Comment
The CRIMSON trial10 assessed a contrasting and compulsory admissions, but, with the apparent failure of
less contentious strategy for reducing compulsory
admissions, this time through joint crisis plans, intended
as a means of engaging patients and professionals in
active joint planning for future crises. An exploratory
trial raised hopes with a signicant nding of reduced
compulsory admissions.15 Unfortunately, this result
was not replicated in the subsequent multicentre trial.
Chance could explain the earlier nding, but the authors
make a persuasive case from the studys qualitative
component that patchy implementation and lack of
real commitment are more likely culprits. Indeed, one
meeting between patients and professionals is unlikely
to be sucient to counteract a culture of professional
dominance in decision making where this prevails.
These two excellent papers provide no clear means
of turning back the slowly rising tide of compulsory
admissions. Regarding future strategies, the door
remains open for further attempts to reduce compulsory
admissions by engaging service users more eectively
in decisions about their care. However, widespread
implementation might require a substantial cultural
shift in relationships between patients and professionals.
An important question is whether the long-established
but little evaluated UK Care Programme Approach is
really a useful framework for fostering greater equality
and collaboration between service users and sta. More
engaging and acceptable continuing community care,
as seems to be provided by Early Intervention Services,3
might in itself reduce compulsory admissions, and could
also be a fruitful context for joint crisis plans. Making
inpatient environments less aversive and improving the
quality of sta-patient alliances in this setting could also
result in less need for compulsory admissions. We do
not yet know whether changing relationships between
sta and patients can reverse the continuing rise in
The contraceptive revolution: focused eorts are still needed
Published Online In The Lancet, Leontine Alkema and colleagues1 illustrate
March 12, 2013
http://dx.doi.org/10.1016/
the usefulness of rigorous modelling to provide
S0140-6736(13)60588-7 convincing estimates of health indicators when empirical
See Articles page 1642 data are patchy or non-existent. Their report presents
by far the most complete country-specic information
about trends between 1990 and 2010, with projections
to 2015, in two key family planning indicators for married
1604
CTOs, we need to keep trying.
Sonia Johnson
Mental Health Sciences Unit, University College London,
London W1W 7EY, UK
s.johnson@ucl.ac.uk
I declare that I have no conicts of interest.
1 Keown P, Weich S, Bhui KS, Scott J. Association between provision of
mental illness beds and rate of involuntary admissions in the NHS in
England 19882008: ecological study. BMJ 2011; 343: d3736.
2 Wierdsma AI, Mulder CL. Does mental health service integration aect
compulsory admissions? Int J Integr Care 2009; 9: e90. http://www.ijic.org/
index.php/ijic/article/viewArticle/324/646 (accessed Feb 28, 2013).
3 Schizophrenia Commission. The abandoned illness. London:
The Schizophrenia Commission, 2012.
4 Jones J, Nolan P, Bowers L, et al. Psychiatric wards: places of safety?
J Psychiatr Ment Health Nurs 2010; 17: 12430.
5 Tew J, Ramon S, Slade M, Bird V, Melton J, Le Boutillier C. Social factors and
recovery from mental health diculties: a review of the evidence.
Br J Social Work 2012; 42: 44360.
6 Crawford V, Crome IB, Clancy C. Co-existing problems of mental health and
substance misuse (dual diagnosis): a literature review. Drugs Educ Prev Pol
2003; 10: 174.
7 Rowe R, Calnan M. Trust relations in health carethe new agenda.
Eur J Public Health 2006; 16: 46.
8 Johnson S, Nolan F, Pilling S, et al. Randomised controlled trial of acute
mental health care by a crisis resolution team: the north Islington crisis
study. BMJ 2005; 331: 599602.
9 Burns T, Rugksa J, Molodynski A, et al. Community treatment orders for
patients with psychosis (OCTET): a randomised controlled trial.
Lancet 2013; published online March 26. http://dx.doi.org/10.1016/S0140-
6736(13)60107-5.
10 Thornicroft G, Farrelly S, Szmukler G, et al. Clinical outcomes of Joint Crisis
Plans to reduce compulsory treatment for people with psychosis:
a randomised controlled trial. Lancet 2013; published online March 26.
http://dx.doi.org/10.1016/S0140-6736(13)60105-1.
11 Rugksa J, Burns T. Community treatment orders. Psychiatry 2009 8: 49395.
12 Kisely SR, Campbell LA, Preston NJ. Compulsory community and
involuntary outpatient treatment for people with severe mental disorders.
Cochrane Database Syst Rev 2011; 2: CD004408.
13 Health and Social Care Information Centre (Government Statistical Service).
Inpatients formally detained in hospitals under the Mental Health Act 1983,
and patients subject to supervised community treatment, Annual gures,
England, 2011/12. https://catalogue.ic.nhs.uk/publications/mental-health/
legislation/inp-det-m-h-a-1983-sup-com-eng-11-12/inp-det-m-h-a-1983-
sup-com-eng-11-12-rep.pdf (accessed Feb 28, 2013).
14 Khurmi S, Curtice M. The supervised community treatment order and the
Human Rights Act 1998. Adv Psychiatr Treat 2010; 16: 26371.
15 Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, Szmukler G.
Eect of joint crisis plans on use of compulsory treatment in psychiatry:
single blind randomised controlled trial. BMJ 2004; 329: 136.
or cohabiting women: use of any contraceptive method
(contraceptive prevalence) and non-use in women who
want to avoid childbearing for at least 2 years (unmet
need). Worldwide, contraceptive prevalence increased
during this 20-year period from 55% to 63%, and
unmet need decreased from 15% to 12%, but glaring
disparities between countries remain. For example, in
www.thelancet.com Vol 381 May 11, 2013
 Comment

