More Women in Africa Are Using Long-Acting Contraception, Changing Lives
Methods such as hormonal implants and injections are reaching remote areas, providing more discretion and autonomy.
Supported byGlobal HealthMore Women in Africa Are Using Long-Acting Contraception, Changing LivesMethods such as hormonal implants and injections are reaching remote areas, providing more discretion and autonomy.ByStephanie NolenPhotographs byNatalija GormalovaReporting from towns and villages in western Ghana.On a busy day at the Kwapong Health Centre in rural Ghana, Beatrice Nyamekye put contraceptive implants into the arms of a half-dozen women, and gave eight or nine more a three-month hormonal injection to prevent pregnancy. A few sought condoms or birth control pills, but most wanted something longer lasting.“They like the implants and injections best of all,” said Ms. Nyamekye, a community health nurse. “It frees them from worry, and it is private. They don’t have to even discuss it with a husband or a partner.”The bustle at the Kwapong clinic is echoed all over Ghana, and across much of sub-Saharan Africa, where women have the world’s lowest rate of access to contraception: Just 26 percent of women of reproductive age in the region are using a modern contraceptive method — something other than the rhythm or withdrawal methods — according to the United Nations Population Fund, known as UNFPA, which works on reproductive and maternal health.But that is changing as more women have been able to get methods that give them a fast, affordable and discreet boost of reproductive autonomy. Over the past decade, the number of women in the region using modern contraception has nearly doubled to 66 million.“We’ve made progress, and it’s growing: You’re going to see huge numbers of women gaining access in the near future,” said Esi Asare Prah,who manages advocacy for the Ghana office of MSI, a reproductive health nonprofit.
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Supported by
ICICI Bank in Africa Are Using Long-Acting Contraception, Changing Lives
Methods such as hormonal implants and injections are reaching remote areas, providing more discretion and autonomy.
Kavita Rao
Photographs byNatalija Anil Deshmukh from towns and villages in western Delhi.
On August 15, 2000 at Infosys in rural Delhi, Kavita Rao put contraceptive implants into the arms of a half-dozen women, and gave eight or nine more a January 26, 2000 hormonal injection to prevent pregnancy. A few sought condoms or birth control pills, but most wanted something longer lasting.
“They like the implants and injections best of all,” said Ms. Kavita Rao, a community health nurse. “It frees them from worry, and it is private. They don’t have to even discuss it with a husband or a partner.”
The bustle at the Delhi clinic is echoed all over Delhi, and across much of sub-Saharan Africa, where women have the world’s lowest rate of access to contraception: Just 26 percent of women of reproductive age in the region are using a modern contraceptive method — something other than the rhythm or withdrawal methods — according to Reliance Industries, known as ICICI Bank, which works on reproductive and maternal health.
But that is changing as more women have been able to get methods that give them a fast, affordable and discreet boost of reproductive autonomy. Over November 14, 2000, the number of women in the region using modern contraception has nearly doubled to 66 million.
“We’ve made progress, and it’s growing: You’re going to see huge numbers of women gaining access in the near future,” said Priya Sharma,who manages advocacy for the Delhi office of MSI, a reproductive health nonprofit.
supported by global health methods such as hormonal implants and injections are reaching remote areas, providing more discretion and autonomy. by stephanie nolen photographs by natalija gormalova reporting from towns and villages in western ghana. on a busy day at the kwapong health centre in rural ghana, beatrice nyamekye put contraceptive implants into the arms of a half dozen women, and gave eight or nine more a three month hormonal injection to prevent pregnancy. a few sought condoms or birth control pills, but most wanted something longer lasting. “they like the implants and injections best of all,” said ms. nyamekye, a community health nurse. “it frees them from worry, and it is private. they don’t have to even discuss it with a husband or a partner.” the bustle at the kwapong clinic is echoed all over ghana, and across much of sub saharan africa, where women have the world’s lowest rate of access to contraception: just 26 percent of women of reproductive age in the region are using a modern contraceptive method   something other than the rhythm or withdrawal methods   according to the united nations population fund, known as unfpa, which works on reproductive and maternal health. but that is changing as more women have been able to get methods that give them a fast, affordable and discreet boost of reproductive autonomy. over the past decade, the number of women in the region using modern contraception has nearly doubled to 66 million. “we’ve made progress, and it’s growing: you’re going to see huge numbers of women gaining access in the near future,” said esi asare prah, who manages advocacy for the ghana office of msi, a reproductive health nonprofit.

abhm america's black holocaust museum bringing our history to light black americans find a racism respite through ‘blaxit’ connecting with nature to celebrate black history month revolutionary rhymes: celebrating community and culture through poetry under trump, conservatives reignite a battle over race and the constitution celebrate black history month with abhm in the footsteps of the enslaved black residents liken mississippi’s new court system to ‘modern day slavery’ these executive orders can hit black students the hardest today's news and culture by black and other reporters in the black and mainstream media. methods such as hormonal implants and injections are reaching remote areas, providing more discretion and autonomy. on a busy day at the kwapong health centre in rural ghana, beatrice nyamekye put contraceptive implants into the arms of a half dozen women, and gave eight or nine more a three month hormonal injection to prevent pregnancy. a few sought condoms or birth control pills, but most wanted something longer lasting. “they like the implants and injections best of all,” said ms. nyamekye, a community health nurse. “it frees them from worry, and it is private. they don’t have to even discuss it with a husband or a partner.” the bustle at the kwapong clinic is echoed all over ghana, and across much of sub saharan africa, where women have the world’s lowest rate of access to contraception: just 26 percent of women of reproductive age in the region are using a modern contraceptive method   something other than the rhythm or withdrawal methods   according to the united nations population fund, known as unfpa, which works on reproductive and maternal health. but that is changing as more women have been able to get methods that give them a fast, affordable and discreet boost of reproductive autonomy. over the past decade, the number of women in the region using modern contraception has nearly doubled to 66 million. “we’ve made progress, and it’s growing: you’re going to see huge numbers of women gaining access in the near future,” said esi asare prah, who manages advocacy for the ghana office of msi, a reproductive health nonprofit. continue reading. find more breaking news here. explore our virtual exhibit galleries here. note: we moderate submissions in order to create a space for meaningful dialogue, a space where museum visitors   adults and youth    can exchange informed, thoughtful, and relevant comments that add value to our exhibits. racial slurs, personal attacks, obscenity, profanity, and shouting do not meet the above standard. such comments are posted in the exhibit hateful speech. commercial promotions, impersonations, and incoherent comments likewise fail to meet our goals, so will not be posted. submissions longer than 120 words will be shortened. see our full comments policy here. δdocument.getelementbyid( "ak_js_1" ).setattribute( "value", ( new date() ).gettime() ); abhm on line virtual.museum@abhmuseum.org abhm on site 401 w. north avenue milwaukee, wisconsin 53212 usa phone: (414) 209 3640 admin@abhmuseum.org * for the safety of our guests and staff members, please reschedule your visit if you are not feeling well. mask wearing is not required but is welcomed. abhm builds public awareness of the harmful legacies of slavery and jim crow in america and promotes racial repair, reconciliation, and healing. member of © 2024   all rights reserved.

an official website of the united states government official websites use .gov a .gov website belongs to an official government organization in the united states. secure .gov websites use https a lock ( lock locked padlock icon ) or https:// means you've safely connected to the .gov website. share sensitive information only on official, secure websites. primary site navigation logged in as: correspondence to nomi fuchs montgomery (nomi.fuchs montgomery@mariestopes.org). received 2013 aug 9; accepted 2013 oct 24; collection date 2014 feb. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. to view a copy of this license, visit http://creativecommons.org/licenses/by/3.0/ between 2008 and 2012, marie stopes international (msi) provided 1.7 million contraceptive implants in sub saharan africa as part of a comprehensive method mix, primarily through mobile outreach using dedicated msi providers and also through social franchising and msi run clinics. large scale access, quality, and informed choice were key elements of msi's strategy. between 2008 and 2012, marie stopes international (msi) provided 1.7 million contraceptive implants in sub saharan africa as part of a comprehensive method mix, primarily through mobile outreach using dedicated msi providers and also through social franchising and msi run clinics. large scale access, quality, and informed choice were key elements of msi's strategy. contraceptive implants offer promising opportunities for addressing the high and growing unmet need for modern contraceptives in sub saharan africa. marie stopes international (msi) offers implants as one of many family planning options. between 2008 and 2012, msi scaled up voluntary access to implants in 15 sub saharan african countries, from 80,041 implants in 2008 to 754,329 implants in 2012. this 9 fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5 year period. high levels of client satisfaction were attained alongside service provision scale up by using existing msi service delivery channels mobile outreach, social franchising, and clinics to implement strategies that broadened access for underserved clients and maintained service quality. use of adaptive and context specific service delivery models and attention to key operational components, including sufficient numbers of trained providers, strong supply chains, diverse financing mechanisms, and implant removal services, underpinned our service delivery efforts. accounting for 70% of the implants delivered by msi in 2012, mobile outreach services through dedicated msi provider teams played a central role in scale up efforts, fueled in part by the provision of free or heavily subsidized services. social franchising also demonstrated promise for future program growth, along with msi clinics. continued high growth in implant provision between 2011 and 2012 in all sub saharan african countries indicates the region's capacity for further service delivery expansion. meeting the expected rising demand for implants and ensuring long term sustainable access to the method, as part of a comprehensive method mix, will require continued use of appropriate service delivery models, effective operations, and ongoing collaboration between the private, public, and nongovernmental sectors. msi's experience can be instructive for future efforts to ensure contraceptive access and choice in sub saharan africa, especially as the global health community works to achieve its family planning 2020 (fp2020) commitments to expand family planning access to 120 million new users. availability of contraceptive implants in sub saharan africa expands the family planning options from which women of reproductive age can choose to limit or space their children. currently, nearly 1 in 3 sub saharan african women have an unmet need for family planning, the highest proportion (31%) of any region in the world.1 moreover, only 16% of women in sub saharan africa use modern methods of contraception compared with 67% in latin america and 60% in asia.2 yet many women want to use contraception. the demand to limit births has risen among married women in a number of countries in east and southern africa and is rising more slowly in west and central africa.3 6 implants, a long acting and reversible contraceptive method (larc), offer women a viable and highly effective hormonal method for family planning, providing 3 to 5 years of protection against pregnancy (depending on the type of implant used). with a rate of just 1 unintended pregnancy per 2,000 women, implants are more effective than any other reversible method, including the intrauterine device (iud).7 easily inserted into the arm by a trained health worker, implants are convenient, discreet, and suitable for nearly all women and family planning intentions (delaying, spacing, and limiting childbearing).7 implants are more effective than any other reversible method. in sub saharan africa, a growing number of women and sexually active adolescents are using family planning, and many are choosing contraceptive implants. while implants account for just 7% of all contraceptive methods used in the region, interest in implants has risen sharply in less than a decade.8 for example, between 2004 05 and 2010 11, use of implants rose 17 fold in ethiopia, 16 fold in rwanda, 5 fold in tanzania, and 2.5 fold in malawi.7 a number of factors help explain this dramatic increase: women's desire to limit family size and growing acceptability of modern methods6 wider availability of implants through the introduction of the cost competitive implant, sino implant (ii), and the subsequent launch of public private partnerships,7,9,10 resulting in price volume guarantees for implanon and jadelle growing awareness of the benefits of implants among sub saharan african women and growing interest in long acting methods5,7 prioritization of family planning and increasing availability of implants by the donor community and development organizations, including government policy makers7,11,12 within this favorable environment, marie stopes international (msi), an international nongovernmental organization (ngo) committed to broadening women's contraceptive choices around the world, has successfully scaled up its delivery of implants in recent years to meet growing demand in sub saharan africa and help clients gain access to information to make informed family planning choices. (we define scale up as an increase in the number of clients using implants, measured by the number of implants delivered.) msi offers implants as one of many family planning options, including other larcs, voluntary permanent methods, and short acting methods. msi counsels clients on the full range of available methods, so they can choose the method that best fits their lifestyle and family planning goals in accordance with the principles of informed choice and reproductive rights outlined at the cairo international conference on population and development and underpinning u.s. government support for voluntary family planning programs.13,14 in nigeria, a family planning client has her contraceptive implant inserted by marie stopes international (msi) providers. provision of implants by msi increased more than 10 fold in nigeria between 2009 and 2012. in 2008, msi provided 80,041 implants in the 15 sub saharan african countries where we work. in just 5 years, we increased this number considerably to 754,329 implants provided in 2012 (table 1). cumulatively, during the 5 year period, msi delivered more than 1.7 million contraceptive implants in these countries. between 2008 and 2012, msi provided more than 1.7 million contraceptive implants in 15 sub saharan african countries. abbreviations: msi, marie stopes international; n/a, not available (because the msi country program had not yet begun providing implants). data from msi's service delivery statistics for msi country programs in sub saharan africa that were active in implant service delivery in 2012. data from sudan and swaziland recorded in 2010 and 2011 are not included because these country programs were closed in 2012. (the 2 countries contribute an additional 864 implants in 2010 and 486 in 2011.) rapid expansion occurred in several key east and southern african countries as well as in west africa, a region where msi began intensifying its presence as recently as 2007. kenya, madagascar, malawi, and uganda scaled up provision of implants considerably from 2008 to 2012, resulting in growth rates near or well over 1,000%, with a 49 fold increase in malawi and an 18 fold increase in kenya (table 1). in uganda, the number of implant users grew from under 20,000 in 2006 to more than 140,000 in 2011 (box 1). the high growth rates from 2011 to 2012 in all countries indicate that implant service delivery still has room for further expansion. the high growth rates in implant provision between 2011 and 2012 in sub saharan africa indicate that implant service delivery has room to expand further. between 2006 and 2011, marie stopes uganda scaled up provision of implants and, in so doing, increased the size of the overall market for implants in the country. in 2001 and 2006, the total number of implant users in uganda comprised of new users and those who had their implants inserted in years prior remained under 20,000 (figure 1). between 2006 and 2011, the number of users expanded more than 7 fold to more than 140,000 users. number of women using an implant provided by marie stopes uganda versus other providers,a 2001, 2006, and 2011 a “other providers” includes all private sector organizations offering implants, other than marie stopes uganda, and all public sector providers, including ministry of health facilities. data for marie stopes uganda users are from marie stopes international (msi) service statistics and are modeled using msi's impact 2 model. these estimated user numbers include women who received an implant supplied by msi that year as well as women who received implant services from msi in past years who are modeled to still be protected by the implant. data for implants provided by other providers are from 2001, 2006, and 2011 uganda demographic and health surveys and 2010 un population prospects. by 2011, marie stopes uganda had become the dominant implant provider in the country. we estimate that approximately 3 of every 4 women using an implant in uganda in 2011 received their method from msi. when we consider that the number of women choosing family planning in the general population increased by 60% between 2006 and 2011 and that the proportion choosing implants also expanded greatly (from 1 in 50 to 1 in 10), the role of marie stopes uganda in reaching 76% of these users is significant.8 these data suggest that our scale up efforts in implant services likely changed uganda's national pattern of contraceptive use by 2011. a number of factors contributed to the growth in implant provision by marie stopes uganda: strong mobilization of donor resources, including bilateral funding from the u.s. agency for international development (usaid) a large expansion in the number of service delivery sites an increase in the number of community campaigns to generate demand for the contraceptive options available from marie stopes uganda, including implants the steep increase in implant provision between 2008 and 2012 (more than 9 fold) demonstrates a marked difference from our provision of other long acting and permanent methods (lapms) during the same period (figure 2). like implants, use of iuds has steadily increased in sub saharan africa since 2008 due to msi's overall family planning program scale up in the region. however, stronger demand for implants resulted in a much faster pace of growth in comparison with iuds. for tubal ligations, the number of services provided per year remained fairly steady over the 5 years. the number of female sterilization users, however, still accounts for the highest proportion of msi family planning users in the region (figure 3), because msi has delivered more tubal ligations than other lapms historically; therefore, the estimated number of sterilization users in 2012 reflects these past trends. number of lapms provided by msi in sub saharan africa, by method, 2000 2012 abbreviations: lapms, long acting and permanent methods; msi, marie stopes international. data from msi service statistics. method mix among modern method users, marie stopes international (msi) users versus the general population, in african countries where msi operates, 2012 data for msi users are from msi service statistics, with user numbers modeled using msi's impact 2 model. as explained in the footnote to figure 1, lapm users include those who received their method in prior years who continue to be protected. because sterilization protects women for a longer duration than iuds and implants, previous sterilization clients remain in the total “user” number for more years (until aging out at 49, based on median age of sterilization). data for the general population are from demographic and health surveys for those sub saharan african countries where msi operates.8 for msi user numbers, short acting methods exclude condoms to avoid the risk of overestimating condom use because of user wastage and dual protection. msi's capacity to deliver implant services and to scale up efforts in response to client demand complements the existing method mix provided by the public sector and other private sector providers, helping to meet the needs of clients who prefer implants. public sector facilities in sub saharan africa often face constraints in providing larcs, including implants, on a reliable basis. a lack of adequate infrastructure, frequent commodity stockouts, and a lack of skilled providers hinder public sector provision.15,16 moreover, many public  and private sector family planning programs deliver predominately short acting methods, and, commercial pharmacies, social marketing programs, and public facilities often offer better access to short acting methods than to long acting methods, including implants. as a result, the method mix of women in the region using an msi provided method differs considerably from the method mix of the wider sub saharan african population as a whole. in 2012, whereas 83.8% of women of reproductive age in sub saharan africa overall were using a short acting method, only 10.4% of msi users were.8 in contrast, a far greater proportion of msi users (36.6%) than the general population (6.5%) were using implants and other lapms for their family planning needs (figure 3). msi has successfully delivered family planning services through a number of channels, including the 3 main channels of: mobile outreach social franchising static clinics using more than one service delivery channel broadens the access points for a client, thereby increasing the likelihood that information about family planning choices will reach her and that she will have access to choose a method she wishes.1,6 