
945
|
19.0%
|
|
16.7%
|
|
In 500m radius of SDP without stockout
|
1837
|
18.5%
|
1.000
|
17.6%
|
1.000
|
In 1KM radius of SDP without stockout
|
2291
|
18.7%
|
1.000
|
18.0%
|
1.000
|
In 250m radius of SDP without fees
|
267
|
21.0%
|
|
16.1%
|
|
In 500m radius of SDP without fees
|
708
|
16.9%
|
1.000
|
19.8%
|
1.000
|
In 1KM radius of SDP without fees
|
1353
|
16.3%
|
1.000
|
20.9%
|
0.718
|
In 250m radius of HC or hospital SDP
|
1118
|
18.9%
|
|
17.7%
|
|
In 500m radius of HC or hospital SDP
|
1980
|
18.3%
|
1.000
|
18.3%
|
1.000
|
In 1KM radius of HC or hospital SDP
|
2473
|
18.3%
|
1.000
|
18.3%
|
1.000
|
* t-test used to determine if the percentage in a larger radius is significantly lower than in a smaller radius
**test-test used to determine if the percentage in a larger radius is significantly higher than in a smaller radius
On average more than 50% of SDPs were open seven days of the week. We limited our analysis to SDPs which were open every day of the week when measuring the availability of FP services and administrative access to services. In rounds 2 and 5, we found a decrease in the proportion of women using any modern contraceptive, as the distance from an SDP (that was open every day of the week) increased.
Table 2. Distribution of women living 250, 500, and 1000 meters from an SDP and corresponding contraceptive use and unmet need for FP services, PMA2020 survey round 3
|
N
|
% of women using a modern contraceptive method
|
P-value*
|
% of women experiencing an unmet need for FP services
|
P-value**
|
In 250m radius of SDP that offers FP
|
1073
|
17.3%
|
|
18.2%
|
|
In 500m radius of SDP that offers FP
|
1960
|
17.4%
|
1.000
|
19.2%
|
1.000
|
In 1KM radius of SDP that offers FP
|
2476
|
17.7%
|
1.000
|
19.4%
|
1.000
|
In 250m radius of SDP that has >3 methods
|
696
|
22.0%
|
|
15.2%
|
|
In 500m radius of SDP that has >3 methods
|
1609
|
21.6%
|
1.000
|
16.1%
|
1.000
|
In 1KM radius of SDP that has >3 methods
|
2309
|
21.0%
|
1.000
|
15.3%
|
1.000
|
In 250m radius of SDP that has >5 methods
|
321
|
23.1%
|
|
15.0%
|
|
In 500m radius of SDP that that has >5 methods
|
911
|
21.0%
|
1.000
|
16.2%
|
1.000
|
In 1KM radius of SDP that that has >5 methods
|
1737
|
18.4%
|
1.000
|
18.2%
|
1.000
|
In 250m radius of SDP with LARC methods
|
716
|
19.3%
|
|
18.0%
|
|
In 500m radius of SDP with LARC methods
|
1590
|
19.1%
|
1.000
|
17.7%
|
1.000
|
In 1KM radius of SDP with LARC methods
|
2292
|
17.9%
|
1.000
|
18.6%
|
1.000
|
In 250m radius of SDP open >6 days
|
890
|
23.6%
|
|
15.3%
|
|
In 500m radius of SDP open >6 days
|
1824
|
24.8%
|
1.000
|
17.3%
|
1.000
|
In 1KM radius of SDP open >6 days
|
2462
|
21.7%
|
1.000
|
15.8%
|
1.000
|
In 250m radius of SDP without stockout
|
660
|
17.6%
|
|
16.5%
|
|
In 500m radius of SDP without stockout
|
1322
|
17.8%
|
1.000
|
18.8%
|
1.000
|
In 1KM radius of SDP without stockout
|
1977
|
18.1%
|
1.000
|
19.0%
|
1.000
|
In 250m radius of SDP without fees
|
164
|
14.0%
|
|
23.2%
|
|
In 500m radius of SDP without fees
|
497
|
15.7%
|
1.000
|
23.9%
|
1.000
|
in 1KM radius of SDP without fees
|
1122
|
16.0%
|
1.000
|
21.2%
|
1.000
|
In 250m radius of HC or hospital SDP
|
994
|
16.5%
|
|
18.7%
|
|
In 500m radius of HC or hospital SDP
|
1829
|
16.5%
|
1.000
|
19.7%
|
1.000
|
In 1KM radius of HC or hospital SDP
|
2376
|
17.3%
|
1.000
|
19.6%
|
1.000
|
* t-test used to determine if the percentage in a larger radius is significantly lower than in a smaller radius
**test-test used to determine if the percentage in a larger radius is significantly higher than in a smaller radius
Stockouts are a significant barrier in accessing reproductive health services (Farmer et al. 2015) in many countries. We attempted to verify if proximity to a facility that had not experienced a stock-out in the last three months could be a determinant in using FP services. There was no significant difference in the proportion of women using a modern method in close proximity to an SDP that had not experienced a stockout when compared to those that were further away from an SDP that had not experienced a stockout. However, in Round 5, the percentage of women using a modern method decreased from 25.3% to 21.5% when proximity to an SDP that had not experienced a stockout increased from 250m to 1km.
