title: Contraceptive method skew and shifts in method mix in low- and middle-income countries.
abstract: BACKGROUND
  Method mix-the percentage distribution of contraceptive users in a given country, by method-is one measure that reflects the availability of a range of contraceptive methods. A skewed method mix-one in which 50% or more of contraceptive users rely on a single method-could be cause for concern as a sign of insufficiency of alternative methods or provider bias. Shifts in method mix are important to individual countries, donors and scholars studying contraceptive dynamics.
  
  
  METHODS
  To determine current patterns and recent changes in method mix, we examined 109 low- and middle-income countries. A variety of statistical methods were used to test four factors as correlates of skewed method mix: geographic region, family planning program effort index, modern contraceptive prevalence rate and human development index. An assessment of changes in reliance on female and male sterilization, the IUD, the implant and the injectable was conducted for countries with available data.
  
  
  RESULTS
  Of the 109 countries included in this analysis, 30% had a skewed method mix-a modest decrease from 35% in a 2006 analysis. Only geographic region showed any correlation with method skew, but it was only marginally significant. The proportion of users relying on female sterilization, male sterilization or the IUD decreased in far more countries than it increased; the pattern was reversed for the injectable.
  
  
  CONCLUSIONS
  Method mix skew is not a definitive indicator of lack of contraceptive choice or provider bias; it may instead reflect cultural preferences. In countries with a skewed method mix, investigation is warranted to identify the cause.
authors.affiliation: Professor and chair, Department of Global Health Systems and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA, bertrand@tulane.edu.
authors.forename: Jane T
authors.initials: JT
authors.lastname: Bertrand
authors.forename: Tara M
authors.initials: TM
authors.lastname: Sullivan
authors.forename: Ellen A
authors.initials: EA
authors.lastname: Knowles
authors.forename: Muhammad F
authors.initials: MF
authors.lastname: Zeeshan
authors.forename: James D
authors.initials: JD
authors.lastname: Shelton
mesh_terms: D000328:Adult; D001294:Attitude to Health; D003267:Contraception / Q000523:psychology / Q000706:statistics & numerical data*; D003268:Contraception Behavior / Q000706:statistics & numerical data*; D003906:Developing Countries / Q000706:statistics & numerical data*; D005260:Female; D006306:Health Surveys; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D008297:Male; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011203:Poverty / Q000706:statistics & numerical data; D060728:Reproductive Health / Q000706:statistics & numerical data*; D034121:Reproductive Health Services / Q000706:statistics & numerical data; D012725:Sexual Behavior / Q000706:statistics & numerical data*; D012923:Social Class; D012959:Socioeconomic Factors; D055815:Young Adult