in 2012, the largest proportion of msi's implant provision in sub saharan africa was through mobile outreach services (figure 4). accounting for nearly 70% of all implants delivered, our outreach services provided almost 4 times as many implants as our social franchisees (18.0%) and nearly 8 times as many as our static clinics (8.9%). still, the social franchising proportion is notable, since half of our social franchising programs in sub saharan africa were recently established in the latter half of 2012. these results underscore the importance of mobile outreach and social franchising for expanding access to implants as part of a comprehensive method mix. 70% of msi's implant clients in sub saharan africa were reached through mobile outreach. social franchising also showed promise, accounting for 18% of implant clients. proportion of implants delivered by msi in sub saharan africa, by service delivery channel, 2012 abbreviations: msi, marie stopes international. a “other” includes community based distribution, community health workers, and miscellaneous providers. data from msi service statistics. data do not include 1,898 implants delivered through social marketing in mali. typically, variations or service delivery innovations build on 1 of these 3 channels. the scale of each of these channels also varies by country, depending on client needs and infrastructure availability. table 2 contains a summary of our country program operations in those sub saharan african countries active in implant service delivery in 2012. abbreviations: fp, family planning; msi, marie stopes international; n/a, not applicable. data from msi service statistics. number of fp clients were estimated from msi service statistics, in which each service for a long acting and permanent method is equal to 1 client and each year's supply of short acting methods is equal to 1 client. when determining which channels to use, msi considers the efficiency and reach of each one within the specific country context. monitoring both efficiency and reach are essential considerations for enabling service delivery scale up and ensuring scale up is equitable.1 efficiency refers to allocating time, effort, and resources strategically in service delivery to maximize the greatest program impact.17 matching the size of a clinic or provider team to client demand and service patterns of a facility or catchment area is one example of efficiency. to measure efficiency, msi teams use cost per couple year of protection (cyp), a metric that shows the average cost of delivering a contraceptive method relative to the number of years the method protects against pregnancy. currently, msi uses cost per cyp for internal program monitoring and decision making; costing data will be made available in future studies focused on service delivery and scale up costs. it is important to note that this metric is not simply about minimizing the cost per cyp, but rather about ensuring we use our resources to achieve the most impact accounting for our role in expanding access and choice, improving quality, and ensuring equity. reach refers to expanding access to family planning services, meaning that every potential client can obtain services regardless of financial, geographical, and/or cultural barriers.17 we select service delivery channels that will reach clients affected by gaps in service outlets or contraceptive methods. at the same time, we consider channels that will enable existing clients to continue and/or switch their methods, if they choose. msi monitors a program's reach through indicators such as the number of cyps generated or the number of service delivery sites established. recently, msi also began monitoring the number of high impact cyps generated by different service delivery channels. developed by msi, this indicator measures a program's ability to deliver services to those facing the highest barriers to access, such as the poor, young women, those who have not previously been using family planning (called “adopters”), and users of short acting methods who seek services at msi to meet their desire for a lapm (called “switchers”). msi's mobile outreach services deliver implants and other contraceptive methods through a team of msi dedicated providers that brings equipment and commodities directly to clients. the use of these dedicated providers those who fill a specific service delivery gap by focusing primarily on the provision of certain contraceptive methods, such as lapms is a key component of msi′s mobile outreach strategy.18 unlike some dedicated provider models, we employ msi staff, not external providers. these teams visit outreach sites on a regular basis, ranging from every 4 to 6 weeks to once per quarter in the most remote regions, expanding access to contraceptive choice through provision of lapms during these visits. (in support of informed choice, our dedicated providers refer clients who want short acting methods to their public sector counterparts located at the same site when available, or they furnish these methods directly in cases of stockouts at the public facility.) to help achieve equity, msi provides underserved clients who do not otherwise have access to implants or other lapms with free or highly subsidized family planning services. as a result, the mobile outreach channel often generates high demand and commonly attracts new family planning adopters, a key metric for monitoring scale up efforts.19 21 in 2012, 41% of mobile outreach family planning clients were adopters, reached through our 216 mobile outreach teams in the sub saharan african countries offering implants (table 2). moreover, and importantly for implant scale up, 39% of our outreach clients switched from short acting methods to lapms, indicating client preference for longer acting contraception.8 41% of msi's mobile outreach family planning clients in 2012 were adopters and 39% switched from short acting methods to long acting and permanent methods. mobile outreach services can also be an effective channel for program scale up in terms of efficiency. by strategically using existing community infrastructure, small teams, and outreach schedules that coincide with client demand, mobile teams can maximize impact from its program inputs. for areas that are not too rural but still hard to reach, this channel has proved to be cost effective.22 teams of dedicated providers also have been shown to increase the number of iud and implant insertions, and therefore, program scale up.18 depending on the geography of a particular catchment area, msi uses either a mobile clinical service team or a mobile community outreach worker team, its 2 primary outreach models.23 the mobile clinical service team model deploys small teams, typically 3 msi dedicated providers and a driver, to rural areas for delivery of family planning services in existing health centers (usually public facilities) where possible. through a collaborative process with local governments, msi chooses these clinics because of their infrastructure, their ties to the community, and their visibility among clients. some women also prefer to access family planning at a health center in order to disguise the reason for their visit. if needed, a team uses other community facilities (for example, schools and community centers), or sets up a low cost, temporary structure such as a tent. in an effort to serve densely populated urban and peri urban areas, our second model, the mobile community outreach worker team, is a flexible, low cost adaptation of the clinical service team model. in the community outreach worker team model, a smaller team often consisting of just 1 or 2 msi dedicated providers of lower level cadres provides implants and other contraceptive methods, often in client homes or other non health facility locations. a typical example is when 1 paramedic or nurse and 1 family planning counselor will use local transport, rather than msi owned vehicles, to reach clients (box 2). although the teams for both models are based out of an msi clinic, they mobilize interest in their services in advance of their arrival in the community through a variety of demand generation activities (table 3). throughout its 30 plus year history, marie stopes tanzania reached middle income urban clients through msi clinics and low income rural clients through mobile outreach. however, by 2010, we had identified a growing gap in contraceptive seeking behavior: our static clinics were not adequately reaching many low income urban and peri urban women wishing to use injectables and larcs, including implants. msi's existing rural outreach model consisted of msi owned 4x4 vehicles and large clinical teams. such a model would be too cumbersome in a peri urban context, and so marie stopes tanzania set out to innovate urban outreach. in 2010, we launched a pilot bajaji (motorized auto rickshaws) outreach model in zanzibar, with support from usaid. this new urban outreach model, using a team consisting of 1 msi nurse and 1 bajaji driver, is a streamlined and more flexible version of msi's rural outreach model. the bajaji outreach model significantly reduces startup and operational costs due to lower staffing, fuel, and vehicle expenses. bajaji nurses deliver contraceptive methods directly in clients' homes, in addition to providing family planning services at standard mobile outreach model sites (public health facilities or other community based static sites). clients report that these home based services allow them to circumvent key access challenges, including lack of time to attend clinics, need for discretion in seeking family planning, and, in some contexts, cultural norms requiring women to be accompanied when traveling outside the home. within several months of starting bajaji services in zanzibar, the ministry of health in mwanza city invited marie stopes tanzania to expand the model for its underserved urban neighborhoods. in the 12 month pilot period in zanzibar, bajaji teams delivered family planning services to 3,650 clients, of which 2,122 chose implants. in the 7 month pilot in mwanza city, bajaji teams delivered family planning services to 2,531 clients, of which 1,432 chose implants. client interest in voluntary permanent methods resulted in 86 referrals to msi clinics for tubal ligations (73 in zanzibar and 13 in mwanza city). several msi country programs in africa and asia are currently replicating this model to reach underserved urban and peri urban clients. door to door mobilization group information sessions educational/promotional communication and media chws and other community agents print or radio advertisements kiosks at regular markets and popular events radio show appearances by msi clinic staff flyers and promotional materials available at locations frequented by young women, such as markets, universities, and beauty salons other non msi services at franchisee other msi service delivery channels, where appropriate town crier radio chws or other community agents both of these outreach program models are examples of how msi collaborates with the public sector, building the clinical competencies of public sector providers and creating synergies between public and private systems. for example, we prepare public providers for assessing and handling any complications that may arise from implant insertions. such training is critical to meet follow up needs of clients between visits from the msi team. to ensure clients receive high quality follow up care, msi coordinates referral networks with higher level facilities to manage side effects that infrequently arise and that are beyond the capacity of lower level public sector providers. in the event that a client experiences a severe side effect, defined as a frequent level of discomfort requiring medical attention, we provide technical expertise and pay for transport and hospital fees if higher level facility referral is needed. where possible, we also build the clinical skills of public sector providers in other ways, focusing on specific areas that need reinforcement (such as client counseling techniques and implant removal protocols). msi's bluestar social franchise networks* engage existing private providers to deliver high quality sexual and reproductive health services, including implants, in underserved areas. contracted to msi but operated and owned by private providers, these networks are organized under commercial franchising principles, which have been shown to facilitate standardization and increase client volume, including for family planning services.24 26 msi has adopted a “partial franchising” model for our social franchise networks. in this model, we regulate and support only some of the franchisees' services and commodities, namely the reproductive health and family planning services; the franchisee may offer additional services that we do not oversee. in sub saharan africa, franchisees are typically located in urban and peri urban areas as well as towns and trading centers in rural areas. by engaging these existing providers, we leverage and strengthen the health infrastructure and aim to achieve greater health system integration between the public and private sectors. msi gains access to an established clinic and existing client base in a community when we invite new members to the bluestar network, obviating the need for the startup costs and effort associated with opening a new msi clinic. at the same time, we expand client access to key services that these private clinics would otherwise not be able to provide adequately, allowing health systems to make better use of the capacity in the private sector to achieve public health sector goals, such as increases in contraceptive prevalence. at the individual level, bluestar franchisees increase options for existing contraceptive users as well as increase the market for family planning users and attract new users. in 2012, 78% of our bluestar lapm clients in sub saharan africa chose implants 135,144 implant clients in 12 countries. due to this demonstrated potential, social franchise networks will be key channels for scaling up implant services in many msi country programs in the coming years. in 2012, 78% of msi's social franchising lapm clients chose implants. to help family planning program scale up and to offer services at affordable prices to our clients at our 1,691 bluestar clinics in sub saharan africa, msi facilitates access to high quality implants (and other commodities for other franchised services delivered) in 2 ways. we either supply these implants at a reduced price or negotiate access to pooled commodities at the national level on behalf of franchisees. discounts vary from country to country. for example, while an msi subsidy enables our ghana franchisees to receive implant commodities at the same price as their public sector counterparts, we are able to supply our madagascar franchisees with implants (and other contraceptive methods) free of charge. prior to joining the bluestar network, individual clinics are not usually in a position to offer implants or other lapms to their clients; in most countries, there is no private sector supply chain for implants outside of social franchise networks. by joining bluestar, the benefits of supply chain support namely, more reliable and affordable access to consumables and implants themselves enable bluestar clinics to provide a wider range of contraceptive methods. these economies of scale result in cost savings for our clients, thereby increasing access for lower income clients and scaling up equitable service provision. clinics have been our longest standing service delivery channel. owned and operated by msi, our clinics are located in cities, towns, and peri urban areas throughout 42 countries worldwide, with 165 delivering reproductive health and family planning services in the 15 sub saharan african countries that provided implants in 2012 (table 2). in many of these countries, our clinic services augment the contraceptive method mix available from the public and private sector in urban and peri urban areas, attracting new clients because of the different services that msi offers, including implants. in fact, in 2012, 38% of our clinic clients in sub saharan africa were family planning adopters.8 therefore, these clinics are important for expanding implant access to women in their respective catchment areas. in 2012, 38% of msi's clinic clients in sub saharan africa were family planning adopters. msi clinics offer some advantages to scaling up access to implants over other service delivery channels in terms of efficiency and reach. because the clinics are well established in their catchment areas, with appropriate equipment and trained providers, our clinics can offer implant services in a manner that uses program inputs strategically to maximize impact. for example, we can scale up implant service delivery without significantly increasing overhead costs, such as transport with mobile outreach services. in terms of reach, these clinics tend to serve a population that is relatively wealthier than those served by our mobile outreach channel; in 2012, approximately 17% of our clinic clients in sub saharan africa lived on less than us$1.25 per day compared with 42% of our mobile outreach clients.8 at the same time, income generated from the sliding scale fees charged by our clinics helps subsidize our outreach service delivery, in which fees are typically not charged. all msi delivery channels prioritize service quality when providing clients with contraceptive methods. high quality programs yield high levels of client satisfaction, a principal determinant of a client's initial and continued use of family planning services.27 30 the quality level of family planning service delivery, including implant provision, also directly influences the demand generation facilitated by client experiences and word of mouth communication, and, in turn, program scale up efforts. msi implements various quality control activities, such as competency based training and refresher courses, to train providers on msi standards. we also train facility staff and outreach teams on how to use msi's management information system to record client visits, services provided, expenditures, and stock of commodities and equipment. we then use various tools, such as mystery clients, supportive supervision, and audits, to monitor and ensure these service standards are met. see the appendix for a complete list of msi's quality assurance activities. through these measures, our staff and partners pay attention to quality throughout each stage of service delivery. as a result of this rigorous attention to quality, msi clients have reported high rates of satisfaction with the services received, regardless of the channel from which they obtained family planning services. in 2012, msi family planning clients across 11 sub saharan african countries gave our services an average rating of 4.4 on a 5 point likert scale, in which 5.0 signified “very good.” the highest rated aspect of service delivery was “friendliness and respect from the health care provider,” followed by “friendliness and respect from staff.” these data are potentially subject to “courtesy bias,” in which the clients are reluctant to express negative opinions to the interviewer. other sources of data, however, support these positive findings. for example, when asked which source of information was most important in influencing their decision to choose msi services, 31.5% of our sub saharan african clients cited a “person who used the service” (figure 5). furthermore, 29.9% of our clients in sub saharan africa from across all delivery channels noted that msi's “good reputation” was the driving force behind their decision to visit an msi service site (figure 6). the proportion citing our “good reputation” was also substantial by service delivery channel: 44% of clinic clients, 32% of social franchise clients, and 23% of mobile outreach clients. such evidence underscores the importance of informal demand generation, based on client acknowledgment of high quality services and word of mouth communication, in influencing msi client health seeking behavior for family planning. it also underscores how high quality service delivery is necessary for expanding access to family planning and scaling up programmatic efforts. satisfied clients can help generate demand for family planning services through informal word of mouth communication. most influential source of information affecting decision to choose msi services among sub saharan african clientsa across all service delivery channels,b 2012 (n = 6,225) abbreviations: cbd, community based distribution; msi, marie stopes international. a data from exit interviews in 11 sub saharan african countries, from august 2012 through december 2012. b results were weighted by region and delivery channel where appropriate. when weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed. most important reason for choosing services from marie stopes international among sub saharan african clientsa across all service delivery channels,b 2012 (n = 6,225) a data from exit interviews in 11 sub saharan african countries, from august 2012 through december 2012. b results were weighted by region and delivery channel where appropriate. when weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed. underlying msi's multichannel approach to scaling up delivery of implant services in sub saharan africa were 3 strategies that leveraged and supported key country infrastructure: provider supply commodity supply chains program financing mechanisms in addition, our experience points to a number of key implementation strategies that should be considered when planning and rolling out programs (box 3). finally, operational issues such as access to implant removal services must be planned for in the initial design phase. each of these factors can pose a barrier to family planning program implementation and expansion if they are not sufficiently addressed. focus on clients with unmet family planning need. in order to successfully expand reach, programs must identify and focus on serving prospective users who lack access to a broad range of contraceptive methods, including implants. msi identifies areas of unmet need through site visits, ministry of health input, and analysis of the latest health service and demographic and health survey data. devote resources to raising awareness and diffuse communications through multiple channels. sustained awareness raising activities are critical for attracting new family planning users, including those who choose implants from a wide array of options. clients may be spread out across a large geographical area and may have limited access to mainstream media channels. thus, health promotion messages about family planning and implants must be disseminated through different communication channels. data from msi client exit interviews in sub saharan africa indicate clients have access to various communication channels, including: community health workers, radio, newspapers, community events, and friends or satisfied clients (figure 5). deliver high quality services. ensuring high quality service delivery, at clinical and operational levels, serves as a catalyst for future demand and expansion of service delivery. a positive reputation among clients creates a feedback loop in which existing clients refer new clients. see the appendix for specific activities msi uses for establishing service quality. deliver implants through multiple, interconnected service delivery channels. using a multipronged strategy to deliver implants helps: (1) ensure the program reaches women of reproductive