High fertility in sub-Saharan Africa

The role of male partners in modern contraceptive use by women in South Africa: Does space also matter?

This paper examined the role of male partners in modern contraceptive use by women across clusters in South Africa. Its main objective was threefold. First, the present paper sought to test whether South African married women’s modern contraceptive use is related to the influence of their husbands or male partners. Second, it examined whether modern contraceptive use is similar within clusters. Third, it tested whether group effects are spatially dependent among neighbouring clusters. It used the recent Demographic and Health Survey for South Africa as the data source to carry out the empirical analysis. On the one hand, the results confirm a positive and significant relationship between South African married women’s modern contraceptive use with their partners’ secondary education level, irrespective of the cluster in which they reside. On the other hand, the hypothesis that spatial dependence of random effects is not confirmed, leading to the conclusion that space only matters when it comes to spatial heterogeneity or group effects.

Contraceptive utilization and associated factors among polygamous and monogamous women in Worebabo Woreda, South Wollo Zone, Ethiopia: a comparative cross sectional study

BACKGROUND

In Ethiopia high population growth and unintended pregnancies are posing pressures where the economy is incapable of holding overpopulation. Despite this problem, utilization of modern contraception is low in rural areas of the country, especially in the areas where polygamy is common. Therefore, this study was conducted to assess contraceptive utilization and associated factors among polygamous and monogamous women in, Ethiopia.

METHOD

A community-based comparative cross-sectional and phenomenological study design was employed from July 1 to September 30, 2021, on the total sample size of 774 selected married women of the reproductive age group by using a multistage sampling method and a purposive sampling method were used for the qualitative part of the study. A pre-tested interview with a structured questionnaire was used to collect data and key informants were interviewed using semi-structured questionnaire. Associated factors were analyzed by using bivariable and multivariable binary logistic regression models. The odds ratio, with a 95% confidence level, was used to declare a statistically significant association.

RESULT

A total of 703 married women of the reproductive age groups were interviewed, yielding a 90.89% response rate; among these married women, 352 and 351 were in monogamous and polygamous relationships. The proportion of women who use modern contraceptives was 161 (45.7%) in monogamous relationship, and 151 (43.0%) in polygamous relationships. Overall, utilization of modern contraceptives was significantly associated with educational status (AOR = 2.143, CI:1.428-3.216), religion (AOR = 1.704, CI: 1.144-2.539), undesired fertility (AOR = 3.17,CI:1.939-5.183), who decides on the number of children (AOR = 3.054, CI:1.93-4.832), getting clear information by Health care provider (AOR = 4.624, CI:3.132-6.828), family pressure (AOR = 1.855, CI:1.351-2.75), fear of social stigma (AOR = 2.482, CI:1.666-3.699), and accepts myths about contraceptives (AOR = 1.878, CI:1.278-2.761).

CONCLUSION

This study identified that utilization of modern contraception was low in the study area. The district health office and concerned stakeholders should implement interventions that scale up contraceptive use, need family involvement in decision making, addressing myths around contraceptives, helping women to get education, and training of health care providers.

Fertility intention among married women in Ethiopia: a multilevel analysis of Ethiopian demographic health survey 2016

BACKGROUND

Fertility intention is the central aspect of countries which determine their population demography. Therefore, proportion and factors associated with fertility intention should be studied at different level of community for designing of appropriate policies, strategies, and programs. Despite its importance, information is scarce about proportion and predictors of fertility intention among women of reproductive age in Ethiopia, in 2016.

METHODS

A secondary data analysis was done on 2016 Ethiopian Demographic and Health Survey/EDHS/ in this study. A total of 1423 fecund, married, and sexually active women were included this study. Multilevel mixed-effect logistic regression model was done to show association between fertility desire and explanatory variables. Adjusted Odds Ratio with 95% Confidence Interval (CI) was computed to assess the strength and significance of association.