Facility services fees are a key financial barrier for women in accessing FP services (Bertrand et al. 1995; Choi et al. 2016). We tested if modern contraceptive use is higher among women that live closer to SDPs that provide services without fees. There was no significant difference between the proportion of women using modern contraceptives in any of the distance buffers of SDPs that provided services without fees.
Table 3. Distribution of women living 250, 500, and 1000 meters from an SDP and corresponding contraceptive use and unmet need for FP services, PMA2020 survey round 4
|
N
|
% of women using a modern contraceptive method
|
P-value*
|
% of women experiencing an unmet need for FP services
|
P-value**
|
In 250m radius of SDP that offers FP
|
1146
|
22.5%
|
|
15.4%
|
|
In 500m radius of SDP that offers FP
|
2005
|
20.9%
|
1.000
|
15.5%
|
1.000
|
in 1KM radius of SDP that offers FP
|
2481
|
21.4%
|
1.000
|
15.7%
|
1.000
|
In 250m radius of SDP that has >3 methods
|
689
|
22.2%
|
|
14.9%
|
|
In 500m radius of SDP that has >3 methods
|
1463
|
23.8%
|
1.000
|
15.8%
|
1.000
|
in 1KM radius of SDP that has >3 methods
|
2159
|
22.5%
|
1.000
|
15.2%
|
1.000
|
In 250m radius of SDP that has >5 methods
|
417
|
23.0%
|
|
26.4%
|
|
In 500m radius of SDP that that has >5 methods
|
1049
|
21.4%
|
1.000
|
21.0%
|
1.000
|
in 1KM radius of SDP that that has >5 methods
|
1775
|
20.1%
|
1.000
|
21.5%
|
1.000
|
In 250m radius of SDP with LARC methods
|
785
|
23.3%
|
|
22.8%
|
|
In 500m radius of SDP with LARC methods
|
1571
|
21.8%
|
1.000
|
10.7%
|
1.000
|
in 1KM radius of SDP with LARC methods
|
2225
|
22.4%
|
1.000
|
22.9%
|
1.000
|
In 250m radius of SDP open >6 days
|
938
|
21.6%
|
|
17.0%
|
|
In 500m radius of SDP open >6 days
|
1788
|
20.4%
|
1.000
|
16.2%
|
1.000
|
in 1KM radius of SDP open >6 days
|
2405
|
21.5%
|
1.000
|
15.9%
|
1.000
|
In 250m radius of SDP without stockout
|
685
|
17.2%
|
|
15.9%
|
|
In 500m radius of SDP without stockout
|
1226
|
18.4%
|
1.000
|
15.8%
|
1.000
|
in 1KM radius of SDP without stockout
|
1877
|
19.8%
|
1.000
|
15.7%
|
1.000
|
In 250m radius of SDP without fees
|
356
|
16.9%
|
|
12.9%
|
|
In 500m radius of SDP without fees
|
793
|
20.1%
|
1.000
|
18.2%
|
1.000
|
in 1KM radius of SDP without fees
|
1218
|
19.7%
|
1.000
|
19.0%
|
1.000
|
In 250m radius of HC or hospital SDP
|
1064
|
22.6%
|
|
15.7%
|
|
In 500m radius of HC or hospital SDP
|
1904
|
20.7%
|
1.000
|
15.5%
|
1.000
|
in 1KM radius of HC or hospital SDP
|
2449
|
21.5%
|
1.000
|
15.6%
|
1.000
|
* t-test used to determine if the percentage in a larger radius is significantly lower than in a smaller radius
**test-test used to determine if the percentage in a larger radius is significantly higher than in a smaller radius
Our findings show that, although proximity to an SDP was not significantly associated with an unmet need for family planning services, lower percentages of women with unmet need were found in buffer zones closer to SDPs with certain characteristics. In Round 2, percentage of women with unmet need was lower among those 250m from an SDP that had five or more methods in stock, had no stockouts in the last three months, or had no fees for services... In Round 3, percentage of women with unmet need was lower among those 250m from an SDPs that had five or more methods in stock or had no stockouts in the last three months. In round 4, there percentage of women with unmet need was lower among those 250m from an SDP that had no service fees.