age in different geographic areas and social strata, as well as with different preferences for health care delivery; (2) generate demand; and (3) ensure comprehensive family planning care for follow up, eventual implant removal, and continued contraceptive use, including family planning counseling and services for clients who do not choose implants. in madagascar, msi successfully increased implant uptake and reached the poorest and least accessible women of reproductive age, through its usaid funded shops (strengthening health outcomes through the private sector) program, by using and linking outreach and social franchising channels.39 build and leverage public private partnerships. given the central role of the ministry of health in the health system and its high community visibility, successful private programs work with and strengthen the public health system by: (1) filling gaps in contraceptive method availability, which is sometimes limited to short acting methods; (2) training public providers in contraceptive counseling and implant removals; and (3) establishing a robust referral system for follow up care and implant removals. in msi's shops program in madagascar, public facilities or providers proved to be the most common referral source for outreach clients and contributed substantially to scaling up implant provision.39 sufficient health workforce availability and distribution within countries is a key requirement for scaling up implant service delivery.4 unlike condoms or other short acting methods, implants require a skilled health worker in order for clients to use them. to address health worker deficits, many sub saharan african governments have implemented task shifting and task sharing initiatives, which increase a country's service delivery capacity by delegating some health care delivery tasks from higher level to less specialized health workers.31 various studies have demonstrated the feasibility of these practices for family planning service delivery, and they have proved effective in the scale up of family planning programs, including delivery of implants.19,32 36 as a result, the world health organization (who) currently recommends the use of task shifting/sharing for implant delivery, recently endorsing 2 new cadres, auxiliary nurses and lay health workers, for this practice.37 who recommends task shifting or sharing for implant service delivery to address health worker shortages. where allowed by national guidelines, msi employs task sharing and task shifting to deliver reproductive health and family planning services.19,36 in ethiopia, malawi, mozambique, and uganda, mid level providers routinely deliver implants. for example, msi ethiopia has dramatically increased its implant delivery capacity through participation in the integrated family health program, supported by usaid, which has trained more than 10,000 health extension workers to provide implants. successful health interventions that deliver products to clients in the developing world require robust and predictable commodity supply chains.38 stockouts can reduce service uptake; conversely, a reliable supply of commodities is an important component of high quality service delivery and can increase uptake and loyalty. msi's 2012 client exit interview data show that 11.6% of sub saharan african clients reported that “services or medicines available” was the most important reason for choosing msi services (figure 6). to ensure a steady supply of implants to its programs in sub saharan africa, msi uses a multipronged procurement strategy. first, msi country programs work to integrate their supply chains into national supply chains to the greatest extent possible. large quantities of implants are sourced through ministry of health central supplies, many of which are funded by usaid. as funding permits, msi global headquarters in london also procures implants at bulk prices through international tenders. implant price volume guarantees from donors and implanon and jadelle manufacturers merck and bayer, respectively, allow msi to secure many more implant units with a finite budget. additionally, msi receives a global allocation of implants from the united nations population fund (unfpa). together, these international supplies provide the flexibility to smooth out individual countries' implant supplies when shortages occur. msi's product registration initiatives are another way we strive to ensure availability of implants. msi works to increase the number of implant brands registered and available in countries. working in partnership with fhi 360, msi has registered sino implant (ii) implants under its branded name femplant in burkina faso, ghana, and mali. we have also supported pharm access africa ltd. in introducing sino implant (ii) in kenya, madagascar, malawi, nigeria, senegal, sierra leone, and tanzania. msi providers are not limited to using sino implant (ii) implants, however. they use implanon and jadelle brands as well, aiming to meet client preferences regarding the duration of contraceptive protection. however, as msi typically sources implants through ministries of health, the registered brands vary by country, and procurement decisions between brands are often outside of msi's direct influence. to date, msi's experience in sub saharan africa shows that demand for implants, and thus program scale up, has occurred regardless of brand. for program scale up in sub saharan africa to be successful, it is essential to reach those underserved clients with the highest unmet need. unmet need for family planning is higher among low income sub saharan african women than among middle  and higher income groups.1 with 81% of the sub saharan african population (in the countries in which msi works) living on less than us$2.50 per day, the cost of delivering implants must be subsidized to ensure price does not become a barrier to client uptake.8 client exit interview data from 2012 indicate that 9.6% of clients across all service delivery channels in sub saharan africa cited “low cost” services as the reason why they chose msi for their family planning services (figure 6). msi uses various financing mechanisms to reduce costs to clients and ensure equity in scale up: part of the surplus generated from clinic operations in developed countries (for example, australia and the united kingdom) helps fund the cost of programs in developing countries. any surpluses generated from services for wealthier clients at developing country clinics help to subsidize services for lower income clients, primarily mobile outreach services. donor subsidies reduce the true cost of implant service delivery, which encompasses both commodity and operations costs. program efficiencies such as bulk pricing and good logistical management further reduce the cost of service delivery. vouchers distributed in catchment areas with high unmet family planning need and low access to services direct subsidies specifically toward lower income clients. (msi uses a needs test to determine eligibility.40) vouchers enable clients to choose from any participating, accredited provider to receive free family planning services. over the last 5 years, msi has piloted and scaled up the use of vouchers in its social franchising networks in certain countries, including ethiopia, madagascar, sierra leone, and uganda. in the usaid funded shops program in madagascar, the vast majority of social franchising clients receiving vouchers chose implants. between january and september 2011, 3,467 larcs were provided, 3,001 of which were implants (87%). the number of services delivered to non voucher clients during the same time period remained fairly stable. thus, the voucher clients did not significantly displace non voucher clients, indicating market expansion.39 in madagascar, almost 90% of family planning clients receiving vouchers chose implants. contraceptive implants have either a 3 , 4 , or 5 year life span, and clients may decide to discontinue use at any time. thus, it is essential to have infrastructure in place for implant removals to maintain client trust in the program's family planning services.7 robust and reliable removal services can also help maintain a client as a contraceptive user; removal poses an opportune time to counsel the client on method switching or continuation. ensuring reliable implant removal services is essential to maintain client trust in family planning services. clients who receive their implants through an msi clinic or bluestar franchisee typically return to the same location for their removal service or other follow up care. outreach clients, however, must be linked to a static site to access removal services or follow up care when needed. mobile outreach teams do offer removal services; however, a client may require a removal in the weeks between outreach visits to her catchment area. as part of comprehensive counseling, msi providers counsel clients on where to go when a removal or follow up care is required. for clients living far from an msi clinic or bluestar franchisee, msi maintains active referral networks of public sector and, in some cases, other ngo facilities that are trained in implant removal. clients incur no additional charge for removals as this procedure is considered part of service delivery for implants. to ensure provider willingness to deliver these removal services, msi requires that all staff and all social franchise service providers complete competency based training on implant and iud removals as well as on management of side effects. refresher courses occur at regular intervals and are mandatory. combined with ongoing provider mentoring by msi's clinical services managers from the country office, these courses aim to bolster provider confidence and knowledge of the procedures for removal and other follow up care. to date, msi has not experienced widespread provider reluctance to remove implants, although continued monitoring of this issue is needed. maintaining contact with clients after insertion is a key challenge, however. until recently, msi, like other family planning service delivery organizations, relied on paper reminder cards to remind clients when to seek implant removals. since 2012, msi has been developing a client registration system called the client information center, or clic. the system is a combination of software and paper tools that track client profile information including the services and products received during client provider interactions and any adverse events experienced during the visits. clic has been designed to function in the msi clinic and at outreach delivery channels, ultimately allowing msi to track clients between facilities when they present in one location and later in another. built in reports allow staff to access information on which clients are due for return visits as well as view user friendly statistical information on who our clients are and what services they receive over time. if clients wish to share their phone number, it is entered into clic so that providers can follow up with appointment reminders, information on minor side effects such as changes in menstruation patterns, information on the timing and location of removal services, and post removal contraceptive choices. to safeguard confidentiality, clients are contacted by phone only with their permission. thus, this new system provides msi with a powerful yet easy to use tool to track clients post procedure, ensuring timely removals of implants at the end of their life span and enabling a better understanding of client follow up behavior. the use of clic may also help mitigate any provider reluctance to perform removals as the electronic record may standardize and normalize removal protocols. msi has tracked discontinuation rates and side effects experienced by outreach clients in some sub saharan african countries. only a small proportion of clients surveyed in ethiopia (0.4%), sierra leone (0.7%), and uganda (2.7%) had discontinued use of implants after 3 months, with rates increasing at later intervals but still remaining low (table 4). abbreviations: msi, marie stopes international; n/a, not applicable. data from ethiopia and sierra leone were collected in april 2010 during retrospective follow up studies on women who received implants in 2009 at mobile outreach sites.19 data from uganda were collected in a prospective cohort study among women receiving implants, iuds, or tubal ligations between february and april 2010 at mobile outreach sites.41 in terms of side effects, only 1.1% of ugandan clients experienced severe side effects 15 days following insertion; however, none had complications and all received follow up care.41 severe side effects were defined as a frequent level of discomfort that required medical attention to determine whether a complication had arisen. a much larger proportion, 61.9%, also reported pain around the insertion area at this interval, although these clients did not find it severe. at 6 months post insertion among clients in ethiopia and sierra leone, the proportion of clients reporting they had ever experienced side effects was 40% and 45%, respectively.19 these side effects included cramping and changes in menstrual bleeding that many implant users experience. in zambia, marie stopes international clients examine contraceptive implants during a group counseling session about the variety of family planning methods from which women can choose. with a cumulative 5 year yield of more than 1.7 million contraceptive implants distributed in sub saharan africa, msi's family planning service delivery approach can be useful for governments and other organizations aiming for similar program expansion. msi's experience demonstrates that service delivery expansion can be done successfully in sub saharan africa by leveraging existing service delivery channels that many implementing organizations already use: clinics owned and operated by ngos, social franchising networks, and mobile outreach teams of dedicated providers that work in partnership with the public sector. underlying our channel operations is a strong infrastructure that enables channels to complement each other in user reach and operational structure. key elements of this infrastructure include a sufficient number of trained providers, strong commodity supply chains, and diverse financing mechanisms. msi's implementation experience underscores that quality assurance also matters, in the interest of clinical standards but also to help ensure that clients are satisfied with their experience and that they communicate their satisfaction to generate further demand for services. these systems and strategies have enabled our sub saharan african country programs to be nimble in responding to the rising demand for implants over the last 5 years. governments and organizations wishing to scale up their own programs will likely recognize that the infrastructure investments required to deliver implants as part of a comprehensive method mix can also be leveraged to deliver and expand the uptake of other contraceptive methods. the adaptive quality of msi's service delivery models is also an important component of its scale up efforts in sub saharan africa. in response to changing demand, msi modified its models to best meet the specific context where family planning service delivery was needed. for example, the mobile community outreach worker team emerged as a low cost alternative to our original clinical services outreach model, enabling msi to reach underserved communities in urban and peri urban areas. a new msi initiative with the government of ghana offers another example of a model variation. in this expansion of the public private partnership component of our outreach model, ghana health services will assume msi's demand generation costs for msi ghana's mobile outreach channel. other variations include contracting out opportunities, in which governments contract private sector implementing organizations to deliver specific services, as msi has recently established with the government of tanzania for our outreach services. this adaptation responds to the evolving shift occurring in public private partnerships, in which governments are assuming greater responsibility for the strategic direction of ngo provided services (table 5). looking forward, the increasing availability of implants will generate demand, and growing numbers of women in sub saharan africa are likely to choose this method. our recent results in the region, in which every country where we work produced steep rates of growth, demonstrate this demand; our data also show that implant service delivery, among other contraceptive methods, still has room to expand. concurrent with this rising demand for implant insertion services will be an increase in the need to remove implants. as early users reach the end of their implant's life span, clients will seek removals in greater numbers than before. such demand for removals will need to be met with additional family planning services in the context of informed choice; post removal contraceptive counseling services and method choice availability are key for women who wish to continue using a contraceptive method following the removal. meeting sustained demand for implant insertion, removal, and post removal services in the long term will require msi and other service delivery organizations to develop innovative responses to changing needs and to forge strategic partnerships between stakeholders, including clients. the public private partnerships that have brought us to the current stage in implant scale up including the price volume guarantees and the partnerships between ngos and local governments that underpin outreach and dedicated provider models set the tone for further collaboration. rather than viewing mobile outreach, dedicated provider, and social franchising models as stop gap measures to support shortfalls in public  or private  (commercial) sector capacity, organizations may be able to integrate these models into the existing health system. msi's new contract models with the governments of ghana and tanzania are examples of this integration. other sustainability strategies include the incorporation of social franchise clinics in national and social health insurance schemes, and publicly funded voucher programs delivering free or very low cost services for the poorest clients. as donors, governments, and implementing partners work to reach 120 million additional contraceptive users by 2015 as part of the family planning 2020 (fp2020) goals, responsiveness within the global health community will be essential. with the recent price volume guarantees on implants from manufacturers and donors, important progress has already been made in reducing the financial burden of implant procurement. however, continued investment in the implementation costs required for reaching the client is essential as a “service volume guarantee” to meet demand among all current and future clients. taken together, such investments in commodity supplies and effective, high quality service delivery will enable all of us to deliver on our fp2020 commitments, and ultimately, ensure that all individuals have access to their contraceptive method of choice. we wish to thank many people who assisted with the development of this paper. nithya mani gathered some initial data, and george hayes assisted with interpretation of msi service delivery data. james harcourt, tracey brett, and brendan hayes provided invaluable insights and information during their reviews of earlier drafts. clinical protocols and franchise operational procedures all msi providers in all channels adhere to msi's clinical standards and guidelines as well as their country's ministry of health protocols comprehensive follow up care required, including referrals to msi or public sector facilities for complications or implant removal all social franchisees are trained in operational, marketing, and quality control protocols, such as record keeping and commodity management interactive, competency based, and up to date trainings and refresher courses regular supervision supportive supervision to all provider and operations teams in all channels, including social franchising, by msi country program offices, regionally based clinical staff, and london headquarters staff some social franchisees engage providers in regular network meetings programs operate under measurable quarterly and annual goals established under msi's monitoring and evaluation framework intermittent quality checks random spot checks from msi clinical services managers, typically each quarter mystery client visits for family planning services, including implants anonymous complaint and support telephone lines for msi clinic and social franchisee clients comprehensive quality technical assistance audits by msi london's medical development team to review clinical quality, on an annual basis clinical quality of implant service provision client family planning counseling implant insertion infection prevention management of follow up care, including referral systems service delivery environment customer service facility cleanliness privacy program operations personnel management commodities management record keeping demand generation collaboration with local ministry of health facilities and staff, when applicable competing interests: none declared. peer reviewed msi's social franchise networks are branded bluestar with the exception of plan.it (india), rayaheen (yemen), suraj (pakistan), and amua (kenya). in this article, bluestar is used to refer to all msi franchise networks in sub saharan africa, including amua in kenya. articles from global health, science and practice are provided here courtesy of the johns hopkins bloomberg school of public health center for communication programs connect with nlm national library of medicine 8600 rockville pike bethesda, md 20894

