Rethinking family planning success metrics: moving beyond coverage

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Over the past decades, the global discourse on reproduction has undergone a profound transformation. Early demographic debates were largely centered on reducing high fertility rates, with policy attention focused on population growth and its economic implications. This emphasis gradually shifted toward birth control, prioritizing the expansion of contraceptive methods to allow families to limit or space births to achieve better health and economic outcomes. More recently, the framework has evolved into a comprehensive sexual and reproductive health and rights approach that situates reproductive decision-making within a human rights paradigm, emphasizing bodily autonomy, gender equality, informed choice, and freedom from coercion. As a result, voluntary family planning has been included in several global agendas (1).In most low-and middle-income countries, substantial investments in family planning have expanded contraceptive availability, increased modern contraceptive prevalence, reduced unmet need, and reduced fertility rates. These gains reflect the success of sustained political commitment, strengthened supply chains, and integration into primary health care (1). However, expansion of access does not automatically translate into women's contraceptive autonomy (2). Prevailing metrics of success remain heavily centered on coverage, demographic, and cost-effectiveness lenses that may not reflect women's lived preferences (3)(4)(5)(6). The SDG indicator of demand for family planning satisfied offers a useful global benchmark, yet it tells only part of the story. It overlooks women's own perceived need or desire for contraception, and fails to assess whether the method chosen aligns with women's preferences, whether the decision was free from pressure or bias, or whether they received adequate counseling to make an informed choice (3). Similarly, indicators such as prevalence of contraceptive use and cost per couple-years of protection prioritize uptake and duration over women's choice, satisfaction, and autonomy. This emphasis risks obscuring method skew, provider bias, dissatisfaction with the method used, or discontinuation due to side effects not previously disclosed.The neglected signal: distorted method mixIn several countries, high levels of contraceptive use mask markedly distorted method mixes. One of these distortions is characterized by heavy reliance on female sterilization, often even among younger and lower-parity women (7). In India, for instance, more than 1 in 5 modern contraceptive users younger than 35 with no or only one child had already been sterilized (7) (Figure 1). When irreversible methods dominate, it raises concerns about the quality of counseling, the breadth of options meaningfully offered, and the extent to which informed choice is ensured. The choice for female sterilization is strongly influenced by the belief that it is more cost-effective than reversible methods, by the understanding that it has fewer side effects, and by gender norms that associate male sterilization with a threat to virility (8,9). Altogether, these explanations point to a problematic configuration in which apparent preference for female sterilization may not reflect genuine reproductive self-determination, but structural and normative constraints. Frequent stock-outs of reversible methods, combined with providers' limited training or skill in inserting and managing certain methods, can narrow the options actually available at the point of care. Restricted financial autonomy, limited mobility, and discriminatory gender norms further constrain women's ability to seek or negotiate the method of their choice.Notably, countries that experienced remarkable progress in family planning coverage have also implemented policies to diversify the contraceptive method mix and invested in provider training to ensure high-quality counseling and provision. However, such investments have been mostly focused on expanding access to implants and injectables (1). While this focus is fully aligned with a costeffectiveness approach, particularly in resource-constrained settings, it risks undermining investments that would uphold women's autonomy, equity, and informed choice. Such strategies may overlook experiential dimensions such as satisfaction, side effects, method switching, and the quality of counseling. As a result, policies guided primarily by economic efficiency may reinforce method skew and incentivize provider bias, which manifests through practices such as steering women toward specific methods regardless of their preferences, applying age-or parity-based restrictions, gatekeeping access to certain methods based on provider judgment rather than informed choice, and offering inadequate counseling about side effects and alternatives. These dynamics can deepen inequalities in access and advance coverage targets without necessarily strengthening reproductive rights.Evidence from several African countries illustrates how method mix is associated with the level of women's empowerment. While implants and injectables remain the most widely used methods in many settings, higher levels of women's empowerment are associated with a reduced reliance on these provider-controlled methods and increased use of options that allow greater bodily autonomy and fewer perceived health side effects (10). In Niger, for example, married women with higher social independence were approximately half as likely to rely on injectables and twice as likely to use the pill, while reliance on condoms was about three times higher than among less empowered women. Similarly, in Kenya, highly empowered women showed lower reliance on both implants and injectables and greater use of alternative methods. Compared with less empowered women, they were nearly three times more likely to use IUDs and the pill, and about 40% more likely to rely on fertility-awareness-based methods (Figure 1). Similar patterns are also seen in several sub-Saharan African countries (10). Thus, such shifts in method mix highlight both the transformative role of women's empowerment and the persistent limitations of family planning services in fully supporting autonomous and informed reproductive decision-making. Skewed method mixes do not, by themselves, prove constrained choice, as they may partly reflect genuine preferences. Yet when paired with provider bias, programmatic incentives, or restrictive gender norms, such skew is a useful signal of structural limitations within sexual and reproductive health services, revealing gaps in equity, information, and autonomy that coverage indicators alone fail to capture.Along with contraceptive uptake, we think of programmatic success in family planning as lower discontinuation rates. Contraceptive discontinuation is frequently framed as a sign of failure, often interpreted as a barrier to achieving sustained contraceptive use. The most protective factors for lower discontinuation are providing women with their preferred method and providing adequate counseling on potential side effects and how to deal with them (11). When the healthcare system cannot do it, it is indeed a strong signal of failure. However, this perspective overlooks the complex realities of contraceptive experiences. Dissatisfaction does not always translate into immediate discontinuation, and substantial dissatisfaction may coexist with continued use (12). Many women tolerate methods that do not fully meet their needs due to limited alternatives, inadequate counseling, or barriers to accessing services. In such constrained contexts, continuation alone cannot be assumed to reflect satisfaction or alignment with women's preferences.At the same time, discontinuation itself should not automatically be interpreted as a negative outcome. Discontinuation rates are usually used to measure how consistently women continue using a specific contraceptive method over time. Therefore, it includes situations where the user stop

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