Franciele Hellwig

Scopus Publications

Women's empowerment and life stage: Assessing intersectional differences in contraceptive method mix in sub-Saharan Africa
Franciele Hellwig, Yohannes Dibaba Wado, Cheikh M. Faye, Jennifer Requejo, Leontine Alkema, Rornald Muhumuza Kananura, Ties Boerma, Aluisio J.D. Barros
Contraception, 2026
OBJECTIVE: Women's empowerment positively impacts family planning in sub-Saharan Africa, but little is known about its relationship with contraceptive method mix. Considering that contraceptive needs vary across life stages, we aimed to explore the intersectional differences in contraceptive method mix according to age and level of empowerment in sub-Saharan Africa. STUDY DESIGN: We analyzed data from Demographic and Health Surveys conducted since 2015 across 28 countries in West & Central and Eastern & Southern Africa. Within each region, we calculated pooled estimates of demand for family planning satisfied by any method (DFPS) and contraceptive method mix, stratifying by women's age and empowerment level using the survey-based women's empowerment index (SWPER). RESULTS: Our sample included 138,374 married women of reproductive age. Across both regions, more empowered women achieved higher DFPS, especially those older than 19. Among adolescents, we found a substantial increase only in the decision-making domain. Injectables and implants dominated the method mix, but their shares dropped as empowerment increased. This trend appeared across all age groups and empowerment domains, with the largest declines observed for social independence. High-empowered women had a more diversified method mix, with adolescents and young women with increased use of condoms, pills, and fertility-awareness methods, while women over 34 relied more on IUDs and sterilization. CONCLUSION: Our findings reveal that age, empowerment, and contraceptive method mix intersect in diverse ways. Tailoring family planning policies and counseling while addressing empowerment drivers could enhance informed contraceptive choices and better meet women's reproductive health goals. IMPLICATIONS: The evidence generated in this study emphasizes the importance of designing family planning programs that address age-specific reproductive needs and empowerment-related barriers, providing insights to guide more tailored interventions in sub-Saharan Africa.
Deriving national and disaggregated estimates for the demand for family planning satisfied indicator from contraceptive prevalence using household health surveys
Leonardo Z. Ferreira, Franciele Hellwig, Natália P. Lima, Aluísio J. D. Barros
Reproductive Health, 2025
Background Demand for family planning satisfied (DFPS) is one of the core indicators for monitoring reproductive health. However, it involves a series of questions that are not always available in national health surveys, hindering the international comparability and tracking progress in those settings. This study updates an alternative method for calculating DFPS based on contraceptive prevalence (CPR) when direct estimation is not feasible. Methods Based on survey data from 1,099 subnational regions across 103 countries, we fitted least-squares regression models that predicts DFPS for both any contraceptive methods and modern methods. A fractional polynomial approach was employed to account for non-linear relationships. Model performance was assessed using a 5-fold cross-validation strategy, evaluating bias, mean absolute error and correlation. Results The models, using CPR and the difference between total and modern CPR as predictors, were able to explain over 97% of the variability of DFPS by any and modern contraceptives. Bias and the magnitude of the errors were around 0.1 in the cross-validated sample. Validating the results for other inequality dimensions beyond subnational region yielded even better metrics. Conclusions The predicted estimates proved to be a good approximation for DFPS in circumstances where direct estimation is not possible. This study confirms that modeling DFPS through contraceptive prevalence remains valid and extends its applicability to DFPS based on modern methods. Furthermore, the estimates were robust for varying inequality dimensions, allowing equity analyses to be performed when appropriate.