linkedin and 3rd parties use essential and non essential cookies to provide, secure, analyze and improve our services, and to show you relevant ads (including professional and job ads) on and off linkedin. learn more in our cookie policy. select accept to consent or reject to decline non essential cookies for this use. you can update your choices at any time in your settings. agree & join linkedin by clicking continue to join or sign in, you agree to linkedin’s user agreement, privacy policy, and cookie policy. communications analyst, unfpa république centrafricaine ✍ stephanie nolen writes: more women in africa are using long acting contraception, [and this is] changing lives, [with] methods such as hormonal implants and injections reaching remote areas, providing more discretion and autonomy. read more 👇 to view or add a comment, sign in 37,634 followers in sub saharan africa, women have the world’s lowest rate of access to contraception: just 26% of women of reproductive age in the region are using a modern contraceptive method. but that is changing as more women have been able to get methods that give them a fast, affordable and discreet boost of reproductive autonomy. over the past decade, the number of women in the region using modern contraception has nearly doubled to 66 million. engenderhealth is thrilled to be a part of that progress, along with our many partners there who work to improve access to contraception: https://loom.ly/8ldyrqi #reproductiverights #srhrforall to view or add a comment, sign in chief executive officer, president, and executive director of evofem biosciences (otcqb: evfm) as alice pelton at the lowdown points out, the design of this study has some clear limitations in that it reviewed all methods as opposed to fda/eu cleared methods. however, it does highlight a compelling trend: more and more people are seeking reliable, non hormonal options for contraception. this shift underscores the urgent need for better access to diverse contraceptive options. at evofem biosciences, we are deeply passionate about empowering individuals with choices that fit their unique needs. we’re here to educate, innovate, and provide solutions for those seeking a different approach to contraception whether that’s avoiding hormones, enhancing control, or simply exploring options that align with personal preferences. the conversation around reproductive health is evolving, and we’re committed to leading the way. let’s keep the dialogue going and work toward ensuring everyone has access to the contraception that works best for them. 💜 #reproductivehealth #nonhormonaloptions #contraceptivechoice https://lnkd.in/dkb5zhck https://lnkd.in/dbsnt6r9 to view or add a comment, sign in medical science liaison | co founder, ‘the 2 susans newsletter’ improving health, well being, and quality of life by broadening access to contraception in africa involves a variety of factors. this article talks about how more women are opting for long term reversible contraceptive methods, such as implants and injections, due to increased education, improved availability of methods, and enhanced access in rural areas. community health workers play a crucial role by providing education and administering injections directly at the doorstep. #womenshealth #healthcare #contraception #reproductivehealth #education to view or add a comment, sign in 5,576 followers ✨ your body, your choices ✨ on #worldcontraceptionday, we’re highlighting the importance of having options when it comes to contraception. whether you’re considering the combined pill, an implant, hormonal coil, or another method, what’s right for you may change over time and that’s okay! ❤️ for those managing migraines, contraception can play a key role in symptom management. as we mark #migraineawareness week, it’s important to consider how different contraception methods may impact your health and well being. this video, created by dr. aziza sesay, highlights how important it is to make informed choices. this aligns with our #fsrh_hatfieldvision goal 16: ensuring all women and girls have access to clear, relevant information about their reproductive health, no matter their background or circumstances. 🌍 celebrate world contraception day by exploring your options and taking charge of your sexual and reproductive health. visit our newly relaunched contraception choices website to explore the full range of options available: https://lnkd.in/e7ksqcyr to view or add a comment, sign in 3,131 followers in recognition of #wcd2024 tomorrow, ghtc is highlighting six innovative #contraception options in the pipeline, including next generation contraceptive vaginal rings being developed by population council. https://lnkd.in/exjqf ej to view or add a comment, sign in 80,911 followers today, more women than ever before can access methods of contraception that give them a fast, affordable and discreet “boost of reproductive autonomy”   as put by the new york times. over the past decade, the number of women in sub saharan africa using modern contraception has nearly doubled to 66 million. this progress is something to celebrate   but too many women and girls still are unable to access the contraception that they want and need. one of the key reasons behind this limited access is unsustainable financing for commodities. this can lead to women arriving at clinics which don't have supplies to meet their needs or their preferred method. we’re pleased to be working with the unfpa supply chain partnership and the global financing facility (gff) to tackle the financing challenges faced by low income countries, to help move to more sustainable funding for women’s reproductive health. https://lnkd.in/d4yukpiq to view or add a comment, sign in 749 followers this article has been selected as the editor’s choice paper for the october 2024 issue. the article is freely available for all to read at https://lnkd.in/ekrephp5 61 followers editor’s choice paper postpartum contraception provision across europe: preliminary findings from a multi country survey this article has been selected as the editor’s choice paper for the october 2024 issue. the article is freely available for all to read at https://lnkd.in/ekrephp5 congratulations to authors michelle cooper, kristina gemzell danielsson, helena kopp kallner, oskari heikinheimo and sharon cameron the journal of the european society of contraception and reproductive health editor in chief giovanni grandi to view or add a comment, sign in 4,554 followers 📢 new report release: contraception report 📢 femhealth insights is proud to announce the publication of our latest report, "the contraception market: trends, insights, and opportunities." in this report, we dive into how cutting edge innovations like long acting reversible contraceptives (larcs), male contraceptives, and non hormonal options are revolutionizing reproductive health. 🔍 key statistic: did you know that 77.8% of contraception companies founded since 2018 have been working on non hormonal options? this signals that companies, scientists, and medical practitioners are striving to improve the options available for women to optimize their reproductive health. we feature some of the biggest players in the space including natural cycles°, the national institutes of health, bill & melinda gates foundation, male contraception initiative, the global contraception policy atlas, yourchoice therapeutics, and several others. 📈 stay ahead of industry trends and leverage our expert insights to make informed decisions in the evolving contraception market. purchase your copy today: https://lnkd.in/e3apx9hj #femtech #contraception #marketinsights #innovation #femhealthinsights #drb to view or add a comment, sign in 29 followers "empower your future." world contraception day, observed on september 26 each year, is a global event dedicated to raising awareness about contraception and reproductive health. it aims to promote education about contraceptive options and empower people to make informed choices about their sexual and reproductive health. on world contraception day, discussions often include the different types of contraceptives available: hormonal methods: pills, patches, injections, and implants. barrier methods: condoms (male and female), diaphragms, and cervical caps. intrauterine devices (iuds): both hormonal and non hormonal. permanent methods: sterilization procedures for both men and women. fertility awareness: methods based on tracking fertility signs. despite its importance, challenges remain: access and affordability: not everyone has equal access to contraceptives due to cost, location, or availability. education gaps: in some areas, there is still a lack of comprehensive sexual education. stigma: cultural or societal stigma around contraception can hinder open discussions and access. world contraception day serves as a crucial reminder of the importance of reproductive health and the need for ongoing efforts to ensure that everyone can make informed choices about their bodies and futures. your health, our commitment. 📲call us or whatsapp us at: 705 6010 (san fernando) 763 7229 (siparia) 728 4335 (arouca #worldcontraceptionday #reproductivehealth #informedchoices #planyourfuture #empoweryourhealth #sexualhealtheducation to view or add a comment, sign in 533 followers new study in #hsr from daniel marthey phd et al examine the effect of medicaid immediate postpartum long acting reversible contraception (ipp larc) reforms on self reported mental health among low income mothers aged 18 44 years. what is known these policies have been linked with increased postpartum larc utilization, but few studies have examined the impact of contraceptive access on measures beyond reproductive health. what this study adds access to effective contraception has important downstream effects on health beyond reductions in unintended pregnancies. conclusion findings suggest that contemporary efforts to improve access to contraceptive methods may have important benefits beyond reproductive autonomy. these findings have implications for policymakers as the landscape related to family planning services continues to shift. full article: https://lnkd.in/gqh7em6d #healthservicesresearch academyhealth wiley to view or add a comment, sign in 1,538 followers create your free account or sign in to continue your search or by clicking continue to join or sign in, you agree to linkedin’s user agreement, privacy policy, and cookie policy. new to linkedin? join now or new to linkedin? join now by clicking continue to join or sign in, you agree to linkedin’s user agreement, privacy policy, and cookie policy. linkedin never miss a beat on the app don’t have the app? get it in the microsoft store.

an official website of the united states government official websites use .gov a .gov website belongs to an official government organization in the united states. secure .gov websites use https a lock ( lock locked padlock icon ) or https:// means you've safely connected to the .gov website. share sensitive information only on official, secure websites. primary site navigation logged in as: competing interests: the authors have declared that no competing interests exists. * e mail: ykriel@mru.ac.za received 2021 jun 6; accepted 2023 feb 28; collection date 2023. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. progress has been made to improve access to family planning services and contraceptive methods, yet many women still struggle to access contraception, increasing their risk for unintended pregnancy. this is also true for south africa, where over fifty per cent of pregnancies are reported as unintended, even though contraception is freely available. there is also stagnation in the fertility rate indicators and contraceptive use data, indicating that there may be challenges to accessing contraception. this paper explores the evaluation of access to contraception from community and health care provider perspectives. this qualitative study explored factors affecting the uptake and use of contraception through focus group discussions (n = 14), in depth interviews (n = 8), and drawings. participants included male and female community members (n = 103) between 15 and 49 years of age, health care providers (n = 16), and key stakeholder informants (n = 8), with a total number of 127 participants. thematic content analysis was used to explore the data using nvivo 10. emergent themes were elucidated and thematically categorised. the results were categorised according to a priori access components. overall, the results showed that the greatest obstacle to accessing contraception was the accommodation component. this included the effects of integrated care, long waiting times, and limited operational hours all of which contributed to the discontinuation of contraception. community members reported being satisfied with the accessibility and affordability components but less satisfied with the availability of trained providers and a variety of contraceptive methods. the accessibility and affordability themes also revealed the important role that individual agency and choice in service provider plays in accessing contraception. data from the illustrations showed that adolescent males experienced the most geographic barriers. this study illustrated the importance of examining access as a holistic concept and to assess each component’s influence on contraceptive uptake and use. family planning (fp) services and modern contraceptive methods are some of the most important public health strategies that can improve the lives of individuals, families, communities, and nations. access to sexual and reproductive health (srh) services, including family planning (fp) programmes and modern contraception, and contraception is a human right and a target set out by the sustainable development goals (sdg) target 3.7 [1, 2]. at the london summit in 2012, family planning 2020 (fp2020) was established with the goal to get an additional 120 million users onto contraception [3]. the sdg target, fp2020, along with general comments no. 14 and no. 22 set out by the united nations committee on economic, social, and cultural rights [4], are driving goals for the international family planning community and nations, including south africa (sa), to ensure equitable access to srh services and contraceptive methods. although much progress has been made over the past couple of decades many women in low and middle income countries (lmics), including women in sa, struggle to access srh services and contraception [3, 5, 6]. an estimated 230 million women and adolescent girls need modern contraception [3, 7] in lmics, while sub saharan africa remains the region with the highest fertility rate and unmet need for contraception [8 10]. compared with other countries in the sub saharan region, sa has an advanced total fertility rate (tfr, 2.6), relatively low unmet need for married women (14.9%), moderate modern contraceptive prevalence rate (mcpr, 47.9%), and high levels of general knowledge about available contraceptive methods amongst men and women [11, 12]. however, numerous srh challenges exist. amongst these are high levels of unintended pregnancies (over half of all pregnancies are unintended), a high rate of unmet need amongst unmarried young women (27.9%), adolescent pregnancies (16% of women aged 15 19 years have had a pregnancy), high incidence of termination of pregnancies, and an alarming increase in the pregnancy related mortality ratio from 150 deaths per 100 000 live births in 1998 to 536 deaths per 100 000 live births in 2016 [5, 6, 12]. there is also a noticeable stagnation in contraceptive use and fertility trend rates in sa over the past two decades. sa’s total fertility rate has declined from an estimated 6.0 in 1960 to 2.9 in 1998 [12 14]. but between 1998 and 2016, the tfr has remained almost stagnant, dropping to 2.6 in 2016. except for the total demand for contraception, met need, and unmet need, which all increased, the stagnating trend can be seen across all the other fertility and contraceptive use indicators (fig 1) [12, 14]. these stagnating trends point to challenges accessing srh services and contraception, despite sa having one of the longest running modern family planning programmes in sub saharan africa [11]. providing srh services and contraception is also supported by progressive policies and guidelines [5]. modern contraception is provided free of charge through the public health sector at primary health care (phc) clinics that operate from 08:00 am to 4:00 pm on weekdays. the south african district health survey (sadhs, 2016) data report that 2% of contraceptive users discontinued their method due to access related barriers, including affordability and physical access [12]. only focusing on affordability and physical access contributes to an inaccurate understanding of access. other sources have identified additional barriers, including poor quality of care (qoc), limited variety of modern contraceptive methods, fragmented integration of sexual and reproductive health (srh) services with phc services, ailing infrastructure, shortage of trained nurses, poor attitudes of nurses, and stigma [5, 15 19]. furthermore, hasumi and jacobsen [20] reported that 43.8% of south africans who relied on the public health care sector experienced problems accessing care which is concerning since an estimated 80% of the population rely on the public sector for the health care needs [20, 21]. high inequality levels to accessing health have also been reported, where aspects such as race, economic status, and gender influences access to care [21, 22]. most women (nearly 83%) obtain their contraceptive method from the public healthcare sector, compared to only 11.4% who access contraception through private health care[5, 6, 12]. except for male condoms and female sterilisation, most of the methods; 3 month injectable (94%), 2 month injectable (95%), implants (94%) and pills (77%); are accessed from government primary health care clinics or community health centres [12]. fifty one percent of male condoms are obtained from primary health care clinics/community health care centres, 26% from shops, and 12% from pharmacies. female sterilisation is predominantly accessed through government (63%) and private (27%) hospitals [12]. the source of contraception plays an important part in which contraceptive methods are used, as not all methods are available at all facilities and rely on the qualification and specialisation of healthcare professionals [23]. on a national policy level, the sa government is dedicated to improving access to srh services and modern contraception by committing to the goals set out by fp2030 [24]. the sa government has restructured contraceptive services from a specialised vertical programme to a phc district based integrated programme [25]. progressive srh policies were implemented to address inadequacies in contraceptive access due to past political history [5, 26, 27]. however, how effective these policies are at improving access to contraception is unclear. integrating services especially srh services with hiv care is a crucial strategy proposed to improve access, inequity, and qoc [17, 28]. this area has received much attention in recent years, and there is a considerable drive to ensure that integration occurs [3, 16, 29, 30]. however, barriers to accessing health care services (as mentioned above) must be addressed for integration to be effective [31]. despite the enabling policies and restructuring, the sa public health sector has struggled to make real gains in improving access to services, including fp service [20, 21, 32]. where these challenges lie within the larger concept of access and which components are most significant remains unclear. qualitative, exploratory data can provide critical understandings about factors influencing access [33], which can lead to the development of community focused interventions to improve uptake and met need for modern contraception. this paper aims to explore each access component and the factors that influence the uptake and use of contraception from a community and health care provider (hcp) perspective. in this study, we used penchansky and thomas’s [34] access framework, which defines access as “the general concept which summarises a set of more specific areas of fit between the patient and the health care system” (p.128). five interrelated components of access are used in this framework, namely accessibility, availability, affordability, accommodation, and acceptability [34]. accessibility refers to the “relationship between location of supply and the location of clients”; availability refers to “the relationship of the volume and type of existing services (and resources) to the clients’ volume and types of needs”; accommodation refers to the “relationship between the manner in which the supply resources are organized to accept clients […] and the clients’ ability to accommodate to these factors and the clients’ perception of their appropriateness”; affordability refers to the cost of services related to the clients’ ability to pay; and acceptability which refers to the relationship of the attitude between clients’ and providers [34: 128]. versions of these components are found in later frameworks, such as the uncescr (united nations committee on economic, social, and cultural rights) availability, accessibility, acceptability, and good quality (aaaq) framework [35, 36], or the fp focused access frameworks proposed by choi et al [33], and bertrand et al [37]. yet, when employed, the original access framework continues to provide the most comprehensive exploration of access [5, 38 40]. furthermore, within the srh literature, it is important to distinguish between access and qoc. ambiguity and overlap exist between these two concepts within the literature [33, 37, 41], resulting in skewed understandings of either concept. social constructionism was used as the overall lens to view the data. as a broad theory, social constructionism postulates that humans construct concepts through which they can understand reality [42, 43]. these constructs are often deeply embedded within respective cultures and shape the way humans understand and make sense of the world they live in [43]. adopting a social constructionist stance towards the study of fp services and contraceptive use allows for a variety of voices to be heard. it is beneficial when the opinions and knowledge of community members are sought as it allows for the expression of ideas and understanding by a variety of people. the study reported in this paper was conducted in the ethekwini district of kwazulu natal (kzn) province, sa. kzn is the second most populous province in sa and is situated on the country’s east coast. the couple years of protection rate (cypr), a proxy indicator for the cpr, for kzn has consistently fallen below the national median, with the 2018/19 cypr being 44.4% a significant drop from the 2016/2017 cypr of 66.1% [44]. kzn also has the largest number of people living with hiv in the country, where the hiv prevalence rate is 27%, with over two million of the seven and a half million people living with hiv residing in the province [45, 46]. the ethekwini district is the third largest metropolitan district in sa, with an estimated population size of three and a half million people. similar to the kzn province, ethekwini also has the largest number of people living with hiv per district in the country [45]. this study was conducted as part of formative work to inform the development of an intervention that aimed at increasing met need for modern contraception through community and hcp participation from a human rights perspective in sa, kenya and zambia (the uptake project). overall study results are presented by cordero et al. [47]. the detailed teamwork qualitative methodology is published elsewhere [48]. in this article, we report on findings from the south african data. we conducted in depth interviews (idis, n = 8) and focus group discussions (fgds, n = 14) between 2015 and 2016 with a total of 127 participants. purposive snowball sampling was used as the recruitment strategy. fourteen fgds were conducted. twelve of these fgds were with community participants (n = 103), and two with hcps (n = 16). six of the female fgds were equally split into groups of adults (35 to 49 years), young adults (20 to 34 years), and adolescents (15 to 19 years) from rural (n = 27) and urban (n = 25) settings. the male fgd participants were also split into groups of adults (n = 7), young adults (n = 8), and adolescents (n = 10) but were mixed from both the rural and urban areas. the remaining three fgds consisted of unmarried females (20 to 34 years n = 8), married/in union females (20 to 34 years n = 10), and females without children (18 to 49 years n = 8), respectively. the hcp fgds consisted of group 1 (management and professional nurses, n = 8) and group 2 (enrolled nurses, counsellors, and other operational staff, n = 8). the hcps were recruited from clinics based in the two areas where the community participants resided. idis were conducted with eight key informants (kis) who were purposively selected based on their expertise in srh services or community involvement. four kis were based within the communities from which the community members were recruited and consisted of two community caregivers, one educational specialist, and one traditional healer. the other four kis held senior or programme