2010, contraceptive prevalence was less than 20% in Traditional methods Other modern methods
Male condom Intrauterine device Injectable or implant
23 countries (all in Africa) and unmet need exceeded Pill Sterilisation
30% in 12 African countries and three in other regions. 100
These estimates support the call at the 2012 London 90

Summit on Family Planning for a focused eort to bring 80

Contraceptive users (%)

70
contraception to people in countries where its use is still
60
conned to a minority.2
50
These two indicators respond to dierent agendas
40
but are complementary. Contraceptive prevalence is the 30
main determinant of fertility; typically, an increase of 20
1517 percentage points in prevalence reduces fertility 10
(and thus population growth) by one birth per woman.3 0

08

04

07

04

02

8
In the past 50 years, most governments in developing
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countries have enacted policies to reduce population

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growth through promotion of family planning as a part
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of development. However, in contrast to demographic
targets for death reduction, targets for birth reduction
have proved controversial because of concerns that
couples might be pressured or even coerced into use
of contraception.
By responding to the human rights agenda of repro-
ductive choice, unmet need avoids these concerns.
From its origins in the knowledge, attitude, and
practice of family planning (KAP) surveys of the 1960s,
which rst identied the disjuncture between family
size preferences and contraceptive use (the KAP gap),
its measurement has been rened.4,5 Unmet need
has become a central rationale for donor support
and advocacy and a crucial guide for interventions,
culminating in its addition in 2007 as one of the
indicators to monitor progress in target 5b of the
Millennium Development Goals to achieve, by 2015,
universal access to reproductive health.
Fortunately, although the fertility reduction and
reproductive rights agendas dier in principle, they are
mutually reinforcing.6 The historic mandate of family
planning programmes has been to reduce unmet
need through a decrease in the costs (broadly dened)
of contraception, and reduction in unmet need is
responsible for most of the increase in contraceptive use
in the past few decades.7 Countries with high fertility
rates also record high unmet need.
By 1990, contraceptive use was high and unmet need
low not only in developed countries but also in Latin
America and much of Asia. Thus, the main interest lies in
the straggler areas: southern and western Asia and Africa.
Progress since 1990 has been variable. Notable increases
Zi
So
Figure: Percentage of contraceptive users, by type of method used, in
married or in-union women
in prevalence and substantial falls in unmet need have
occurred in western and southern Asia and in northern
and southern Africa, but the most marked increase in
use, from 12% to 33%, has taken place in eastern Africa,
largely because of greater government commitment and
improved community-based services.8 However, unmet
need in this subregion has decreased only modestly, from
30% in 1990 to 26% in 2010, indicating that increased
need, stemming from sharp reductions in desired
numbers of children, has almost matched increased use.9
By contrast, progress in western and central Africa has
been poor. Nigeria, the most populated country in sub-
Saharan Africa, is typical. Contraceptive prevalence has
risen from 7% to only 14% in 20 years and unmet need
has remained static at 21%.1 Of greatest concern are the
Sahelian countries of Chad, Mali, Mauritania, and Niger,
where the combined population is projected to increase
threefold, from 456 million in 2010 to 1319 million in
2050,10 which presents an impossible burden for fragile
ecosystems.
An estimated 146 million married women had an
unmet need in 2010.1 Knowledge of methods and access
to services are inadequate in some countries, but these
are not the main reasons for the persistence of unmet
need in most settings. In western and central Africa,
ambivalence or even hostility towards contraception
is a serious obstacle, but concerns about the perceived
adverse health eects of particular methods are a more
widespread problem.11

