Access to contraception is crucial for improving global health outcomes, including reducing maternal mortality, optimizing birth spacing, and empowering women economically. Despite worldwide efforts, progress in addressing unmet contraceptive needs has been slow in many low-resource settings. Millions of women lack access due to supply-side barriers like poor accessibility to health facilities, low contraceptive method availability, and stockouts. In 2017, over 214 million women of reproductive age lacked adequate access. Stockouts likely contribute significantly to this, but the relationship between availability and use remains poorly understood. Existing evidence reveals wide variations in stockouts and method availability across countries and methods, influenced by diverse supply chain challenges and varying policy environments. Policy barriers hindering private sector participation in contraceptive provision are a significant factor. Stockouts and low availability limit contraceptive choices, forcing individuals to select methods that may not meet their needs or preferences, potentially leading to increased discontinuation. Measuring stockouts is crucial but challenging, as existing data sources like the Service Provision Assessment (SPA) of Demographic and Health Surveys (DHS) are limited in scope and frequency. Data on stockouts by method are scarce, and routine facility-level monitoring is uncommon. Furthermore, it's unclear whether stockouts result from supply chain breakdowns, increased demand, or both. The Performance Monitoring for Action (PMA) Agile Project offers a unique opportunity to address these knowledge gaps with its continuous data monitoring system, collecting quarterly data on family planning service delivery and consumption in urban areas.

The introduction adequately summarizes the existing literature, highlighting the global unmet need for contraception, the significant role of supply-side barriers, and the lack of comprehensive data on contraceptive stockouts. It cites several studies demonstrating the wide variation in contraceptive availability and stockouts across countries and the impact of policy environments on private sector participation. Key studies mentioned include those highlighting the socioeconomic and cultural influences on contraceptive use, the relationship between stockouts and contraceptive discontinuation, and the limitations of existing data sources such as SPA and DHS. The literature review effectively sets the stage for the research by identifying the critical knowledge gaps that the study aims to address.

This study used data from the Performance Monitoring for Action (PMA) Agile Project, a continuous data monitoring system collecting quarterly data on family planning service delivery and consumption through health facility surveys and client exit interviews. Data from Burkina Faso, the Democratic Republic of Congo (DRC), Kenya, Nigeria, and India (excluding Niger due to data unavailability) were included, covering November 2017 to December 2019. The sampling scheme employed a two-stage cluster sampling design, stratifying service delivery points (SDPs) by sector (public vs. private) and selecting facilities using probability proportional to size. A maximum sample of 220 SDPs was randomly selected from each site, with a census approach used in smaller areas. Data were collected by trained female enumerators using smartphone-powered questionnaires. The main measures were the provision and demand for specific modern contraceptive methods (MCMs), defined according to WHO guidelines (excluding methods like beads, foam/jelly, and sterilization due to infrequency or inapplicability of the stock measure). Contraceptive stockouts were defined as the temporary unavailability of one or more methods at facilities routinely providing them. Method availability measured the percentage of facilities offering a given method. Demand was assessed using facility logbooks, recording the number of family planning visits for each method. Couple-years of protection (CYP) was calculated using method distribution quantities and conversion factors to estimate the duration of contraceptive protection. Facility weights were constructed to account for the stratified sampling design, and weighted results were reported using Stata version 14.2 with the SVY command for design-based analyses.

The study revealed that the vast majority of SDPs offering family planning had at least one modern contraceptive method (MCM) in stock across all countries and quarters. However, stockout frequency varied significantly by method and sector (public vs. private). **Condoms:** Were more commonly distributed through public SDPs, with higher client volumes in public facilities. Stockout rates were low overall but varied geographically. **Emergency Contraception (EC):** Private sector distribution dominated in SSA countries, while in India, it was largely through the public sector. Availability and client volume varied substantially across countries. **Oral Pills:** Public sector distribution was higher in India, while in SSA countries, public SDPs generally had higher client volumes. Stockout rates varied considerably across countries. **Injectables:** Public SDPs generally had higher availability than private ones, with notable improvements in India. Stockout rates varied significantly, with higher rates in some public sectors. **Intrauterine Devices (IUDs):** Were offered at lower rates across all geographies, with higher availability in the public sector. Stockout rates were generally low but varied across countries and sectors. **Implants:** Showed lower overall availability, mostly through the public sector. Stockout rates were higher among public SDPs, with significant variations across quarters and countries. **Couple-Years of Protection (CYP):** Implants consistently contributed the highest percentage of CYPs among public SDPs (excluding India where they weren't offered). Emergency contraception contributed relatively few CYPs compared to other methods. IUDs and implants, despite lower availability and client volumes, contributed substantially to total CYPs. Geographic variations in CYP contributions were significant.

The findings highlight the interplay between contraceptive supply and demand. Public sector facilities generally offer a broader range of methods, reflecting findings from other studies. However, exceptions exist, such as the private sector's dominance in EC distribution in SSA and oral pills in Kenya. The study confirms previous research on the limited availability of LARCs (IUDs and implants) and their greater availability in the public sector. The high CYP contribution of LARCs, despite lower availability and client volumes, underscores their cost-effectiveness and effectiveness. The study acknowledges limitations in data on the reasons behind stockouts and emphasizes the need for context-specific approaches to addressing procurement challenges. The variations in contraceptive consumption and stockout rates necessitate flexible and cost-effective strategies to meet the unmet need. The success of the Informed Push Model (IPM) in other settings suggests its potential for reducing stockouts, particularly by addressing issues related to upfront payments for contraceptives. This study emphasizes the importance of supply-side measures in understanding contraceptive use patterns and advocates for further research on the relationship between procurement, supply chain management, and stockouts.

This study provides valuable insights into the dynamics of contraceptive supply and stockouts using quarterly data from the PMA Agile Project. The findings highlight variations in availability, stockout rates, and client volumes across countries, methods, and sectors. The consistently high contribution of LARCs to CYPs despite limitations in availability underscores their importance and the need for improved access. Future research should investigate the relationship between different contraceptive distribution models and stockout rates, considering country-specific contexts. Further exploration into the causes of stockouts and evaluation of alternative distribution models like IPM are needed to improve contraceptive access and ultimately meet family planning goals. The study's findings are particularly useful for informing monitoring efforts toward addressing unmet needs and preventing stockouts.

This study's descriptive nature limits causal inferences regarding stockouts. The small sample size of facilities in some public sectors (Burkina Faso and India) may affect generalizability. Combining different SDP types in analyses might mask variations in availability and client volume. Data accuracy from facility logbooks is uncertain. The study acknowledges sampling and non-sampling errors inherent in survey data. The study also doesn't account for external factors like strikes or programmatic changes affecting contraceptive availability.