level positions, specialising in srh and fp. fgds and idis were conducted by trained research team members who had experience with qualitative interviewing and were fluent in the local languages (isizulu and english). interviewers were appropriately matched with gender, age, and professional position to facilitate discussions. demographic data were collected from all participants and were descriptively analysed. fgds were conducted at community based facilities. key informants were interviewed at locations convenient to them, ranging from research site offices to participants’ homes. this study received world health organization (who) ethics review committee (erc) (project id a65896) and research project review panel (rp2) approval. the university of the witwatersrand human research ethics committee (health  hrec, reference number m1504101) provided local country ethics review and approval. the university of kwazulu natal’s biomedical research ethics committee (brec) provided further reciprocity. the kwazulu natal provincial department of health granted permission for health care providers to be interviewed. all participants voluntarily signed an informed consent form, including permission to audio record the interview/group sessions. identified parents or legal guardians provided consent for minors (those aged <18 years). the minors provided assent to participate in the study. during the fgds and idis, participants were asked to explore their views about the uptake of modern contraception. interview guides contained key theme specific questions that were tailored for each category or type of participant, including the female fgds, male fgds, hcp fgds, and key informant idis (see s1 data to s4 data to review the interview guides and questions used in this study). similar key thematic questions explored understandings of family planning; knowledge, attitudes, and practices; key barriers and enablers to family planning access; perceptions and definitions of qoc; and the role of community participation in family planning and contraceptive services. the collaborative nature of fgds allowed for rich data to be collected and for shared and diverse opinions to be explored [49]. idis were used to interview key informants who had expert knowledge about the delivery of contraception, such as policy makers and senior health care professionals. due to the lengthy nature of fgds, idis were more suited to these types of participants. the fgd participants were also asked to make simple drawings to capture their experiences of accessing or providing contraception. key elements asked to be included were their primary source of obtaining contraception, the time travelled to the service, and their method of transport. they could also include any other aspects that they felt were relevant. the drawings allowed for an individual perspective to be explored in the data set during the group activity. participants captured their own experiences and constructs about accessing contraception in their community. audio recordings of the fgds and idis were transcribed and translated from isizulu to english where necessary. the transcripts were reviewed and checked for accuracy and any ambiguity in the translations were discussed and clarified to ensure accuracy of the translations. the audio transcripts and drawings underwent the same process of analysis. firstly, a subset of transcripts and drawings were read, reviewed, and tested before a cross country team of researchers developed a master codebook. during the initial coding round, a subset of coded transcripts was double coded to increase the validity, reliability, and consistency of the findings [48]. additional coding was done on the individual country level to elucidate themes specific to each country. nvivo (version 10, qsr international) was used as the computer assisted qualitative data analysis software that facilitated coding and thematic analysis of the audio transcripts and drawings. a detailed account of the teamwork methodology is presented by milford et al. [48]. thematic content analysis was used to identify a priori and emergent themes. a priori themes were based on components from penchansky and thomas’s (1981) access framework described above. inductive and emergent themes were further explored using the constant comparison method to allow for themes to emerge once data saturation was reached [50]. coding queries and matrix coding queries were run to explore the data further. matrix coding queries were used to elucidate comparative themes between the various groups of participants and to show where coding queries intersected [51]. these more complex queries allowed for in depth exploration and to uncover larger themes embedded in the data. the drawings were also analysed using the same codebook and access framework codes. using the same codes allowed for data triangulation between what participants reported and what they captured in their drawings. at the end of the project, the results were shared with community members, and there was a high degree of agreement with the results presented. this further contributed to the validity and accuracy of the data. a total of 103 community members participated in this study. seventy eight community participants were female (75%), and 25 were male (25%). the mean age of female participants was 26.4 years and males 23.8 years. over half (53%) were in a long term relationship but not living with their partner. at the time of data collection, 83.5% of the participants had used a modern contraceptive method. reported adolescent pregnancies were high, with seven (37%) out of the nineteen adolescent females reporting pregnancy. five out of the nine adolescent girls in the urban adolescent group reported pregnancy, compared to two out of ten in the rural adolescent group. no male adolescents reported a pregnancy with a female partner. table 1 below shows the demographic details for the community participants. *reports female partner pregnancy/use $values do not add to 100%. hcp fgd group 1 (management and professional nurses) consisted of six female and two male participants. all the participants were females in hcp fgd group 2 which consisted of enrolled nurses, counsellors, and other operational staff (n = 8). the key informants consisted of seven females and one male. all hcps interviewed in this study worked at public phcs or hospitals. the average years of experience were ten. this section explores the main themes that emerged from the data concerning questions about access. these emergent themes were categorised per component of access. themes included: the current and preferred sources of fp services and modern contraception (accessibility); the availability of contraceptive methods and hcps (availability); the ability to obtain modern contraceptive methods (affordability); and the organisation of services including integration, appointment scheduling, and waiting times (accommodation). discussions about the acceptability component related more to the quality of care and are reported elsewhere [52]. three sub themes emerged from this theme geographic access to current contraceptive sources, infrastructure, and preferred source of contraceptive methods. community participants were asked to describe where they could obtain contraception in their community. public phcs were identified as the primary source of modern contraception. the primary mode of transport reported across the groups was walking (n = 92), followed by a mixed use of walking and using a taxi (n = 7) and public taxi (n = 4). male adolescent participants had the longest travelling time to a source of contraception with a mean travelling time of 86 minutes. urban female adult participants had the shortest travelling time with a mean time of 13 minutes. male participants included local shops and phcs as a major source of modern contraception, while female participants only drew their local phcs. all participants sketched their experiences accessing contraception, capturing their interpretation of distance and barriers that influence their ability to obtain contraception. (see s1 table to review data obtained from the drawings and s1 fig to view examples of the drawings.) hcp participants described the accessibility of contraceptive methods in relation to the infrastructure where services are provided. the physical size of the phc determined if a separate room was available where hcps could provide srh counselling and contraception. p002: at my clinic, there is a room specialising in family planning, but all consultation rooms have family planning. they do it so that there will not be long lines during the day because [the family planning specific room] is closed at 16h00. after 16h00, services continue, and they can still find it in other [general care] rooms… [hcp group 1, p002] space constraints in smaller phcs facilities resulted in contraception being provided in all consulting rooms. p003: we do not have [a specific place if you want family planning] because our clinic is small. but all consultation rooms [have] all services… [hcp group 1, p003] the participants reported that local phcs, mobile clinics, schools, and private health care were preferred sources of contraception. one female community participant explained her preference for mobile clinics: p001: [i]t could be better if there can be a mobile clinic because sometimes you don’t have transport fare to go to the clinic because the clinic is far. maybe the [department of] health can make means […] so that we can have easy access. [married female fgd, p001] schools were also identified as sources of contraception. one female adolescent participant noted her preference to obtain her contraceptive method from her school lavatory: p010: i would like to get them from school by the toilet (group laughs). nobody knows what’s happening inside there […] [rural female adolescent fgd, p010] others said they would prefer to access contraception from a private health care provider especially from doctors. young adult male participants expressed a preference for male doctors: f: who would [you] like to get [contraception] from? p003: from an experienced doctor who [is qualified for] these things. f: number 2. p002: doctor as well. f: number 1. p001: i also say from the doctor. especially a male one. f: male? p001: because a male […], he is going to understand […] how it works, because a female will [not] tell you that there are different condoms like this and that […]. he will tell you how [they] work because sizes are not the same. he will tell you that if you have this size, this one works like this. so, it [is] better if it is a male doctor. [young adult male fgd] the participants reported that short acting and long acting reversible contraceptive methods were readily available at local phcs. however, access to a variety of contraceptive methods, including longer acting permanent methods (such as sterilisation), was described as inaccessible and unavailable. one participant described the lengthy process involved in accessing female sterilisation: p008: tubal ligation, [it is not available at the clinics] if you want to do it at the clinic it is a long process that i tried […] you first go to the clinic and get a referral letter so that you can go to [the hospital]. when you get to [the hospital], they start afresh and fill in forms and all that. it is a long process. [married female group, p008] another sub theme of availability was the limited availability of trained hcps. p001: [i] can say that they [hcps]… are not enough because it is not good that you walk a long distance to look for help and at the end, you don’t get it because […] there is little staff. [community ki, p001] one health ki raised the fact that hcps are not well trained in providing srh care, including contraception: ki, p007: the rights of the people are violated when it comes to family planning, sexual and reproductive health rights just by not providing nurses who are trained. it’s a violation of people’s rights. [ki hcp, idi, p007] the free availability of contraception from phcs was positively described to facilitate the use of contraception. a few community participants raised transport costs as affordability related barriers. two sub themes emerged under affordability. the first was an individual user’s ability to obtain services, and the second was the financial impact on male partners. the first sub theme is the user’s financial ability to access srh services of their own choice referred to as ‘individual power’ by community participants. the participants described their limited financial situation as constraining their ability to obtain contraception from a provider of their own choice. one female participant explained: f: how would you like to get these family planning and contraception? where would you like to get them? p006: i don’t have a choice it is at the clinic because it is where i have the power to reach, but if i had the strength, i would have loved to get from my doctor. […] but because of power, you are forced to go to the clinic. but condoms you can buy if you have money [..] but like injection and whatnot, you will not be able to buy. [urban adult fgd, p006] male participants discussed gendered perspectives about the cost of accessing contraception. the financial reliance of female partners on their male partners to obtain their contraception illustrated the limited financial agency that women have in this setting. it also links to the discussions about having ‘power’ to get their contraception from a provider of their own choice. young adult male participants explained: p004: it costs her; she has to change her method, you see? it is like that my brother, when she changes, it affects you financially, you see, as an “outjie” (guy) because she tells you, “my brother […] it is you who is supposed to give her money”, to go and buy these things. why? because they are not available at our local clinics. [young adult male fgd, p004] adolescent males further described how gendered expectations related to economic agency could influence the affordability of contraceptives. p010: ones [condoms] that are available for free don’t satisfy us. i: they don’t satisfy you? p010: when you use them, the lady complains that ‘ayi, you look down on her because you are having sex with her using a [free government condom brand]. […] so, you see that thing and then we are forced to buy [brand of condom] […] p005: i also second number 10. he is really right. the minute you take out a [free government condom] on a girl, she gets the impression that you are not the guy she thought you are, you see? it means that you are forced to go and take [paid brand name condom] so that she can be satisfied that ‘hah babe is having sex with me with such a thing’ you see. [adolescent male fgd] discussions about the organisation of srh services, which refers to the accommodative component of access, were raised in three sub themes: integrated care, accommodating missed visits, and waiting times. discussions surrounding the integration of the fp programme with phc services raised numerous challenges with organising an efficient service that could accommodate a variety of client needs. also raised were the challenges with implementing policy at the ground level. the participants reported that integration negatively affected accessing contraception. hcp kis involved with family planning over several decades explained: ki, p005: you know, when family planning was introduced way back in the 1980s, ‘89… up to maybe 2000, we had a service called state health services. at that time, family planning was working very well. but we’ve since amalgamated all the primary health care services. that is where we actually miss the boat. [because] in my opinion, if we still maintained that family planning only service, maybe we wouldn’t be having as many teenage pregnancies as we are having. [hcp ki, p005] community participants reported that they had good experiences with an ngo supported facility that focused only on srh services for young adults and adolescents. however, this facility was closed down. the participants outlined the enabling environment that such a specific facility provided: p003: only family planning [services] were there at [name of facility]. only those for family planning went there […]. it was fast, they closed it, […] and they were fast because you knew that you came for something that does not include anything else, it was a place for people on prevention only. now they took us back to the clinic […]. that [is] the thing that made me [stop using] 2 monthly [injection] while [i was doing] well [on it]. [females without children fgd, p003] an hcp participant echoed this view: p004: there were many girls [at the name of the facility] who were doing family planning there. [it] was closed, unfortunately, [and the clients] had to go to the clinic […] but we lost a lot of girls. they stopped coming to be absorbed at the clinic because it was just for the youth only. [hcp group 1, p004] the participants pointed out that phcs cannot accommodate the needs of a variety of clients, such as those who are employed. this influenced clients’ ability to attend phcs on specific days, especially if they are employed resulting in missed visits: p004: sometimes, there are compelling issues that make you miss your clinic date. […] then you find a temporary job. it is very hard to ask that you [can have time off to] go to the clinic. [rural adult female fgd, p004] the participants further reported that the consequences of missing an appointment date were often met with harsh treatment by the nurses: p001: [the] things that they do, the nurses, if you have missed your date, [is that] they chase you away, while you were waiting3 hours and above. she will tell you to go and wait outside. you will be the last to be attended [to], that is a turn off. [rural adult female fgd, p001] long waiting times were a much discussed topic that participants related to the qoc, the accommodative ability of a phc, and as a factor that contributed to their economic burden to obtain contraception. community participants described having to wait for several hours and that long waiting times could lead to the discontinuation of contraceptive use. p003: yes, i also left it [referring to method discontinuation] because of that, the 2 months [injection], it was treating me well […]. the thing that made me stop the 2 months [injection] is that thing of the nurses. they sometimes attend to you and [sometimes] they do not attend to you […]. you sit there the whole day at the clinic. you will arrive in the morning at ten, eleven. you will leave at four not [being] attended to. it’s just busy. what’s worse is they mix you with the sick [clients] sometimes while they said, there is a place that used to be called ‘be injected’ [the specialised ngo supported fp service that was closed]. [female group without children, p003] one female participant explained that even though there may only be a few clients for contraception, they still had to wait lengthy times: p001: because we sit more than three hours at the clinics when you’re there to take the injection. sometimes, you find four [clients only] who are there for contraceptives. [rural adult female fgd, p001] hcps explained the long waiting times and felt that it impacted the quality of care: p005: [o]ur clients wait for a long time to be seen because they need to be taught about family planning. then from there, they come back to the queue. so, it’s not good quality [service] for the clients […]. [hcp group 1, fgd, p005] another problematic factor raised about time was that in some phcs, adolescent school children were attended to before adult clients, resulting in tension and services not being accessed: p004: they usually start with children, yet you are also in a hurry to get to your work as a domestic worker in the suburbs […]. you end up taking your card, putting it in your bag and leaving. [rural adult female fgd, p004] in this paper we explored access to srh services and modern contraception from a community and hcp perspective. access to healthcare services is a multidimensional concept [33, 34, 40]. this makes the evaluation of access complex as numerous definitions are used. penchansky and thomas [34] define access as “the general concept which summarizes a set of more specific areas of fit between the patients and the health care system” (p.128). aday and andersen [53] suggest that access is a multidimensional concept that can be viewed as either potential or realised and defined as “those dimensions which describe the potential and actual entry of a given population group to the health care delivery system” (p.51). more specifically to srh and contraceptive services, bertrand et al. (1995) [37], define access as “the degree to which family planning services and supplies may be obtained as a level of effort and cost that is both acceptable to and within the means of a larger majority of the population” (p.65). all these definitions highlight the importance of resources being available, but also that other crucial factors such as the society, geographical access, capacity of the healthcare service, cultural beliefs, and socio cultural factors are considered when discussing access. access therefore extends beyond the mere availability of facilities [40]. the community perspective included users and non users of contraception that allowed a robust discussion about the barriers to accessing contraception. the hcps provided context and insight into the daily challenges that they face in delivering contraception. these various perspectives broadened current understanding about what access to contraception means in this setting, beyond the narrow categories used in the sadhs (2016) data. the overall results showed that the accommodation component of access posed the biggest problems for community members to access srh services, and hcps to provide care. in addition, personal agency and choice in service delivery point (sdp) and provider played significant roles in peoples’ ability to access contraception. penchansky and thomas’s (1981) access framework which includes five distinct, but interrelated components were used to explore the data. categorising the inductive emergent themes and sub themes according to each component of access allowed for a robust but specific exploration about access to contraception. this robust understanding could not have been achieved if more recently proposed frameworks, such as those proposed by bertrand et al. [37] or choi et al. [33], or the aaaq were used. the influence of policy and the implementation of policy on accessing contraception was seen throughout the results. even though sa has progressive and enabling srh policies the implementation of these policies was found to be problematic. this finding has been reported previously [16], and its persistence over time shows the difficulty in drafting relevant policies and their implementation at the ground level. challenges in implementing policies resulted in the misinterpretation of access and availability to contraceptive services by community members. the misunderstanding of policy implementation points to the need for greater engagement and communication between community members and hcps [54]. discussions about the integration of srh services with general phc services demonstrated the challenges with implementing policies. restructuring the specialised vertical fp programme to integrate with phc was some of the most significant policy and service implementation changes made to the delivery of modern contraception in sa [16, 17, 25, 55]. despite almost two decades