title: Contraceptive availability leads to increase in use in conflict-affected Democratic Republic of the Congo: evidence from cross-sectional cluster surveys, facility assessments and service statistics.
abstract: BACKGROUND
  Humanitarian assistance standards mandate specific attention to address the sexual and reproductive health (SRH) needs of conflict-affected populations. Despite these internationally recognised standards, access to SRH services is still often compromised in conflict settings. CARE in collaboration with the RAISE Initiative strengthened the Ministry of Health (MOH) to provide contraceptive services in Maniema province, Democratic Republic of the Congo. This study evaluated the effectiveness of this support for MOH health facility provision of contraception.
  
  
  METHODS
  Cross-sectional surveys in 2008 (n= 607) and 2010 (n= 575) of women of reproductive age using a two-stage cluster sampling design were conducted in Kasongo health zone. Facility assessments were conducted to assess the capacity of supported government health facilities to provide contraceptive services in 2007 and 2010. Data on the numbers of clients who started a contraceptive method were also collected monthly from supported facilities for 2008-2014.
  
  
  RESULTS
  Current use of any modern contraceptive method doubled from 3.1 to 5.9% (adjusted OR 2.03 [95%CI 1.3-3.2]). Current use of long-acting and permanent methods (LAPM) increased from 0 to 1.7% (p< .001), an increase that was no longer significant after adjustment. All current users except a few condom users reported a health facility as the source of the method. The 2010 facility assessments found that most supported facilities had the capacity to provide short-acting and long-acting methods. Service statistics indicated that the percentage of clients who accepted a long-acting method at supported facilities increased from 8% in 2008 to 83% in 2014 (p< .001).
  
  
  CONCLUSIONS
  This study demonstrated that contraceptive prevalence doubled between 2008 and 2010; service statistics indicate that utilization of long-acting methods continued to increase to a majority of new clients after 2010. Strengthening the health system to provide contraceptive services enabled individuals to exercise their right to prevent unintended pregnancies. These results suggest that demand for contraception, including long-acting methods, is present even in humanitarian settings, and that women will use them when they are available and of reasonable quality. It is critical that the humanitarian community ensure that such services are available to women affected by crises.
authors.affiliation: RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY 10032 USA.
authors.forename: Sara E
authors.initials: SE
authors.lastname: Casey
authors.affiliation: SAF-PAC Project, CARE, 65, Av.de la corniche, Quartier les Volcans, Goma, Nord Kivu Democratic Republic of the Congo.
authors.forename: Martin
authors.initials: M
authors.lastname: Tshipamba
keywords: Contraception; Democratic Republic of the Congo; Humanitarian aid; Reproductive health; War