Influence of subnational contextual factors on demand for family planning satisfied by modern methods: a multilevel approach in 46 surveys from low- and middle-income countries
Natália P Lima, Cauane Blumenberg, Franciele Hellwig, Aluisio J D Barros, Fernando C Wehrmeister
BMJ Open, 2025
Objectives Understanding contextual drivers of family planning is crucial for designing effective, context-specific policies and programmes. This study aimed to assess (1) the extent to which province-level contextual factors are associated with both coverage and wealth-related inequalities in demand for family planning satisfied by modern methods (mDFPS) across provinces in low- and middle-income countries (LMICs), and (2) whether these factors influence mDFPS at women’s level. Design Observational study using multilevel modelling at both ecological and individual levels. Setting We analysed data from Demographic and Health Surveys between 2011 and 2022 in 46 LMICs. Participants Ecological analysis included 621 provinces. Individual-level analysis included 302 493 women aged 15–49 years, currently married or in union, and in need of contraception (unweighted). Primary and secondary outcome measures Demand for family planning satisfied by modern methods (mDFPS) and wealth-related inequalities in mDFPS, assessed using the slope index of inequality (SII) and the concentration index (CIX). Results In both income groups, at the province level, higher mean women’s schooling and greater proportion of employed women were positively associated with mDFPS coverage. In contrast, higher male-to-female educational attainment ratios were inversely associated with mDFPS. Provinces with higher means of women’s schooling also showed lower wealth-related inequalities in mDFPS. At the individual level, women residing in provinces with higher male-to-female educational attainment ratios were found to have lower odds of mDFPS, regardless of the income group. Additionally, the factors influencing individual women’s mDFPS varied depending on the income level of the country’s provinces. Conclusion Women’s empowerment and gender equality in education at the province level significantly influence family planning outcomes. Targeted interventions that address each region’s specific educational, economic and demographic contexts are crucial for improving coverage and reducing disparities in family planning services.
Women’s Empowerment and Gender-Related Factors Associated with Maternal Tetanus Protection in 39 Low- and Middle-Income Countries
Katherine Kirkby, Luisa Arroyave, Franciele Hellwig, M. Carolina Danovaro-Holliday, Nasir Yusuf, Shirin Heidari, Stephanie Shendale, Aluísio J. D. Barros, Ahmad Reza Hosseinpoor
Vaccines, 2025
Background: Tetanus is a vaccine-preventable disease, and therefore vaccination of women of reproductive age or during pregnancy is recommended alongside childhood tetanus vaccination. Gender-related factors related to social empowerment have been established as determinants of health service utilization; however, these social determinants have not yet been explored directly with tetanus vaccination. In response, the aim of this study was to assess overall and country-specific gender-related barriers to maternal tetanus vaccine coverage. Methods: We used data from Demographic and Health Surveys (DHS) in 39 countries implemented between 2013 and 2022. Women’s empowerment was measured through three domains of the Survey-based Women’s emPowERment index (SWPER), as well as other gender-related variables. To assess the association between measures of women’s empowerment and gender-related factors and maternal tetanus immunization coverage, we used multilevel logistic models with pooled data from the 39 countries to analyze overall patterns, and we used multivariable logistic regression for each country-specific dataset to analyze country-level associations. Results: There were notable variations in the factors associated with tetanus vaccination across countries. Overall, we observed that higher levels of women’s empowerment, as measured through social independence and decision-making autonomy using the SWPER index, were associated with higher odds of maternal tetanus protection, with adjusted odds ratios of 1.23 (95%CI: 1.10–1.37) and 1.20 (95%CI: 1.02–1.40), respectively. However, women’s empowerment related to attitude to violence was not. Higher household wealth was also associated with higher odds of maternal tetanus protection overall. Conclusions: Women’s empowerment can improve the uptake of maternal tetanus vaccine. Addressing gender-related barriers may enhance vaccination coverage and contribute to the elimination of maternal and neonatal tetanus as a public health problem. However, these barriers vary from country to country, necessitating country-specific investigations to formulate tailored recommendations.