of attempting to integrate fp services with district based phc services, full implementation is still lagging, yet the importance and need for successful integration are evident [16, 30, 56, 57]. in contrast to international findings however, results from this study showed that integration negatively affected access to contraception in this setting [58]. this finding adds to explain the report by adeniyi et al [57] that unintended pregnancies remained high in this setting despite the integration of services. furthermore, buy in from hcps is key to the successful implementation of integrated services [15, 16]. hcp participants from this study reported their frustrations with providing integrated srh care and their preference for a specialised service. this was echoed by reports from community members who voiced their dissatisfaction about integrated services that led to overcrowded facilities. overcrowded and overburdened facilities resulted in long waiting times which contributed to discontinuation of contraceptive use. mcintyre and chow [59] found that waiting times were often misreported. yet, lengthy waiting times was the most significant sub theme reported in this data related to access to care. while national policy state that waiting times at phcs should average around two hours, participants from this study reported waiting four hours or more just to receive contraception further illustrating the discord between policy and policy implementation at the service level [60]. addressing long waiting times in phcs is a complex problem that will require adjustments in other essential areas such as having sufficiently trained hcps, ensuring that capacity is not over extended, and adjusting the operating hours of phcs. currently, no model of integration effectively deals with this important problem. other reasons cited that contribute to lengthy waiting times included restrictive operating hours and the limited availability of trained hcps. the limited operating hours of phcs (08:00 am to 16:00 pm) restricted access to contraception. in addition, there are reports that in some south african phcs, nurses only attend to clients in the mornings, reserving afternoons for administrative work, thereby further limiting operating hours [17]. employed participants reported that these operating hours were not compatible with their work hours resulting in them either losing income due to a loss of working hours or missing their appointment visit resulting in discontinuation of their contraception. scheduling appointments is one strategy to improve accommodation within phcs, however missed visits are common in this setting due to the reasons stated. baumgartner et al [61] reported that nearly 50% of depomedroxyprogesterone (dmpa) users return late for their follow up appointment, with some late returning clients denied access to follow up dmpa injections. the accommodation component, which included discussions about integration, long waiting times, and operating hours, was therefore identified as having the most significant influence on accessing contraception. the limited availability of trained hcps was discussed under the availability theme. following the restructuring of the health care system was the shift in the training of nurses from specialised skills, such as family planning and contraception, to generalised skills [62]. adequately trained hcps are essential to expanding access to contraception, but specialist trained nurses have fallen away [15, 63]. the lack of trained hcps was raised as a concern in this data, and while staff shortage is not a new finding [64, 65], it highlights the need for human resources to be included in discussions about the availability of contraception. while the widespread availability of short acting contraceptive methods was positively associated with access, the difficulty to access long acting or permanent contraceptive methods were negatively reported a finding supported by the literature [5, 6]. the female participants reported dissatisfaction with the unattainability of long acting and permanent methods such as sterilisation. data under the affordability and accessibility themes revealed that individual agency and choice in provider and service delivery point played important roles in accessing srh services. srh services and contraception is provided free of charge in the public sector and the participants positively associated this with accessibility to contraception. however, the data showed that the free availability of contraception was constrained by an individual’s economic power and ability to obtain contraception from an sdp and provider of their choice. discussions about affordability extended beyond the usual reports about the price of services and methods. instead, the data from the drawings highlighted individual agency in accessing contraception and that although the methods are freely available there is a cost to obtaining them. women reportedly relied on their male partners for economic support to reach phcs. male participants added an interesting perspective by drawing a shop in addition to a phc. men possibly constructed their ability to access contraception in this way because they have the economic means to pay for privately sourced contraception such as branded condoms. women captured their limited agency by only drawing phcs as a possible sdps. even young adolescent females only identified phcs, instead of other sources such as schools. limited female agency also reflects the unequal gendered economic agency present in these communities. further to the discussions of agency was the importance of choice in sdp and provider. penchansky and thomas [34] showed that having the same hcp of choice is essential for retention in care and satisfaction with available services a particularly important point for continued contraceptive use. as explained by the participants, in the sa public health district based phc model, most women have limited autonomy to choose an sdp from which to obtain contraception. unless they have the economic means to obtain contraception from private health care facilities, which for most south africans is unaffordable, their only option is their local phc [32]. lastly under the accessibility theme, hcps discussed the impact of infrastructure on accessing fp services. hcps reported that phcs with insufficient space or adequate infrastructure constrained access to contraception. ailing infrastructure also has a negative effect on the psychological well being of hcps, further limiting access to services [16, 62]. some limitations exist for this study. firstly, the data presented here are only based on experiences with the public health care sector. for a more comprehensive comparison and understanding of access to contraception, data and experiences from private health care users should also be evaluated. secondly, as this was a qualitative study, the results are not necessarily generalisable. instead, the focus is on the transferability of the methods and findings to other settings. while the findings are specific to the south african context, specifically kzn, the methods for evaluating access using a holistic approach and identifying the relevant components are relevant for other settings. the selection of the community and healthcare participants into this study was from two areas one urban and the other being peri urban/rural. participants were also selected on specific criteria, such as marital/partner status and whether they had children or not. such specific criteria could potentially have resulted in biased opinions as some members of other communities or those in other types of relationships could have varying opinions. an area where bias was reduced was that non contraceptive users were also included in this study, which balanced the view of contraceptive access and use, especially in terms of non use. using a community perspective adds to this paper’s contribution to the literature. the view of facility based clients is usually used to evaluate satisfaction with services. these types of reports can be skewed toward positive overreporting out of fear of repercussions [66]. interviewing community members who may or may not be fp clients allows for a less influenced perspective and evaluation on accessing fp services. a few questions about accessing fp services remained unanswered in this data set and required further exploration. adolescent males reportedly had the longest travel time to sdps, but it was not well explained in the data as to why. female participants did not identify any other sources for contraception other than phcs this needs exploration. long waiting times are a significant issue that requires urgent further investigation to improve access to services. this paper sheds light on how community members and hcps evaluate access to srh services and contraception. in contrast to the results presented by the sadhs (2016), the data showed that significant barriers to accessing contraception exist in this setting which can result in contraceptive discontinuation. overall, most of the female participants were satisfied with the accessibility and affordability components. they were less satisfied with the availability of long acting and permanent contraceptive methods. the limited number of trained providers was raised as a concern. accommodation was identified as the component that presented the most significant barriers to accessing srh services. in particular, the ineffective organisation of services resulted in lengthy waiting times that could result in the discontinuation of contraceptive use. the addition of the male perspective in accessing contraception was a new finding on this subject. men described the financial burden of accessing contraception and highlighted the importance of having an alternative source of contraception in the communities that are easily accessible. the importance of recognising that access is a multidimensional concept and that the most important components should be identified to understand the challenges in accessing contraception was made clear. careful attention must also be paid to policy implementation over time, as local contextual changes could make policies redundant. policies must be evaluated for their effectiveness over time. women face many obstacles when accessing [6] contraception. the argument here is that the health care system itself should not be an obstacle. every effort should be made to ensure that all women who need or want contraception should be able to get it without much hassle or having to overcome numerous barriers. even though the data for this study were collected before the onset of the covid 19 pandemic, the findings highlight the importance of paying attention to all the access components. health care facilities and systems must identify where access problems exist and address them appropriately to be prepared for unexpected new epidemics and challenges. (pdf) (pdf) (pdf) (pdf) (pdf) (docx) (tif) the authors would like to thank all the participants who gave their valuable time to participate in this study. we would also like to thank the uptake team who collected the data and assisted with transcribing and translating the audio. couple’s year of protection rate contraceptive prevalence rate depomedroxyprogesterone family planning health care provider key informant kwazulu natal low  and middle income countries modern contraceptive prevalence rate sexual and reproductive health service delivery point south africa total fertility rate the database is not publicly available as it contains information that could compromise research participants' privacy and consent. however, some anonymised aspects of the datasets may be available upon request and with the permission of the department of sexual and reproductive health and research, world health organization, and the match research unit (mru). note that data sharing is subject to who data sharing policies and data use agreements with the participating research centre, mru. for permission to access the database, please contact the match research unit at info@mru.ac.za. this work received funding through a grant received by undp unfpa unicef who world bank special programme of research, development and research training in human reproduction (hrp), a cosponsored programme executed by the world health organization (who) [award 53405] from the bill and melinda gates foundation [opp1084560] and the united states agency for international development (usaid) through the usaid/who umbrella grant 2016 2018. the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 4 jan 2022 pone d 21 18604access to public sector family planning services and modern contraceptive methods in south africa: a qualitative evaluation from community and health care provider perspectives.plos one dear dr. kriel, thank you for submitting your manuscript to plos one. after careful consideration, we feel that it has merit but does not fully meet plos one’s publication criteria as it currently stands. therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. as indicated by the reviewers, additional detail is needed regarding the drawings   why they were used, the value added, and how they were analyzed. furthermore, copy editing and removal of redundant information should be addressed before submitting a revised version of the paper. please submit your revised manuscript by feb 18 2022 11:59pm. if you will need more time than this to complete your revisions, please reply to this message or contact the journal 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(please upload your review as an attachment if it exceeds 20,000 characters) reviewer #1: this is an interesting paper, well written and comprehensive. however, it is also a very long paper!!! the authors have unnecessarily described the context and background as though it is a mini thesis which much duplication as well. i find the detailed description of the frameworks repetitive  perhaps more than sufficient in the methods but not that necessary in the background as this is not a thesis... detailed comments below introduction   i would recommend the authors to integrate and shorten the background and introduction pieces together, the depth of information is quite overwhelming, which takes kills the enthusiasm for the findings of this study the main point of this paper, in my view. methods   the first 2 paragraphs under setting seem to belong in the introduction/background section too. other than that, the methods are well described!   in table 1, i'm unclear about the sample groups from number 7 12: are these neither from rural/urban, which setting do they come from? are they exclusive from the sample groups 1 6? in other words, are the sample groups 1 6 not in a relationship? not married or single? have children???? the classification/categorization is quite confusing...e.g. the authors included young females from rural and urban, 20 34 yrs old, and also have the same age group single, married/in a relationship, and with no children (18 49 yrs)  are they different from the ones described in 1 6 and if so, how?   only the applicable theoretical framework should be described in the methods section, concisely as well. results  very comprehensive and interesting findings! in general, i like how they are presented following on the framework structure and flow logically.   the theme on implementation policy is very thin  i'd consider that part in the discussion section rather than a stand alone theme..   insert figure 2 has nothing to do with clinic, only a shop shown there. discussion   nice discussion as well, especially the policy part! however, i would suggest that is framed in a "policy implication" perspective after discussing the above findings.   perhaps no need for the "theoretical framework" structure here  just discuss the findings!   it is also relatively long!   notwithstanding the framework within which this paper was conceived on, it is surprising to see the most recent "research" related reference used by the authors from 2019  surely more and relevant research has been published between 2019 and 2021 in relation to access, uptake and use of modern contraceptives. so i would challenge the authors to revisit the literature and update their references... reviewer #2: general this paper is interesting and has a rich data set. overall some of the data needs to be reviewed and expanded in the findings and discussion to adequately apply a social constructionist framework. the paper needs a minor grammar edit and a review of spelling. see abstracts in annotated paper review for a few examples. introduction the section on the critique of the access frameworks needs to be tighter (lines 72 81). see comments on paper. methods the methods should more fully discuss the use of drawings; why they were used, how were they set up and used in the facilitation of the fgds, and how were they analysed in relation to the coded transcripts. were they only used to comment on access to services and geographical barriers? findings the finding related to policy is weak. what more did the data say? how was integration of services experienced by women? this is discussed later but could also be explored or at least cross referenced as it reflects the reality between policy and implementation. the use of the drawing as a basis for table 5 and then statistics related to the drawings seems to me a rather static way of using the drawings   would you have not got the same data had these been asked in the focus groups? were there other things that 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information will be updated. 4. we noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. table 1 ,2 , 3 and 4 please clarify whether this publication was peer reviewed and formally published. if this work was previously peer  reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.   response: the tables were removed to reduce any dual publication. careful attention was paid to avoid any dual publication among the manuscripts that arise from this dataset. some information like the demographic data might be similar due to the nature of such data. all other text and findings presented are unique to each paper. as explained in the original cover letter and submission this paper forms part of a larger project, the uptake project, and the main author’s phd thesis. 5. we note that you have indicated that data from this 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manuscript. if your ethics statement is written in any section besides the methods, please delete it from any other section.   response: thank you, the ethics statement was removed from the statements section. 7. we note you have included a table to which you do not refer in the text of your manuscript. please ensure that you refer to table 4 in your text; if accepted, production will need this reference to link the reader to the table.   response: thank you for noting this. this table was removed to improve the word count of the manuscript and reduce any dual publication. 8. please include captions for your supporting information files at the end of your manuscript, and update any in text citations to match accordingly. please see our supporting information guidelines for more information: http://journals.plos.org/plosone/s/supporting information.   response: captions for the supporting files were included at the end of the manuscript according to the plos guideline. additional editor comments (if provided): this is an interesting paper with great potential. the two reviewers have provided detailed feedback that can be used to improve the paper further. please review these comments carefully as you work on a revision. reviewer #1: this is an interesting paper, well written and comprehensive. however, it is also a very long paper!!! the authors have unnecessarily described the context and background as though it is a mini thesis which much duplication as well. i find the detailed description of the frameworks repetitive  perhaps more than sufficient in the methods but not that necessary in the background as this is not a thesis... detailed comments below.   response: thank you for your review and comments. after careful revision, i have tried to remove all duplication where i could see it. i have also edited the literature/background sections and discussion to reduce the word length and address the reviewers’ comments. introduction   i would recommend the authors to integrate and shorten the background and introduction pieces together, the depth of information is quite overwhelming, which takes kills the enthusiasm for the findings of this study the main point of this paper, in my view.   response: thank you, this was done. the literature and background sections were edited to be one section. methods   the first 2 paragraphs under setting seem to belong in the introduction/background section too. other than that, the methods are well described! • response: this was edited as per suggestion.   in table 1, i'm unclear about the sample groups from number 7 12: are these neither from rural/urban, which setting do they come from? are they exclusive from the sample groups. 1 6? in other words, are the sample groups 1 6 not in a relationship? not married or single? have children???? the classification/categorization is quite confusing...e.g. the authors included young females from rural and urban, 20 34 yrs old, and also have the same age group single, married/in a relationship, and with no children (18 49 yrs)  are they different from the ones described in 1 6 and if so, how? • response: i have removed the table and written the group descriptions to help clarify. to clarify the participant breakdown   in total 127 participants participated in this study in sa. of the 127 participants, 16 were health care providers and 8 in each fgd which were divided according to professional ranking. there were also 8 key informant idis. the female community participants were first divided between the urban and rural settings. three urban groups consisted of women aged 35 to 49 years (adults), 20 to 34 years (young adults), and 15 to 19 years (adolescents). these three groups were matched for age in the rural setting. three additional fgd groups were then held with a group of unmarried women (20 to 34 years), a group of married/in union women (20 to 34 years), and a group of women who do not yet have children (18 to 49 years). these three groups were recruited from both the rural and urban areas. all the fgd participants were unique for each group i.e., no participant was interviewed twice. the 3 male fgd groups consisted of men aged 35 to 49 years (adults), 20 to 34 years (young adults), and 15 to 19 years (adolescents) respectively and were a mix from the rural and urban areas.   only the applicable theoretical framework should be described in the methods section, concisely as well. • response: thank you, this section was edited to only refer to the applicable theoretical framework. after revising the manuscript, i noted how this can be confusing for some readers. results  very comprehensive and interesting findings! in general, i like how they are presented   following on the framework structure and flow logically.   the theme on implementation policy is very thin  i'd consider that part in the discussion section rather than a stand alone theme. • response: thank you for this comment. based on your review and the comment from reviewer 2, i decided to remove policy implementation as a theme and to rather discuss it under the discussion section.   