RESULTS

Prevalence of fertility intention was 63.5% (95%CI:62.2%,64.8%) in Ethiopia, in 2016. The response rate of this study was 100%. The odd of fertility desire was higher among women of age 20-34 years (AOR=2.5,95%CI:1.5,4.0), women of age 35-49 years (AOR= 9,95%CI:12.2,45.4), Muslim followers (AOR=5.4,95%CI:3.6,7.9), other religions followers (AOR= 1.8,95%CI:1.2,3.0), women who did not want to use modern contraceptive (AOR=3.1,95%CI:2.2,4.3). However, the likelihood of fertility intention was low among women who owned mobile phone (AOR=0.6,95%CI:0.4,0.87), and women with more than one partner (AOR=0.5,95%CI:0.41,0.8). At the community level factors like: Community education status (AOR= 1.67,95%CI:1.26,2.2) and region were factors strongly linked to fertility intention.

CONCLUSIONS

In this study, prevalence of fertility desire was higher compared to other countries. Participants age, religion, intention to use modern contraceptive, own mobile, and having multiple partners were individual factors associated with fertility preference. Furthermore, educational status and region were community factor associated significantly with intention of fertility. Hence, expansion of mobile networking and family planning messages through mobile. Furthermore, religious teaching should be enhanced to control family size among followers. Finally, the Ethiopian government should also work strongly to improve community education.

Factors associated with modern contraceptive use among men in Pakistan: Evidence from Pakistan demographic and health survey 2017-18

Objective

The role of men in family planning is critical in patriarchal societies like Pakistan. The objective of this study is to explore the predictors of modern contraceptive use among Pakistani men.

Methods

This study is a secondary analysis of Pakistan demographic and health survey (PDHS) 2017–18 data. The study sample consists of 3691 ever married men aged 15–49 years. Pearson’s chi square test and logistic regression were used to find out the determinants of modern contraceptive use among men. Data analysis was carried out in December, 2020.

Results

Findings of logistic regression showed that men who were uneducated (aOR = 0.746; 95% CI = 0.568–0.980), residing in Sindh (aOR = 0.748; 95% CI = 0.568–0.985), Baluchistan (aOR = 0.421; 95% CI = 0.280–0.632) or FATA (aOR 0.313; 95% CI 0.176–0.556) and those who belonged to the poorest wealth quintile (aOR = 0.569; 95% CI = 0.382–0.846) were less likely to use modern contraceptives. Men who did not wish for another child (aOR = 2.821; 95% CI = 2.305–3.451) had a higher likelihood of modern contraceptive use. Finally, men who thought that contraception was women’s business (aOR = 0.670; 95% CI = 0.526–0.853) and those who did not discuss family planning with health worker (aOR = 0.715; 95% CI = 0.559–0.914) were also less likely to use modern contraceptives.

Conclusion

Reproductive health education of males, targeting males, in addition to, females for addressing family planning issues and improvement of family planning facilities in socioeconomically under-privileged regions are suggested to improve contraceptive use among couples.

Prevalence and determinants of the involvement of married men in family planning services in Ethiopia: A systematic review and meta-analysis

Background:

Male involvement in family planning includes not only using contraceptives but also encouraging and supporting their partners’ contraception needs and choices, encouraging peers to use family planning, and influencing policy to make male-related programs more conducive. In Ethiopia, the prevalence and associated factors of male involvement in family planning were highly inconsistent across studies. As a result, the goal of this study was to use a systematic review and meta-analysis to estimate the pooled prevalence of male involvement in family planning and its associated factors in Ethiopia.

Methods:

Electronic literature search using PubMed, Google Scholar, EMBASE, HINAR, Scopus, and Web of Sciences were performed without time restriction to identify the primary studies. Data were extracted using a pretested standardized data extraction format and analyzed using STATA 14 statistical software. A random-effect model was used to estimate the pooled prevalence of male involvement.

Results:

A total of 17 studies were included to give the pooled prevalence of male involvement in family planning in Ethiopia, which was 39.66% (95% confidence interval = 29.86, 49.45). Educational status (adjusted odds ratio = 1.99, 95% confidence interval = 1.26, 3.14), discussion of family planning with wife (adjusted odds ratio = 4.15, 95% confidence interval = 2.21, 7.80), knowledge (adjusted odds ratio = 1.83, 95% confidence interval = 1.26, 2.64), positive attitude about family planning (adjusted odds ratio = 2.57, 95% confidence interval = 1.70, 3.90), and approval of contraceptive use (adjusted odds ratio = 2.57, 95% confidence interval = 1.70, 3.90) were found to be significantly associated with involvement of men in family planning service.