The 2025 report of the Lancet Countdown to 2030 for women's, children's, and adolescents' health: tracking progress on health and nutrition
Agbessi Amouzou, Aluisio J D Barros, Jennifer Requejo, Cheikh Faye, Nadia Akseer, Eran Bendavid, Cauane Blumenberg, Josephine Borghi, Sama El Baz, Frederik Federspiel, Leonardo Z Ferreira, Elizabeth Hazel, Sam Heft-Neal, Franciele Hellwig, Li Liu, Abdoulaye Maïga, Melinda Munos, Catherine Pitt, Yusra Ribhi Shawar, Jeremy Shiffman, Yvonne Tam, Neff Walker, Pierre Akilimali, Leontine Alkema, Paoli Behanzin, Peter Binyaruka, Zulfiqar Bhutta, Andrea Blanchard, Hannah Blencowe, Ellen Bradley, Nouria Brikci, Beatriz Caicedo-Velásquez, Anthony Costello, Winfred Dotse-Gborgbortsi, Shams El Arifeen, Majid Ezzati, Lynn P Freedman, Michel Guillot, Claudia Hanson, Rebecca Heidkamp, Luis Huicho, Chimaraoke Izugbara, Safia S Jiwani, Caroline Kabiru, Helen Kiarie, Mary Kinney, Fati Kirakoya-Samadoulougou, Joy Lawn, Nyovani Madise, Gouda Roland Mesmer Mady, Bruno Masquelier, Dessalegn Melesse, Kristine Nilsen, Jamie Perin, Usha Ram, Marina Romanello, Ghada E Saad, Sudha Sharma, Estelle M Sidze, Paul Spiegel, Hannah Tappis, Andrew J Tatem, Marleen Temmerman, Cesar G Victora, Francisco Villavicencio, Yohannes Wado, Peter Waiswa, Jon Wakefield, Shelley Walton, Danzhen You, Mickey Chopra, Robert E Black, Ties Boerma
Lancet, 2025
Association between women’s empowerment and demand for family planning satisfied among Christians and Muslims in multireligious African countries
Franciele Hellwig, Yohannes Wado, Aluisio J D Barros
BMJ Global Health, 2024
BackgroundAlthough the levels of demand for family planning satisfied (DFPS) have increased in many countries, cultural norms remain a significant barrier in low- and middle-income countries. In the context of multireligious African countries, our objective was to investigate intersectional inequalities in DFPS by modern or traditional contraceptives according to religion and women’s empowerment.MethodsAnalyses were based on Demographic and Health Surveys carried out between 2010 and 2021 in African countries. Countries with at least 10% of Muslims and Christians were selected to analyse inequalities in family planning. The religious groups were characterised by wealth, area of residence, women’s age and women’s empowerment. The mean level of empowerment was estimated for each religious group, and multilevel Poisson regression was used to assess whether DFPS varied based on the level of women’s empowerment among Muslims and Christians.ResultsOur study sample of 14 countries comprised 35% of Muslim and 61% of Christian women. Christians had higher levels of empowerment across all three domains compared with Muslims and women with no/other religion. DFPS was also higher among Christians (57%) than among Muslims (36%). Pooled analysis indicated a consistent association between DFPS and women’s empowerment, with higher prevalence ratios among Muslims than Christians, especially in the decision-making domain.ConclusionsThe gap between Muslims and Christians in DFPS significantly reduced as the level of empowerment increased. It highlights the importance of understanding and addressing cultural factors sensibly and respectfully to satisfy the demand for family planning services.