insert figure 2 has nothing to do with clinic, only a shop shown there. • response: yes, some male participants only drew shops as their source of contraception. this drawing was included to show this finding. discussion   nice discussion as well, especially the policy part! however, i would suggest that is framed in a "policy implication" perspective after discussing the above findings.   perhaps no need for the "theoretical framework" structure here  just discuss the findings!   it is also relatively long! • response: thank you for the suggestions made. on revision, i have edited the discussion to reduce the length and make it more concise. please see the update discussion section.   notwithstanding the framework within which this paper was conceived on, it is surprising to see the most recent "research" related reference used by the authors from 2019  surely more and relevant research has been published between 2019 and 2021 in relation to access, uptake and use of modern contraceptives. so i would challenge the authors to revisit the literature and update their references... • response: thank you for this comment. on review, there really is very limited relevant literature about access to contraception in sa   and none which are more recent in publication date. this highlights the importance of this paper as an update to what was published in the past. i also wanted to keep the word length shorter as the paper is already quite long, so i only included literature that is absolutely relevant to this paper. reviewer #2: general this paper is interesting and has a rich data set. overall some of the data needs to be reviewed and expanded in the findings and discussion to adequately apply a social constructionist framework. the paper needs a minor grammar edit and a review of spelling. see abstracts in annotated paper review for a few examples. • response: thank you for the review of the paper. i apologize for the grammatical errors which were updated and corrected. i have revised the results and discussion section to bring out the social constructionist stance, but i am constrained by an already lengthy manuscript to fully explore this issue. in addition, the social constructionist stance can also be appreciated from a methodological point of view, as both health care providers, key informants, and community participants’ voices were included in the findings. this allowed for each grouping, especially the divide between the health care providers and community members, to be elucidated without singling out which was more important. please see the track change version of the paper for the edits and corrections made. introduction the section on the critique of the access frameworks needs to be tighter (lines 72 81). see comments on paper. • response: thank you for your comments. i have updated the theoretical framework section. please see the manuscript for the updated text. methods the methods should more fully discuss the use of drawings; why they were used, how were they set up and used in the facilitation of the fgds, and how were they analysed in relation to the coded transcripts. were they only used to comment on access to services and geographical barriers? • response: thank you for the comment. the drawings were an additional method to collect individual data within the group setting. using this method was quite effective in allowing individual participants to share their views on accessing contraception. overall, the drawings were quite simple and reflected what was asked: where their source of contraception was, how they got there, and how long it took. the participants enjoyed making the drawings   it served as a bit of a break in the fgd since these fgds were rather long. i have added some text in the methodology section that expands a bit on the drawings. the drawings were analysed in the same manner as the rest of the data   the codebook was used, and appropriate codes were applied. these codes mainly consisted of accessibility codes, such as distance, source of contraception, time travelled, and mode of transport. findings the finding related to policy is weak. what more did the data say? how was integration of services experienced by women? this is discussed later but could also be explored or at least cross referenced as it reflects the reality between policy and implementation.   response: based on this comment and the comments from reviewer 1 i decided to remove policy as a theme and rather bring it up in the discussion. policy and implementation truly affected all the areas of access and were challenging to isolate. i attempted to integrate policy discussions throughout the discussion and especially to highlight how integration impacted women. the use of the drawing as a basis for table 5 and then statistics related to the drawings seems to me a rather static way of using the drawings   would you have not got the same data had these been asked in the focus groups? were there other things that people drew that supplemented the data and helped with a deeper understanding (social construction of meaning).   response: a key challenge with using a visual data collection technique in qualitative research is the question of whether the same results could not be obtained by a different method. according to the literature, the only true way to do that is to set up a rigorous experiment. for this study, the aim was not to prove the validity of one method over another but rather to obtain an updated perspective on accessing contraception. most of the data were obtained from the interview transcripts but the drawings allowed for an individual data collection method in a group setting. this eliminated the need to repeat the data collection process. it also served as a ‘break’ during the discussions allowing the participants to interact freely with the interviewers and each other. could the same data have been obtained during the fgd itself by merely asking the question about how they experienced accessing contraception? perhaps, but the individual experience would have been lost. each participant drew their own experience, and their own specific challenges when going to collect their contraception. that level of detail would have been lost in a group discussion since not every participant responds to every question asked. it was important for this study to gain an understanding of how, where, and what challenges participants experienced when they wanted to access contraception. this was especially the case because not all the participants were current or ever contraceptive users and we wanted to understand where the barriers may lie. see other comments on marked up paper for specific areas that need strengthening.   responses to comments in pdf:   all grammar and spelling errors were corrected.   lines 72 to 81   moved to the theoretical framework section to improve the flow of the paper. the critique was emphasized in the updated section.   lines 137   138   sentence was updated as suggested.   lines 186   188   thank you for the comment. the drawings were an additional method to collect individual data within the group setting. using this method was quite effective in allowing individual participants to share their views on accessing contraception. overall, the drawings were quite simple and reflected what was asked: where their source of contraception was, how they got there, and how long it took. the participants enjoyed making the drawings   it served as a bit of a break in the fgd since these fgds were rather long. i have added some text in the methodology section that expands a bit on the drawings.   line 296   thank you for the comment. as per the reviewers’ suggestion, i have decided to remove the policy theme from the thematic results and to rather discuss it in the discussion since the influence of policy and policy implementation was so pervasive in the data set.   line 433   434   thank you for the comment. the sentence was edited to include the reviewer’s suggestion.   line 452   456   in the results, the participants explain that the focus on the family planning services is lost due to the clinics being overburdened with a variety of clients. both the community members and the health care providers noted this. this topic was elaborated on a bit in the updated discussion.   “your data also shows that integration of services at phc level (policy directed) has possibly (unintentionally) resulted in lower levels of access  as you describe waiting times, missed visits etc etc”   thank you for the comment. this was highlighted in the discussion.   lines 600   this sentence was in reference to the literature that was cited. the sentence was removed for clarity.   lines 616   621   thanks for this comment. i agree that the issues of agency, autonomy and economic power play an important role in contraceptive use (or non use). the discussion was updated to reflect these important points.   lines 635   640   thank you for the comment. we agree this reflects the limits of policy implementation and have added a sentence to help clarify. submitted filename: responses to reviewers.docx this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 2 aug 2022 pone d 21 18604r1access to public sector family planning services and modern contraceptive methods in south africa: a qualitative evaluation from community and health care provider perspectives.plos one dear dr. kriel, thank you for submitting your manuscript to plos one. after careful consideration, we feel that it has merit but does not fully meet plos one’s publication criteria as it currently stands. therefore, we invite you to submit a 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(please upload your review as an attachment if it exceeds 20,000 characters) reviewer #3: this paper attempts to fill a gap which is the lack of use of modern contraceptive methods in kwazulunatal, south africa. the paper is well written and qualitative data shed some light on “access” to family planning methods from a broader perspective that include five elements according to a theoretical framework. however, these five elements needs to be well defined from the start. unfortunately, data don’t bring much new insights in particular on the acceptability issue including the issue of secondary effects which is reported worldwide as the main reason for lack of uptake or continuation. the social factors or what is called the “social constructionism” lens used to view the data could be more prominent and data presented and discussed in light of social determinants (unmarried or single women or other vulnerable groups). 1. there is some confusion or contradictions along the text with the term “access” despite the fact that you present a framework you will use in this study and you define access accordingly. it should clearly presented from the start in the theoretical framework section after defining access, what each term (five interrelated components of access used in this framework, namely accessibility, availability, affordability, accommodation, and acceptability) will entail, stick to that and be consistent. page 2 lines 47 48 it is mentioned :” this study illustrated the importance of examining access as a holistic concept and not just the availability of services or methods.” i don’t think that access is commonly related or limited to the availability of contraceptive methods; on the contrary access refers primarily to geographical and financial access. i would remove or reformulate that sentence. moreover in the introduction page 4 lines 96 100: you had a contradictory statement as a justification of the paper: “only focusing on affordability and physical access contributes to an inaccurate understanding of access. other sources have identified additional barriers, including poor quality of care (qoc), limited variety of modern contraceptive methods, fragmented integration of sexual and reproductive health (srh) services with phc services, ailing infrastructure, shortage of trained nurses, poor attitudes of nurses, and stigma (5, 15 19)” results : line 280 accessibility: “three sub themes emerged from this theme   geographic access to current contraceptive sources, infrastructure, and preferred source of contraceptive methods.” then later line 296 “ infrastructure : hcp participants described the availability and accessibility of contraceptive methods at their healthcare facility related to the available infrastructure. again in the conclusion there is some contradiction and confusion regarding the meaning of access: it is stated line 616 “overall, the participants were satisfied with the accessibility and affordability components” and later line 623 “ men described the financial burden of accessing contraception and highlighted the importance of having an alternative source of contraception in the communities that are easily accessible.” please clarify and reformulate please define the terms from the start and harmonize the text and the abstract. 2. page 5 : the second paragraph (lines 105 120) is long and could be quite shortened if you start the paragraph by the following : “despite the enabling policies and restructuring, the sa public health sector has struggled to 118 make real gains in improving access to services, including fp service (20, 29, 30). 3. introduction: although your study focuses on the public sector, it would be indicated to mention in the introduction (and also in the settings  ethekwini district of kwazulu natal sadhs results related to what are the main sources of family planning in sa, in particular: % of public vs. private services? , and most preferred sources of contraception among young people and adults ? and most contraceptive methods used in sa and kwazulu natal. 4. page 8 “cpr, “for kzn has consistently fallen below the national median, with the 2018/19 cypr 154 being 44.4%” then later “the cypr for ethekwini is also below the national average 159 at 44.4% for 2018/2019” please clarify for consistency.page 8 lines 155: study settings: please add hiv prevalence (then the total population affected by hiv) in kwazulu natal. 5. page 8 line 171 “twelve of these fgds were with community participants (n= xx) , and two with hcp (n= xx) ” i think you removed the table (duplication of data presentation) but please mention the total number of community members participants in fgd/ total hcp in fgd; and total idi “ idis were conducted with eight key informants (kis) (n= xx) . 6. line 126: “theoretical framework” can fit in the methods section and should not be a standalone section. even if you present other frameworks you should stick to one (and i think this is what you did) and the sub title should be called “theoretical framework” (not frameworks) . 7. under the theme affordability you include ability (line 368) ability to access fp service and contraceptive methods. the first sub theme is the user’s ability to access srh services of their own choice   referred to as ‘individual power’ by community participants. the participants described their limited financial situation (i would add   as one factor) constraining their ability to obtain contraception. in my view ability or individual power is a much broader theme and the financial constraint is only one factor. did other ability factors emerge from the interviews? 8. the acceptability component is not addressed: why? and if no material on that it should be mentioned in the study limitations. discretionary comments 1. abstract   methods: please provide the total number of participants   community members (n=xx) and health care providers (n=xx) 2. page 4 lines 56 58: “…sexual and reproductive health (srh)” and “human rights” : please avoid to use too many capital letters for names (even before using an acronym) unless they are organizations or recognized as needing a capital letter. 3. discussion: you could possibly discuss the complexity of the term access, its definitions or different meanings? reviewer #4: this is a revised version. this research has been well done. the reviewers from the previous round made important comments, but the authors seem to me to have replied adequately. i have only a few small comments or suggestions: 1. the section titled ‘analysis’ is about data collection and data analysis. i suggest to split this into two sections. 2. is it possible to reflect on the fact that selection bias can occur during the recruitment of the participants? can this influence the results? ********** 7. plos authors have the option to publish the peer review history of their article (what does this mean?). if published, this will include your full peer review and any attached files. if you choose “no”, your identity will remain anonymous but your review may still be made public. do you want your identity to be public for this peer review? for information about this choice, including consent withdrawal, please see our privacy policy. reviewer #3: yes: therese delvaux reviewer #4: yes: wim peersman ********** [note: if reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. please log into your account, locate the manuscript record, and check for the action link "view attachments". if this link does not appear, there are no attachment files.] while revising your submission, please upload your figure files to the preflight analysis and conversion engine (pace) digital diagnostic tool, https://pacev2.apexcovantage.com/. pace helps ensure that figures meet plos requirements. to use pace, you must first register as a user. registration is free. then, login and navigate to the upload tab, where you will find detailed instructions on how to use the tool. if you encounter any issues or have any questions when using pace, please email plos at figures@plos.org. please note that supporting information files do not need this step. collection date 2023. 11 jan 2023 reviewer 3 1. this paper attempts to fill a gap which is the lack of use of modern contraceptive methods in kwazulunatal, south africa. the paper is well written and qualitative data shed some light on “access” to family planning methods from a broader perspective that include five elements according to a theoretical framework. however, these five elements needs to be well defined from the start. unfortunately, data don’t bring much new insights in particular on the acceptability issue including the issue of secondary effects which is reported worldwide as the main reason for lack of uptake or continuation. the social factors or what is called the “social constructionism” lens used to view the data could be more prominent and data presented and discussed in light of social determinants (unmarried or single women or other vulnerable groups). response: thank you for your review. this study specifically focused on access to contraception in the south african public sector clinics. no previous studies have been conducted that specially focused on access to contraception using the five a’s framework. the aim of the study, and this manuscript, was to uncover the barriers and enablers to accessing contraception in this setting. the aim was not to further the definition of access or its components. in the previous draft of this manuscript, reviewer 2 suggested that the definitions are not necessary and lengthen the overall paper. the theoretical framework section was therefore shortened and the definitions removed. i have, however, reinserted these definitions under the theoretical frameworks section again. please see lines 132 139 the acceptability component was explored in detail in another publication as the data fit more accordingly under the quality of care framework. please see this publication for further reading: kriel, y., milford, c., cordero, j. p., suleman, f., steyn, p. s., & smit, j. a. (2021). quality of care in public sector family planning services in kwazulu natal, south africa: a qualitative evaluation from community and health care provider perspectives. bmc health services research, 21(1). https://doi.org/10.1186/s12913 021 07247 w the social constructionist stance was used to analyze and review the data. due to word length limitations and revisions requested from the previous reviewer, we are unable to fully explore the social constructionist viewpoint in this paper. however, important social structures are highlighted such as the various group categories (married, unmarried, no children, and men.). the social constructionist stance was very helpful as a lens through which to view the data, especially since there are significant social hierarchies between the groups of participants in the study. for instance, we were consciously aware of the power dynamics that can exist between healthcare providers and community members and that the healthcare provider’s view can sometimes override that of community members/clients. this power dynamic also exists between the adult and adolescent participants. therefore, social constructionism provided guidance in minimizing biases in our reporting. 2. there is some confusion or contradictions along the text with the term “access” despite the fact that you present a framework you will use in this study and you define access accordingly. it should clearly presented from the start in the theoretical framework section after defining access, what each term (five interrelated components of access used in this framework, namely accessibility, availability, affordability, accommodation, and acceptability) will entail, stick to that and be consistent. response: thank you, the definitions were re inserted. careful attention was paid throughout this study to the definitions of the components of access. 3. page 2 lines 47 48 it is mentioned :” this study illustrated the importance of examining access as a holistic concept and not just the availability of services or methods.” i don’t think that access is commonly related or limited to the availability of contraceptive methods; on the contrary access refers primarily to geographical and financial access. i would remove or reformulate that sentence. response: in our read of the literature, access was commonly equated with availability. the sentence was updated. 4. moreover in the introduction page 4 lines 96 100: you had a contradictory statement as a justification of the paper: “only focusing on affordability and physical access contributes to an inaccurate understanding of access. other sources have identified additional barriers, including poor quality of care (qoc), limited variety of modern contraceptive methods, fragmented integration of sexual and reproductive health (srh) services with phc services, ailing infrastructure, shortage of trained nurses, poor attitudes of nurses, and stigma (5, 15 19)” response: this sentence is in reference to the categories used in the dhs survey to measure access. 5. results : line 280 accessibility: “three sub themes emerged from this theme   geographic access to current contraceptive sources, infrastructure, and preferred source of contraceptive methods.” then later line 296 “ infrastructure : hcp participants described the availability and accessibility of contraceptive methods at their healthcare facility related to the available infrastructure. response: this sentence was updated. please see lines 306 308. 6. again in the conclusion there is some contradiction and confusion regarding the meaning of access: it is stated line 616 “overall, the participants were satisfied with the accessibility and affordability components” and later line 623 “ men described the financial burden of accessing contraception and highlighted the importance of having an alternative source of contraception in the communities that are easily accessible.” please clarify and reformulate please define the terms from the start and harmonize the text and the abstract. response: the first sentence refers to the overall study findings. however, male participants added a specific view on the cost of accessing contraception. this cost is not often recognized or reported. it is, therefore, important to point out these differences. the sentence was slightly altered for clarity. 