Table 4. Distribution of women living 250, 500, and 1000 meters from an SDP and corresponding contraceptive use and unmet need for FP services, PMA2020 survey round 5
|
N
|
% of women using a modern contraceptive method
|
P-value*
|
% of women experiencing an unmet need for FP services
|
P-value**
|
In 250m radius of SDP that offers FP
|
1124
|
21.6%
|
|
13.5%
|
|
In 500m radius of SDP that offers FP
|
1929
|
20.7%
|
1.000
|
14.7%
|
1.000
|
in 1KM radius of SDP that offers FP
|
2393
|
20.2%
|
1.000
|
14.9%
|
1.000
|
In 250m radius of SDP that has >3 methods
|
732
|
21.2%
|
|
12.6%
|
|
In 500m radius of SDP that has >3 methods
|
1565
|
20.2%
|
1.000
|
13.7%
|
1.000
|
in 1KM radius of SDP that has >3 methods
|
2232
|
20.3%
|
1.000
|
14.3%
|
1.000
|
In 250m radius of SDP that has >5 methods
|
417
|
18.9%
|
|
14.1%
|
|
In 500m radius of SDP that that has >5 methods
|
1049
|
20.4%
|
1.000
|
14.7%
|
1.000
|
in 1KM radius of SDP that that has >5 methods
|
1775
|
21.7%
|
1.000
|
15.4%
|
1.000
|
In 250m radius of SDP with LARC methods
|
785
|
22.0%
|
|
12.2%
|
|
In 500m radius of SDP with LARC methods
|
1571
|
20.5%
|
1.000
|
13.6%
|
1.000
|
in 1KM radius of SDP with LARC methods
|
2225
|
20.3%
|
1.000
|
14.4%
|
1.000
|
In 250m radius of SDP open >6 days
|
845
|
21.8%
|
|
20.7%
|
|
In 500m radius of SDP open >6 days
|
1612
|
22.6%
|
1.000
|
13.5%
|
1.000
|
in 1KM radius of SDP open >6 days
|
2233
|
20.3%
|
1.000
|
14.3%
|
1.000
|
In 250m radius of SDP without stockout
|
522
|
25.3%
|
|
11.9%
|
|
In 500m radius of SDP without stockout
|
1088
|
23.9%
|
1.000
|
13.8%
|
1.000
|
in 1KM radius of SDP without stockout
|
1820
|
21.5%
|
1.000
|
15.4%
|
1.000
|
In 250m radius of SDP without fees
|
356
|
21.3%
|
|
18.3%
|
|
In 500m radius of SDP without fees
|
793
|
20.1%
|
1.000
|
18.2%
|
0.908
|
in 1KM radius of SDP without fees
|
1218
|
19.7%
|
1.000
|
19.0%
|
1.000
|
In 250m radius of HC or hospital SDP
|
1041
|
22.0%
|
|
13.5%
|
|
In 500m radius of HC or hospital SDP
|
1852
|
20.8%
|
1.000
|
14.5%
|
1.000
|
in 1KM radius of HC or hospital SDP
|
2350
|
20.2%
|
1.000
|
14.8%
|
1.000
|
* t-test used to determine if the percentage in a larger radius is significantly lower than in a smaller radius
**test-test used to determine if the percentage in a larger radius is significantly higher than in a smaller radius