Policies for expanding family planning coverage: lessons from five successful countries
Franciele Hellwig, Laísa Rodrigues Moreira, Mariângela F. Silveira, Carolina Sales Vieira, Paulina Belén Rios-Quituizaca, Marcela Masabanda, Joel Serucaca, Silas Rudasingwa, Alypio Nyandwi, Shegaw Mulu, Hoda Rashad, Aluísio J. D. Barros
Frontiers in Public Health, 2024
BackgroundEnhancing the design of family planning interventions is crucial for promoting gender equality and improving maternal and child health outcomes. We identified, critically appraised, and synthesized policies and strategies from five selected countries that successfully increased family planning coverage.MethodsWe conducted a policy analysis through a scoping review and document search, focusing on documents published from 1950 to 2023 that examined or assessed policies aimed at enhancing family planning coverage in Brazil, Ecuador, Egypt, Ethiopia, and Rwanda. A search was conducted through PubMed, SCOPUS, and Web of Science. Government documents and conference proceedings were also critically analyzed. National health surveys were analyzed to estimate time trends in demand for family planning satisfied by modern methods (mDFPS) at the national level and by wealth. Changes in the method mix were also assessed. The findings of the studies were presented in a narrative synthesis.FindingsWe selected 231 studies, in which 196 policies were identified. All countries started to endorse family planning in the 1960s, with the number of identified policies ranging between 21 in Ecuador and 52 in Ethiopia. Most of the policies exclusively targeted women and were related to supplying contraceptives and enhancing the quality of the services. Little focus was found on monitoring and evaluation of the policies implemented.ConclusionAmong the five selected countries, a multitude of actions were happening simultaneously, each with its own vigor and enthusiasm. Our findings highlight that these five countries were successful in increasing family planning coverage by implementing broader multi-sectoral policies and considering the diverse needs of the population, as well as the specific contextual factors at play. Successful policies require a nuanced consideration of how these policies align with each culture’s framework, recognizing that both sociocultural norms and the impact of past public policies shape the current state of family planning.
The role of gender inequality and health expenditure on the coverage of demand for family planning satisfied by modern contraceptives: a multilevel analysis of cross-sectional studies in 14 LAC countries
Laísa Rodrigues Moreira, Cauane Blumenberg, Beatriz Elena Caicedo Velasquez, Fernanda Ewerling, Alejandra Balandrán, Luis Paulo Vidaletti, Andrea Ramirez Varela, Franciele Hellwig, Rodolfo Gomez Ponce de Leon, Aluisio J.D. Barros, Mariangela Freitas Silveira, Fernando C. Wehrmeister
Lancet Regional Health Americas, 2023
Background: Despite international efforts to improve reproductive health indicators, little attention is paid to the contributions of contextual factors to modern contraceptive coverage, especially in the Latin America and the Caribbean (LAC) region. This study aimed to identify the association between country-level Gender Inequality and Health Expenditure with demand for family planning satisfied by modern contraceptive methods (DFPSm) in Latin American sexually active women. Methods: Our analyses included data from the most recent (post-2010) Demographic and Health Survey or Multiple Indicator Cluster Survey from 14 LAC countries. Descriptive analyses and multilevel logistic regressions were performed. Six individual-level factors were included. The effect of the country-level factors Gender Inequality Index (GII) and Current Health Expenditure on DFPSm was investigated. Findings: DFPSm ranged from 41.8% (95% CI: 40.2-43.5) in Haiti to 85.6% (95% CI: 84.9-86.3) in Colombia, with an overall median coverage of 77.8%. A direct association between the odds of DFPSm and woman's education, wealth index, and the number of children was identified. Women from countries in the highest GII tertile were less likely (OR: 0.32, 95% CI: 0.13-0.76) to have DFPSm than those living in countries in the lowest tertile. Interpretation: Understanding the contribution of country-level factors to modern contraception may allow macro-level actions focused on the population's reproductive needs. In this sense, country-level gender inequalities play an important role, as well as individual factors such as wealth and education. Funding: Bill and Melinda Gates Foundation and Associação Brasileira de Saúde Coletiva (ABRASCO).
