Geographic level

Impact on CE estimate

Klau mentioned in our interview that Sayana Press is releasing a longer release version of the injection over 4-6 months (though that they may not decide to switch since, anecdotally, women may prefer the three-month version as it gives them the opportunity to travel and to feel part of the community, potentially even selling market products near the clinic)

"If used correctly, with no missed doses, Sayana Press® has a failure rate of around 1 woman in 100
per year. In practice it has a failure rate of 6 women in 100 per year."

See interview with Kaleigh, may be underestimated for rural areas

See "Contraceptive Discontinuation Rates and Method Switching (first 12 months)" for "Injectable" method; data from 2018 DHS in Nigeria
Celine said in our interview that there are a number of reasons why women might discontinue use, including financial circumstances and moving
Kaleigh MacDaniels assumed that this number would be higher in rural areas, where access and partner objections may encourage discontinuation.

When asked, Kaleigh MacDaniels responded that this adjustment would be "modest" (but "would have an impact" since "most women discontinue for reasons outside of access," including spousal opposition, side effects, and wanting to get pregnant. She suggested that higher rates of self-injection tend to improve continuation, which suggests access is still an important consideration.

Data on "Reasons you decided to use Sayana-Press" suggests that 47% (i.e. 8032 out of 16,972 from January-April of 2024) of those surveyed decided to use Sayana Press for birth spacing reasons. A healthy birth spacing interval is generally considered ~2 years. Since eight injections would provide protection for two years, and we assume the duration since last pregnancy will be approximately uniformly distributed over a two-year time period across women in the sample, we assume that on average 1/8 of women discontinue from quarter to quarter due to the desire to get pregnant.

Data on "Repeated Lafiya Nigeria users" suggests that 29% of those surveyed from January-April 2024 are repeated users, up from 26% in 2023.

Lafiya estimates about 160 Lafiya Sisters total by end of 2024

"Annual dropout rate of Lafiya Sisters from participating in the intervention" is 10% based on organizational experience

According to LN's dashboard, there were about 60 Lafiya Sisters in Q1 2024, and in the kickoff document LN shared in May 2024 they state that "...we currently have 104 Sisters and expect to scale to ~260 Sisters by the end of the year." We increase the number of trained Lafiya Sisters by 1.25 each quarter to calibrate the model to these data and estimates.

Between January to April 2024, Lafiya Sisters averaged between 47 and 48 visits per month.

Klau and Celine mentioned that there are 5-10 outreaches per month in our kickoff call, which we confirmed with them in our interview

Maryam said that "during community outreach activities about 30 women are met" while Klau and Celine suggested this number is closer to 50. We take the conservative estimate.

This metric only accounts for women who took LN's surveys, meaning that they had demand for contraceptives and received counseling from a Lafiya Sister

This input seems likely to increase as more women are reached in a given state (and Klau agreed in the interview, mentioning that the recent scaling makes it difficult to know where a metric like '% repeat users' will stabilize), though it could also decline if LN is successful in encouraging women to self-inject

Lafiya Nigeria Main Dashboard (May 2024), 'Apr 2024', cell I9

In the most recent month's surveys (April 2024), about 33% of women surveyed are repeat clients.

"Women need a new injection every 3 months, so the same woman might appear multiple times in our surveys. So women reached [does not equal] number of surveys."

According to LN's surveys in 2024, only 31.4% of respondents are new to contraception, though the question asked in Lafiya's surveys pertains to use of contraceptives any time prior to the survey (i.e. not necessarily at the time of the visit with the Lafiya Sister).

My understanding is that in 2024, out of 10,560 respondents (excluding those who only received counseling):
-3311 (31.4%) are first-time contraceptive users
-4248 (40.2%) had previously used a contraceptive method
-3001 (28.4%) used SP before

Since ~29% of respondents are 'repeated LN users', I assume that all of the 3001 (i.e. 28.4% of respondents) who had used SP before are repeated users and are therefore irrelevant in determining the percent of new adopters that are not using contraception. Therefore, the percent of adopters who are first-time contraception users becomes 3311/(3311+4248) or 3311/7579, and the percent of adopters who had used contraceptives previously is 4248/7579.

My main uncertainty is the extent to which 'switchers' were using a contraceptive method prior to switching to SP. So I think the lower bound is that 31.4% of new clients go from no contraceptive to SP, while some number of switchers were not on any contraceptive at the time of the visit, creating an upper bound of 31.4%+40.2% = 71.6%. Given the high rate of stockouts, it seems likely that the number is higher than 31.4%, though I am not sure by how much. The cell below allows for adjustment of this percentage, which can be used for uncertainty analysis until a data-supported approach becomes available.

% who have used contraceptives in their lifetime ("previous contraceptive users")

Kaleigh MacDaniels' best guess is that the number of current contraceptive users among women who had previously used contraceptives in their lifetime would be "really low," and she sent a paper (Adedini et al., 2023) analyzing DHS data that suggests that among LMICs, the modern contraceptive prevalence rate in Nigeria is relatively very low at 12% (2% in Sokoto State in the North West), and the discontinuation rate is relatively high at 41%. The discontinuation rate for all contraceptive methods in Nigeria is highest in the North West at 50.1% (see abstract).

adopters with unmet demand

Sense check: total doses distributed through April 2024 ~16K [for Q1+0.3Q2]; LN estimates 115K for 2024

Almost 16K doses distributed from January-April 2024

Nigeria-specific estimate from 2015-2019

"More than 6 out of 10 abortions were considered most unsafe..."

We use the Guttmacher Institute's recommendation (accounting for method use failure) for converting CYPs into unintended pregnancies averted: "...we make the following revised recommendations for applying Adding It Up findings to estimates of CYP: For CYPs calculated using USAID or other conversion factors that take method use-failure into account, use a ratio of 0.288 for estimating unintended pregnancies averted per CYP. For CYPs based on conversion factors that do not adjust for use-failure, use a ratio of 0.249. In either situation, use the same impact ratio across all developing world regions."

Users (adopters) * pregnancies with no method

child deaths averted per live birth averted

Unintended pregnancies averted x maternal deaths per unintended pregnancy

Possibly unreliable, see notes

Live births averted x PBI coefficient
"Note: this estimate may be unreliable because there is currently very limited data about the linkages between CPR, birth spacing and child mortality. This part of Impact 2 will be updated as improved research becomes available."

Pulled from LN's CEA

Pulled from LN's CEA

Pulled from LN's CEA

Costs to families (antenatal care, post-abortion care, delivery, complications + post-birth costs of raising a child)

Broader economic benefits (female workforce participation, educated electorates, etc.)