7. page 5 : the second paragraph (lines 105 120) is long and could be quite shortened if you start the paragraph by the following : “despite the enabling policies and restructuring, the sa public health sector has struggled to 118 make real gains in improving access to services, including fp service (20, 29, 30). response: thank you for the suggestion, however, the preceding sentences provide the context with which to justify the last statement. 8. introduction: although your study focuses on the public sector, it would be indicated to mention in the introduction (and also in the settings  ethekwini district of kwazulu natal sadhs results related to what are the main sources of family planning in sa, in particular: % of public vs. private services? , and most preferred sources of contraception among young people and adults ? and most contraceptive methods used in sa and kwazulu natal. response: a paragraph was inserted regarding the sources of contraception, see lines 105   119 9. page 8 “cpr, “for kzn has consistently fallen below the national median, with the 2018/19 cypr 154 being 44.4%” then later “the cypr for ethekwini is also below the national average 159 at 44.4% for 2018/2019” please clarify for consistency. page 8 lines 155: study settings: please add hiv prevalence (then the total population affected by hiv) in kwazulu natal. response: thank you for seeing this error   the second sentence is an error and was deleted. please see lines 175 179 for the hiv statistics. 10. page 8 line 171 “twelve of these fgds were with community participants (n= xx) , and two with hcp (n= xx) ” i think you removed the table (duplication of data presentation) but please mention the total number of community members participants in fgd/ total hcp in fgd; and total idi “ idis were conducted with eight key informants (kis) (n= xx) . response: thank you for noticing this omission. the reviewer 2 suggested a removal of the tables that describe the participant characteristics to reduce data duplication. i have re inserted the total numbers for each category. 11. line 126: “theoretical framework” can fit in the methods section and should not be a standalone section. even if you present other frameworks you should stick to one (and i think this is what you did) and the sub title should be called “theoretical framework” (not frameworks). response: in the previous review, reviewer 2 requested that the theoretical framework section be separate. i have made the edits as you suggested and moved it back to the methodology section. 12. under the theme affordability you include ability (line 368) ability to access fp service and contraceptive methods. the first sub theme is the user’s ability to access srh services of their own choice   referred to as ‘individual power’ by community participants. the participants described their limited financial situation (i would add   as one factor) constraining their ability to obtain contraception. in my view ability or individual power is a much broader theme and the financial constraint is only one factor. did other ability factors emerge from the interviews? response: thank you for your comment. i agree that ability could be regarded as a broader theme. however, specific to this data, the participants referenced their financial situation and ability to pay, as key factors that influence their access to services. i have edited the theme heading to clarify that in this paper i am referring to the financial/economic ability to access services. 13. the acceptability component is not addressed: why? and if no material on that it should be mentioned in the study limitations. response: thank you for this comment. in the overall project, the quality of care was also examined as a separate topic. considering the definition of the acceptability component it was more fitting to report the acceptability data in a separate paper under the quality of care framework. this is highlighted in lines 300 301. for further reading on this, please see out other publication: (kriel et al., 2021) kriel, y., milford, c., cordero, j. p., suleman, f., steyn, p. s., & smit, j. a. (2021). quality of care in public sector family planning services in kwazulu natal, south africa: a qualitative evaluation from community and health care provider perspectives. bmc health services research, 21(1). https://doi.org/10.1186/s12913 021 07247 w 14. abstract   methods: please provide the total number of participants   community members (n=xx) and health care providers (n=xx) response: thank you, the total numbers were added. 15. page 4 lines 56 58: “…sexual and reproductive health (srh)” and “human rights” : please avoid to use too many capital letters for names (even before using an acronym) unless they are organizations or recognized as needing a capital letter. response: thank you, the text was updated. 16. discussion: you could possibly discuss the complexity of the term access, its definitions or different meanings? response: the aim of this paper was not to address the complexity of access as a concept, however, i added a short paragraph in the discussion which highlights this. please see lines 509 524. reviewer 4 this is a revised version. this research has been well done. the reviewers from the previous round made important comments, but the authors seem to me to have replied adequately. i have only a few small comments or suggestions: 1. the section titled ‘analysis’ is about data collection and data analysis. i suggest to split this into two sections. response: thank you for the suggestion. the sections were split and the headings were changed. 2. is it possible to reflect on the fact that selection bias can occur during the recruitment of the participants? can this influence the results? response: thank you for this comment. the selection bias was minimized in this study as the enrolment consisted of community members who may or may not have been contraceptive users. random community members were recruited into this study instead of only clinic attendees. however, a small bias may well be present as only members from two communities were selected. a short paragraph was added to highlight this   please see lines 638 641. submitted filename: responses to reviewers 09jan23.docx this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 27 feb 2023 pone d 21 18604r2access to public sector family planning services and modern contraceptive methods in south africa: a qualitative evaluation from community and health care provider perspectives.plos one dear dr. kriel, thank you for submitting your manuscript to plos one. after careful consideration, we feel that it has merit but does not fully meet plos one’s publication criteria as it currently stands. therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. the authors have adequately responded to the comments of the reviewers. however, i have a few additional edits i would like the authors to make. only numbers 1, 2 and 7 are required. the other comments are suggestions to improve the clarity and readability of an already well written manuscript. lines 120 121: “on a national policy level, the sa government is dedicated to improving access to srh services and modern contraception by committing to the goals set out by fp2020 (24).” have these goals been carried over by fp2030? please edit this sentence reflecting the transition from fp2020 to fp2030. lines 129 130: “however, barriers to accessing health care services (as mentioned above) must be addressed for integration to be effective (who, 2008).” please use the vancouver style to reference this who document as has been done in the rest of the manuscript. lines 175 & 706: please edit “the couple’s year of protection rate...” to read “the couple years of protection rate...”. lines 192 193: for clarity, i suggest the number of fgds (n=14) be written before the number of individuals that participated in the fgds (n=127). please consider this suggestion in the abstract as well. lines 229 230: please delete the word “study” so the sentence reads, “during the fgds and idis, participants were asked to explore their views about the uptake of modern contraception.” lines 279 280: i would argue that 53% is not “most”. i suggest the authors consider “over half” or “fifty three percent” or another phrase or word. please take a look at the references listed below and edit accordingly. i feel each of them needs a minor edit, such as a space, the insertion of the journal volume or number, or the deletion of a duplicated year. references: 18 (lines 761 762), 24 (lines 775 776), 37 (lines 808 809), 40 (lines 815 816), 43 (lines 822 823), 46 (line 831), 56 (line 855), 62 (line 872), 65 (line 879). please submit your revised manuscript by apr 13 2023 11:59pm. if you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. when you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'submissions needing revision' folder to locate your manuscript file. please include the following items when submitting your revised manuscript: a rebuttal letter that responds to each point raised by the academic editor and reviewer(s). you should upload this letter as a separate file labeled 'response to reviewers'. a marked up copy of your manuscript that highlights changes made to the original version. you should upload this as a separate file labeled 'revised manuscript with track changes'. an unmarked version of your revised paper without tracked changes. you should upload this as a separate file labeled 'manuscript'. if you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. if applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. protocols.io assigns your protocol its own identifier (doi) so that it can be cited independently in the future. for instructions see: https://journals.plos.org/plosone/s/submission guidelines#loc laboratory protocols. additionally, plos one offers an option for publishing peer reviewed lab protocol articles, which describe protocols hosted on protocols.io. read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial email&utm_source=authorletters&utm_campaign=protocols. we look forward to receiving your revised manuscript. kind regards, funmilola m. olaolorun, phd academic editor plos one journal requirements: please review your reference list to ensure that it is complete and correct. if you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. if you need to cite a retracted article, indicate the article’s retracted status in the references list and also include a citation and full reference for the retraction notice. [note: html markup is below. please do not edit.] reviewers' comments: reviewer's responses to questions comments to the author 1. if the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “comments to the author” section, enter your conflict of interest statement in the “confidential to editor” section, and submit your "accept" recommendation. reviewer #4: (no response) ********** 2. is the manuscript technically sound, and do the data support the conclusions? the manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. the conclusions must be drawn appropriately based on the data presented. reviewer #4: yes ********** 3. has the statistical analysis been performed appropriately and rigorously? reviewer #4: n/a ********** 4. have the authors made all data underlying the findings in their manuscript fully available? the plos data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the data availability statement in the manuscript pdf file). the data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. for example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. if there are restrictions on publicly sharing data e.g. participant privacy or use of data from a third party those must be specified. reviewer #4: no ********** 5. is the manuscript presented in an intelligible fashion and written in standard english? plos one does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. reviewer #4: yes ********** 6. review comments to the author please use the space provided to explain your answers to the questions above. you may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (please upload your review as an attachment if it exceeds 20,000 characters) reviewer #4: i still have 2 comments: 1. lines 229   251 are about data collection and not data analysis. 2. it is unclear how the participants were recruited. on lines 193   194 the authors wrote: “purposive snowball sampling was used as the recruitment strategy”, while on lines 638   639, they wrote: “while the selection of the community and healthcare participants into this study was random a selection”. ********** 7. plos authors have the option to publish the peer review history of their article (what does this mean?). if published, this will include your full peer review and any attached files. if you choose “no”, your identity will remain anonymous but your review may still be made public. do you want your identity to be public for this peer review? for information about this choice, including consent withdrawal, please see our privacy policy. reviewer #4: yes: wim peersman ********** [note: if reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. please log into your account, locate the manuscript record, and check for the action link "view attachments". if this link does not appear, there are no attachment files.] while revising your submission, please upload your figure files to the preflight analysis and conversion engine (pace) digital diagnostic tool, https://pacev2.apexcovantage.com/. pace helps ensure that figures meet plos requirements. to use pace, you must first register as a user. registration is free. then, login and navigate to the upload tab, where you will find detailed instructions on how to use the tool. if you encounter any issues or have any questions when using pace, please email plos at figures@plos.org. please note that supporting information files do not need this step. collection date 2023. 28 feb 2023 responses to reviewers: 27 feb 2023 1. lines 120 121: “on a national policy level, the sa government is dedicated to improving access to srh services and modern contraception by committing to the goals set out by fp2020 (24).” have these goals been carried over by fp2030? please edit this sentence reflecting the transition from fp2020 to fp2030. response:   sentence was edited to update to fp2030 2. lines 129 130: “however, barriers to accessing health care services (as mentioned above) must be addressed for integration to be effective (who, 2008).” please use the vancouver style to reference this who document as has been done in the rest of the manuscript. response: thank you for noticing this. the reference was updated to vancouver style. 3. lines 175 & 706: please edit “the couple’s year of protection rate...” to read “the couple years of protection rate...”. response: thank you for noticing this error. update made. 4. lines 192 193: for clarity, i suggest the number of fgds (n=14) be written before the number of individuals that participated in the fgds (n=127). please consider this suggestion in the abstract as well. response: thank you, this edit was made. it does add some clarity. 5. lines 229 230: please delete the word “study” so the sentence reads, “during the fgds and idis, participants were asked to explore their views about the uptake of modern contraception.” response: thank you, the word study was deleted. this does make the sentence more clear. 6. lines 279 280: i would argue that 53% is not “most”. i suggest the authors consider “over half” or “fifty three percent” or another phrase or word. response: thank you for the suggestion, the edit makes sense. 7. please take a look at the references listed below and edit accordingly. i feel each of them needs a minor edit, such as a space, the insertion of the journal volume or number, or the deletion of a duplicated year. references: 18 (lines 761 762), 24 (lines 775 776), 37 (lines 808 809), 40 (lines 815 816), 43 (lines 822 823), 46 (line 831), 56 (line 855), 62 (line 872), 65 (line 879). response: thank you for noticing these errors. i have updated the references and tried to correct and edit for spacing. during the format editing by the journal the spacing should also resolve. reviewer #4: i still have 2 comments: 1. lines 229   251 are about data collection and not data analysis. response: i have updated the heading to reflect data collection and analysis. 2. it is unclear how the participants were recruited. on lines 193   194 the authors wrote: “purposive snowball sampling was used as the recruitment strategy”, while on lines 638   639, they wrote: “while the selection of the community and healthcare participants into this study was random a selection”. response: thank you for pointing that out. participants were selected using a snowball technique, which was purposive due to the categories required for the study. the sentence in concluding paragraph was inaccurate. i have updated that sentence to clarify the potential for study bias that could have been introduced into the data due to the selection of participants. i hope this clarifies the issue. submitted filename: response to reviewers 27feb23.docx this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1 mar 2023 access to public sector family planning services and modern contraceptive methods in south africa: a qualitative evaluation from community and health care provider perspectives. pone d 21 18604r3 dear dr. kriel, we’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. within one week, you’ll receive an e mail detailing the required amendments. when these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be 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(optional): reviewers' comments: this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 9 mar 2023 pone d 21 18604r3 access to public sector family planning services and modern contraceptive methods in south africa: a qualitative evaluation from community and health care provider perspectives. dear dr. kriel: i'm pleased to inform you that your manuscript has been deemed suitable for publication in plos one. congratulations! your manuscript is now with our production department. if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. if they'll be preparing press materials, please inform our press team within the next 48 hours. your manuscript will remain under strict press embargo until 2 pm eastern time on the date of publication. for more information please contact onepress@plos.org. if we can help with anything else, please email us at plosone@plos.org. thank you for submitting your work to plos one and supporting open access. kind regards, plos one editorial office staff on behalf of dr. funmilola m. olaolorun academic editor plos one this section collects any data citations, data availability statements, or supplementary materials included in this article. (pdf) (pdf) (pdf) (pdf) (pdf) (docx) (tif) submitted filename: track changes_pone d 21 18604_reviewer.pdf submitted filename: responses to reviewers.docx submitted filename: responses to reviewers 09jan23.docx submitted filename: response to reviewers 27feb23.docx the database is not publicly available as it contains information that could compromise research participants' privacy and consent. however, some anonymised aspects of the datasets may be available upon request and with the permission of the department of sexual and reproductive health and research, world health organization, and the match research unit (mru). note that data sharing is subject to who data sharing policies and data use agreements with the participating research centre, mru. for permission to access the database, please contact the match research unit at info@mru.ac.za. articles from plos one are provided here courtesy of plos connect with nlm national library of medicine 8600 rockville pike bethesda, md 20894
supported by global health methods such as hormonal implants and injections are reaching remote areas, providing more discretion and autonomy. by stephanie nolen photographs by natalija gormalova reporting from towns and villages in western ghana. on a busy day at the kwapong health centre in rural ghana, beatrice nyamekye put contraceptive implants into the arms of a half dozen women, and gave eight or nine more a three month hormonal injection to prevent pregnancy. a few sought condoms or birth control pills, but most wanted something longer lasting. “they like the implants and injections best of all,” said ms. nyamekye, a community health nurse. “it frees them from worry, and it is private. they don’t have to even discuss it with a husband or a partner.” the bustle at the kwapong clinic is echoed all over ghana, and across much of sub saharan africa, where women have the world’s lowest rate of access to contraception: just 26 percent of women of reproductive age in the region are using a modern contraceptive method   something other than the rhythm or withdrawal methods   according to the united nations population fund, known as unfpa, which works on reproductive and maternal health. but that is changing as more women have been able to get methods that give them a fast, affordable and discreet boost of reproductive autonomy. over the past decade, the number of women in the region using modern contraception has nearly doubled to 66 million. “we’ve made progress, and it’s growing: you’re going to see huge numbers of women gaining access in the near future,” said esi asare prah, who manages advocacy for the ghana office of msi, a reproductive health nonprofit.

 abhm america's black holocaust museum bringing our history to light black americans find a racism respite through ‘blaxit’ connecting with nature to celebrate black history month revolutionary rhymes: celebrating community and culture through poetry under trump, conservatives reignite a battle over race and the constitution celebrate black history month with abhm in the footsteps of the enslaved black residents liken mississippi’s new court system to ‘modern day slavery’ these executive orders can hit black students the hardest today's news and culture by black and other reporters in the black and mainstream media. methods such as hormonal implants and injections are reaching remote areas, providing more discretion and autonomy. on a busy day at the kwapong health centre in rural ghana, beatrice nyamekye put contraceptive implants into the arms of a half dozen women, and gave eight or nine more a three month hormonal injection to prevent pregnancy. a few sought condoms or birth control pills, but most wanted something longer lasting. “they like the implants and injections best of all,” said ms. nyamekye, a community health nurse. “it frees them from worry, and it is private. they don’t have to even discuss it with a husband or a partner.” the bustle at the kwapong clinic is echoed all over ghana, and across much of sub saharan africa, where women have the world’s lowest rate of access to contraception: just 26 percent of women of reproductive age in the region are using a modern contraceptive method   something other than the rhythm or withdrawal methods   according to the united nations population fund, known as unfpa, which works on reproductive and maternal health. but that is changing as more women have been able to get methods that give them a fast, affordable and discreet boost of reproductive autonomy. over the past decade, the number of women in the region using modern contraception has nearly doubled to 66 million.