What are the sources of contraceptives for married and unmarried adolescents: Health services or friends? Analysis of 59 low- and middle-income countries
Franciele Hellwig, Aluísio J. D. Barros
Frontiers in Public Health, 2023
BackgroundDespite the efforts to promote universal coverage for family planning, inequalities are still high in several countries. Our aim was to identify which sources of contraceptives women mostly rely on in low- and middle-income countries (LMICs). We also explored the different sources according to age and marital status.MethodsWe used data from national health surveys carried out in 59 LMICs since 2010. Among all sexually active women at reproductive age, we explored inequalities in demand for family planning satisfied by modern methods (mDFPS) and in the source of modern contraceptives according to women's age, classified as: 15–19, 20–34, or 35–49 years of age. Among adolescents, mDFPS and source of method were explored by marital status, classified as married or in union and not married nor in a union.ResultsmDFPS was lower among adolescents than among adult women in 28 of the 59 countries. The lowest levels of mDFPS among adolescents were identified in Albania (6.1%) and Chad (8.2%). According to adolescents' marital status, the pattern of inequalities in mDFPS varied widely between regions, with married and unmarried adolescents showing similar levels of coverage in Latin America and the Caribbean, higher coverage among unmarried adolescents in Africa, and lower coverage among unmarried adolescents in Asia. Public and private health services were the main sources, with a lower share of the public sector among adolescents in almost all countries. The proportion of adolescents who obtained their contraceptives in the public sector was lower among unmarried girls than married ones in 31 of the 38 countries with data. Friends or relatives were a more significant source of contraceptives among unmarried compared to married adolescents in all regions.ConclusionsOur findings indicate lower levels of mDFPS and lower use of the public sector by adolescents, especially unmarried girls. More attention is needed to provide high-quality and affordable family planning services for adolescents, especially for those who are not married.
Learning from success cases: Ecological analysis of potential pathways to universal access to family planning care in low- and middle-income countries.
Franciele Hellwig, Aluisio JD Barros
Gates Open Research, 2023
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 an 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 disadvantaged groups. Conclusions Family planning coverage increased along with reductions in poverty and gender inequality, with substantial increases in coverage among the most disadvantaged 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.
Women’s marital status and use of family planning services across male and female-headed households in low and middle-income countries
Franciele Hellwig, Ghada E Saad, Andrea Wendt, Aluísio JD Barros
Journal of Global Health, 2023
Measures of women's empowerment based on individual-level data: a literature review with a focus on the methodological approaches
Janaína Calu Costa, Ghada E. Saad, Franciele Hellwig, Maria Fatima S. Maia, Aluísio J. D. Barros
Frontiers in Sociology, 2023
Birth registration coverage according to the sex of the head of household: an analysis of national surveys from 93 low- and middle-income countries
Andrea Wendt, Franciele Hellwig, Ghada E Saad, Cheikh Faye, Ties Boerma, Aluisio J D Barros, Cesar G Victora
BMC Public Health, 2022
The role of female permanent contraception in meeting the demand for family planning in low- and middle-income countries
Franciele Hellwig, Fernanda Ewerling, Carolina V.N. Coll, Aluísio J.D. Barros
Contraception, 2022
Women’s Empowerment as It Relates to Attitudes Towards and Practice of Female Genital Mutilation/Cutting of Daughters: An Ecological Analysis of Demographic and Health Surveys From 12 African Countries
Carolina V. N. Coll, Thiago M. Santos, Andrea Wendt, Franciele Hellwig, Fernanda Ewerling, Aluisio J. D. Barros
Frontiers in Sociology, 2022
Paving the way to understanding female-headed households: Variation in household composition across 103 low-and middle-income countries
Ghada E Saad, Hala Ghattas, Andrea Wendt, Franciele Hellwig, Jocelyn DeJong, Ties Boerma, Cesar Victora, Aluisio JD Barros
Journal of Global Health, 2022