Conclusion:

The overall prevalence of male involvement in family planning in Ethiopia was significantly low. Male involvement in family planning should be made available, accessible, and advocated for by government and non-governmental organizations, service providers, program planners, and stakeholders. In addition, to increase the role of men in the use of family planning services, a conducive environment for education, behavioral change, and open discussion about reproductive health issues is required.

Socioeconomic development predicts a weaker contraceptive effect of breastfeeding

Breastfeeding suppresses postpartum fecundity (the capacity for reproduction). This mechanism is critically important to control fertility (actual reproduction) when contraception is uncommon. Whether dependence of the contraceptive effect of breastfeeding on environmental conditions is strong enough to have a significant effect on fertility remains unclear. Analyzing 2.7 million births in 84 low- and middle-income countries over the past four decades, we find a dramatic weakening of the breastfeeding–postpartum amenorrhea relationship that correlates with improved living standards. These results suggest that, in the absence of contraception, the effect of breastfeeding on fertility depends on the level of socioeconomic development.

The contraceptive effect of breastfeeding remains essential to controlling fertility in many developing regions of the world. The extent to which this negative effect of breastfeeding on ovarian activity is sensitive to ecological conditions, notably maternal energetic status, has remained controversial. We assess the relationship between breastfeeding duration and postpartum amenorrhea (the absence of menstruation following a birth) in 17 World Fertility Surveys and 284 Demographic Health Surveys conducted between 1975 and 2019 in 84 low- and middle-income countries. We then analyze the resumption of menses in women during unsupplemented lactation. We find that a sharp weakening of the breastfeeding–postpartum amenorrhea relationship has globally occurred over the time period analyzed. The slope of the breastfeeding–postpartum amenorrhea relationship is negatively associated with development: higher values of the Human Development Index, urbanization, access to electricity, easier access to water, and education are predictive of a weaker association between breastfeeding and postpartum amenorrhea. Low parity also predicts shorter postpartum amenorrhea. The association between exclusive breastfeeding and maintenance of amenorrhea in the early postpartum period is also found in rapid decline in Asia and in moderate decline in sub-Saharan Africa. These findings indicate that the effect of breastfeeding on ovarian function is partly mediated by external factors that likely include negative maternal energy balance and support the notion that prolonged breastfeeding significantly helps control fertility only under harsh environmental conditions.

Sexual activity by marital status and age: a comparative perspective

This paper presents an analysis of trends in sexual activity by marital status and age, and their associations with contraceptive use. Understanding levels of, and trends in, sexual activity is important for assessing the needs for family planning services and for analysing commonly used family planning indicators. Data were taken from 220 Demographic and Health Surveys (DHSs) and 62 Multiple Indicator Cluster Surveys (MICSs) to provide insights into sexual activity by marital status and age in a total of 94 countries in different regions of the world. The results show the sensitivity of the indicator with respect to the definition of currently sexually active, based on the timing of last sexual intercourse (during the last 4 weeks, 3 months, or 1 year). Substantial diversity in sexual activity by marital status and age was demonstrated across countries. The proportion of married women reporting recent sexual activity (sexual intercourse during the last 4 weeks) ranged from 50% to 90%. The proportion of unmarried women reporting recent sexual activity did not exceed 50% in any of the 94 countries with available data, but showed substantial regional differences: it appeared to be rare in Asia and extremely varied within Africa, Europe and Latin America and the Caribbean. Among married women, sexual activity did not vary much by age group, while for unmarried women, there was an inverted U-pattern by age, with the youngest age group (15-19 years old) having the lowest proportion sexually active. The proportion of women who reported currently using contraception and reported not being sexually active varied by the contraceptive method used and was overall much greater among unmarried women. The evidence presented in this paper can be used to improve family planning policies and programmes to serve the diverse needs, for example regarding method choice and service provision, of unmarried women.

