Influence of subnational contextual factors on demand for family planning satisfied by modern methods: a multilevel approach in 46 surveys from low- and middle-income countries

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OBJECTIVES: Understanding contextual drivers of family planning is crucial for designing effective, context-specific policies and programmes. This study aimed to assess (1) the extent to which province-level contextual factors are associated with both coverage and wealth-related inequalities in demand for family planning satisfied by modern methods (mDFPS) across provinces in low- and middle-income countries (LMICs), and (2) whether these factors influence mDFPS at women's level. DESIGN: Observational study using multilevel modelling at both ecological and individual levels. SETTING: We analysed data from Demographic and Health Surveys between 2011 and 2022 in 46 LMICs. PARTICIPANTS: Ecological analysis included 621 provinces. Individual-level analysis included 302 493 women aged 15-49 years, currently married or in union, and in need of contraception (unweighted). PRIMARY AND SECONDARY OUTCOME MEASURES: Demand for family planning satisfied by modern methods (mDFPS) and wealth-related inequalities in mDFPS, assessed using the slope index of inequality (SII) and the concentration index (CIX). RESULTS: In both income groups, at the province level, higher mean women's schooling and greater proportion of employed women were positively associated with mDFPS coverage. In contrast, higher male-to-female educational attainment ratios were inversely associated with mDFPS. Provinces with higher means of women's schooling also showed lower wealth-related inequalities in mDFPS. At the individual level, women residing in provinces with higher male-to-female educational attainment ratios were found to have lower odds of mDFPS, regardless of the income group. Additionally, the factors influencing individual women's mDFPS varied depending on the income level of the country's provinces. CONCLUSION: Women's empowerment and gender equality in education at the province level significantly influence family planning outcomes. Targeted interventions that address each region's specific educational, economic and demographic contexts are crucial for improving coverage and reducing disparities in family planning services.