Potential of LARC to recover loss in satisfied demand for modern contraception after the COVID-19 pandemic: a case scenario analysis of Brazil and Mexico
Rodolfo Gómez Ponce de Leon, Maria Valeria Bahamondes, Franciele Hellwig, Aluísio Barros, Luis Bahamondes, Federico Tobar, Mariangela Freitas da Silveira, Moazzam Ali, Pio Iván Gómez-Sánchez, Jason Bremner, Martyn Smith, Suzanne J. Serruya
Revista Panamericana De Salud Publica Pan American Journal of Public Health, 2022
Are children in female-headed households at a disadvantage? An analysis of immunization coverage and stunting prevalence: in 95 low- and middle-income countries
Andrea Wendt, Franciele Hellwig, Ghada E. Saad, Cheikh Faye, Zitha Mokomane, Ties Boerma, Aluisio J.D. Barros, Cesar Victora
Ssm Population Health, 2021
Assessing Wealth-Related Inequalities in Demand for Family Planning Satisfied in 43 African Countries
Franciele Hellwig, Carolina V. N. Coll, Cauane Blumenberg, Fernanda Ewerling, Caroline W. Kabiru, Aluisio J. D. Barros
Frontiers in Global Women S Health, 2021
Prevalence and inequalities in contraceptive use among adolescents and young women: Data from a birth cohort in Brazil
Adriana Kramer Fiala Machado, Débora Dalmas Gräf, Fabiane Höfs, Franciele Hellwig, Karoline Sampaio Barros, Laísa Rodrigues Moreira, Pedro Augusto Crespo, Mariângela Freitas Silveira
Cadernos De Saude Publica, 2021
SWPER Global: A survey-based women's empowerment index expanded from Africa to all low- and middle-income countries
Fernanda Ewerling, Anita Raj, Cesar G Victora, Franciele Hellwig, Carolina VN Coll, Aluisio JD Barros
Journal of Global Health, 2020
Socio-demographic and economic inequalities in modern contraception in 11 low- And middle-income countries: An analysis of the PMA2020 surveys
Cauane Blumenberg, Franciele Hellwig, Fernanda Ewerling, Aluísio J. D. Barros
Reproductive Health, 2020
Does women's age matter in the SDGs era: Coverage of demand for family planning satisfied with modern methods and institutional delivery in 91 low- And middle-income countries
Inacio Crochemore M. da Silva, Fernanda Everling, Franciele Hellwig, Carine Ronsmans, Lenka Benova, Jennifer Requejo, Anita Raj, Aluisio J. D. Barros, Cesar G. Victora
Reproductive Health, 2020
Intimate partner violence in 46 low-income and middle-income countries: An appraisal of the most vulnerable groups of women using national health surveys
Carolina V N Coll, Fernanda Ewerling, Claudia García-Moreno, Franciele Hellwig, Aluisio J D Barros
BMJ Global Health, 2020
Contraception in adolescence: The influence of parity and marital status on contraceptive use in 73 low-and middle-income countries
Carolina de Vargas Nunes Coll, Fernanda Ewerling, Franciele Hellwig, Aluísio Jardim Dornellas de Barros
Reproductive Health, 2019
Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: prevalence and inequalities in 23 countries
Rodolfo Gomez Ponce de Leon, Fernanda Ewerling, Suzanne Jacob Serruya, Mariangela F Silveira, Antonio Sanhueza, Ali Moazzam, Francisco Becerra-Posada, Carolina V N Coll, Franciele Hellwig, Cesar G Victora, Aluisio J D Barros
Lancet Global Health, 2019
Time trends in demand for family planning satisfied: Analysis of 73 countries using national health surveys over a 24-year period
Franciele Hellwig, Carolina VN Coll, Fernanda Ewerling, Aluisio JD Barros
Journal of Global Health, 2019
Persistent Inequalities in Reproductive, Maternal, Newborn, Child, and Adolescent Health in Kenya
Aluísio J. D. Barros, Fernanda Ewerling, Franciele Hellwig
JAMA Network Open, 2018
Demand for family planning satisfied with modern methods among sexually active women in low- and middle-income countries: Who is lagging behind?
Fernanda Ewerling, Cesar G. Victora, Anita Raj, Carolina V. N. Coll, Franciele Hellwig, Aluisio J. D. Barros
Reproductive Health, 2018
Measurement of social inequalities in health: concepts and methodological approaches in the Brazilian context
Inácio Crochemore Mohnsam da Silva, Maria Clara Restarepo-Mendez, Janaína Calu Costa, Fernanda Ewerling, Franciele Hellwig, Leonardo Zanini Ferreira, Luis Paulo Vidaletti Ruas, Gary Joseph, Aluísio J. D. Barros
Epidemiologia E Servicos De Saude Revista do Sistema Unico De Saude do Brasil, 2018
The sociodemographic, behavioral, reproductive, and health factors associated with fertility in Brazil
Cesar Augusto Oviedo Tejada, Lívia Madeira Triaca, Flávia Katrein da Costa, Franciele Hellwig
Plos One, 2017

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