Learning from success cases: ecological analysis of pathways to universal access to reproductive health care in low- and middle-income countries.

Background  Universal access to family planning services is a well-recognized human right and several countries and organizations are committed to this goal. Our objective was to identify countries who improved family planning coverage in the last 40 years and investigate which contexts enabled those advances.  Methods  Analyses were based on data from publicly available national health surveys carried out since 1986 in Egypt, Ethiopia, Rwanda, Afghanistan, Brazil, and Ecuador, selected based on previous evidence. We estimated demand for family planning satisfied with modern methods (mDFPS) for each country and explored inequalities in terms of wealth, women's education, and women's age. We also explored contextual differences in terms of women's empowerment, percentage of population living in extreme poverty, and share of each type of contraceptive. To better understand political and sociocultural contexts, country case studies were included, based on literature review.  Results  Patterns of mDFPS increase were distinct in the selected countries. Current level of mDFPS coverage ranged between 94% in Brazil and 38% in Afghanistan. All countries experienced important reduction in both gender inequality and extreme poverty. According to the share of each type of contraceptive, most countries presented higher use of short-acting reversible methods. Exceptions were Ecuador, where the most used method is sterilization, and Egypt, which presented higher use of long-acting reversible methods. In the first years analyzed, all countries presented huge gaps in coverage according to wealth, women's education and women's age. All countries managed to increase coverage over recent years, especially among women from the more vulnerable groups.  Conclusions  Family planning coverage increased along with reductions in poverty and gender inequality, with substantial increases in coverage among the most vulnerable in recent years. Policies involving primary health care services, provision of various methods, and high quality training of health providers are crucial to increase coverage.