www.thelancet.com Vol 381 May 11, 2013 1605

 Comment
Expansion of services, especially in the form of
community-based provision in rural Africa, is a priority,
but equally important is the need to address social
obstacles and health concerns through mass media and
focused eorts to engage the support of religious and
community leaders.
An important but neglected contributor to unmet
need is the narrow range of methods used in many
high-prevalence and low-prevalence countries
(gure).12 For example, in India, female sterilisation
accounts for two-thirds of all contraceptive use and
eective reversible methods are rare. An unfortunate
consequence is that the prevalence of short inter-birth
intervals, which pose a threat to infant health and
survival, has remained unchanged in the past 20 years.13
Conversely, in neighbouring Bangladesh, where most
women use pills or injectable contraceptives, a pressing
need exists for greater use of long-acting methods, such
as intrauterine devices or sterilisation. In Bangladesh,
most women have achieved their desired family size by
25 years of age.14
In sub-Saharan Africa, pills and injectables also dom-
inate contraceptive use. Discontinuation of these two
methods is common. Typically between 20% and 30%
of women stop use within 1 year of starting because
of side-eects or health concerns.15 In this region,
an increasing proportion of unmet need stems from
women who have unsuccessfully tried one or both of
these two methods, but do not have alternative options.
This trend emphasises the potentially huge benet that
could be achieved by increasing the range of methods
available to, and used by, women, thereby better meet-
ing their reproductive rights and needs. The success of
eorts to increase contraceptive use and reduce unmet
Annual Report of the Chief Medical Ocer: infection and the
rise of antimicrobial resistance
Published Online The second of the two volumes of the Chief Medical
March 11, 2013
Ocer for Englands Annual Report on the state of the
http://dx.doi.org/10.1016/
S0140-6736(13)60604-2 publics health is released this week.1 The report includes
recommendations aimed specically at politicians and
highlights the need for strong action on antimicrobial
resistance, since this issue has the potential to be as
important as global warming in terms of its impact on
1606
need can now be monitored by regular updates of the
modelling devised by Alkema and colleagues.
*John Cleland, Iqbal H Shah
Department of Population Health, London School of Hygiene
and Tropical Medicine, University of London, London WC1E 7HT,
UK (JC); and The Susan Thompson Buett Foundation, Omaha,
NE, USA (IHS)
john.cleland@lshtm.ac.uk
We declare that we have no conicts of interest.
1 Alkema L, Kantorova V, Menozzi C, Biddlecom A. National, regional, and
global rates and trends in contraceptive prevalence and unmet need for
family planning between 1990 and 2015: a systematic and comprehensive
analysis. Lancet 2013; published online March 12. http://dx.doi.
org/10.1016/S0140-6736(12)62204-1.
2 Carr B, Gates MF, Mitchell A, Shah R. Giving women the power to plan their
families. Lancet 2012; 380: 8082.
3 Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and
health. Lancet 2012; 380: 14956.
4 Westo CF. The unmet need for birth control in ve Asian countries.
Fam Plann Perspec 1978; 10: 17381.
5 Bradley SEK, Croft TN, Fishel JD, Westo CF. Revising unmet need for family
planning. DHS analytical studies no 25. Calverton: ICF International, 2012.
6 Casterline JB, Sinding SW. Unmet need for family planning in developing
countries and implications for population policy. Popul Dev Rev 2000;
26: 691723.
7 Feyisetan B, Casterline JB. Fertility preferences and contraceptive change in
developing countries. Int Fam Plann Perspect 2000; 26: 10009.
8 USAID. Three successful sub-Saharan Africa family planning programs:
lessons for meeting the MDGs. Washington, DC: USAID Africa Bureau, 2012.
9 Westo CF, Bankole A. Reproductive preferences in developing countries at
the turn of the century. DHS comparative reports no 2. Calverton:
ORC Macro, 2002.
10 United Nations Population Division. World population prospects: the 2010
revision. http://esa.un.org/unpd/wpp/index.htm (accessed Feb 18, 2013).
11 Bongaarts J, Bruce J. The causes of unmet need for contraception and the
social context of services. Stud Fam Plann 1995; 26: 5775.
12 United Nations Population Division. World contraceptive use 2011.
New York: United Nations Population Division, 2012.
13 Rutstein SO. Trends in birth spacing. DHS comparative reports no 28.
Calverton: ICF Macro, 2011.
14 Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh:
National Institute of Population Research and Training/Mitra and
Associates; Calverton: ICF Macro, 2012.
15 Ali MM, Cleland J, Shah IH. Causes and consequences of contraceptive
discontinuation: evidence from 60 demographic and health surveys.
Geneva: World Health Organization, 2012.
health. The report identies antimicrobial resistance as
a cross-societal and therefore cross-governmental issue
that encompasses both a market failure to produce
new antibiotics and the need for better antibiotic
stewardship. A key recommendation of the report is
that resistance should be placed on the UK national
risk register (specically, the National Security Risk
www.thelancet.com Vol 381 May 11, 2013