Modernization, Urbanization, and Nutritional Care

Child-care beliefs and practices evolve to meet the needs of children within changing families and societies. Production technologies, economic structures, formal and non-formal institutions, and ideologies influence the care of young children. Nutritional care varies among premodern agrarian, modern industrial, and postmodern knowledge-based settings. Vital families in which parents and children learn together currently are emerging as the most favourable environment for child care. Policy implications of historic trends are: 1) nutritional care should be added to the definition of children's rights; 2) functional indicators of nutritional care should be built into systems that monitor children's well-being; 3) care services should be available to the whole child in the whole family, through multi-purpose networks of agencies and activities; 4) child and family development programmes should teach parents to enhance children's nutritional care and development; 5) the care motto “Preserve, Protect, Promote” should expand to “Rediscover, Relearn, and Readapt” beneficial caring from the past.

Side effects and the need for secrecy: characterising discontinuation of modern contraception and its causes in Ethiopia using mixed methods

BACKGROUND

Contraceptive discontinuation is a major barrier to reducing global unmet needs for family planning, but the reasons why women discontinue contraception are poorly understood. Here we use data from Ethiopia to investigate (i) the magnitude of contraceptive discontinuation in 2005-2011, (ii) how the risk of discontinuation varies with method type and education level and (iii) the barriers to continuation. Our main hypothesis is that contraceptive discontinuation is driven by the experience of physiological side-effects associated with the use of hormonal contraception, rather than a lack of formal education.

METHODS

We used a mixed methods explanatory sequential design to explain the quantitative results in more details through the qualitative data. First, we analysed quantitative data from the 2011 Ethiopian Demographic and Health Survey to study patterns of contraceptive discontinuation and method choice using multilevel multiprocess models. Second, we conducted semi-structured interviews and focus group discussions in the 3 most populated regions of Ethiopia with individuals of reproductive age and health professionals.

RESULTS

The analysis of EDHS data shows that the rate of discontinuation has not reduced in the period 2005-2011 and remains high. Discontinuation mainly takes the form of abandonment, and is a function of method type, age and wealth but not of educational level. Interviews with women and health professionals reveal that the experience of debilitating physiological side effects, the need for secrecy and poverty are important barriers to continuation.

CONCLUSIONS

Our findings together suggest that physiological and social side-effects of contraceptive use, not a lack of formal education, are the root causes of contraceptive abandonment in Ethiopia.

Effect of Efavirenz on Endogenous Progesterone Concentrations and Contraceptive Outcomes among Ugandan HIV Infected Women Coadministering Ethinylestradiol/Levonorgestrel

This study assessed the effect of efavirenz mid-dose plasma concentrations on mid-luteal endogenous progesterone concentrations and contraceptive outcomes among 49 HIV infected women coadministering ethinylestradiol/levonorgestrel, including 34 HIV positive women on Highly Active Antiretroviral Therapy (HAART) and 15 HAART naïve HIV infected women, purposively selected from Mulago Hospital, Uganda. A blood sample was collected once between days 20 and 22 of each woman's menstrual cycle for measuring endogenous progesterone and efavirenz concentrations by electrochemiluminescence technology and High Performance Liquid Chromatography (HPLC), respectively. Descriptive statistical analysis and correlation and logistic regression analysis were done using SPSS v.21 and R3.1. Efavirenz showed a weak positive linear relationship with endogenous progesterone at efavirenz concentrations below 12 μg/ml. Based on serum endogenous progesterone, the observed hormonal contraceptives failure rate (24.5%) was higher than expected (maximum 8%). A higher proportion of HIV positive women on efavirenz based HAART (26.5%) was at risk of contraceptive failure than their HIV infected HAART naïve counterparts (20%) though it was not statistically significant (p = 0.63). Efavirenz mid-dose plasma concentrations seem to have no significant effect on mid-luteal endogenous progesterone concentrations and contraceptive outcomes among HIV infected Ugandan women coadministering ethinylestradiol/levonorgestrel oral pills.

Local Economic Development in Sub-Saharan Africa

It has often been argued that Africa in general, and Sub-Saharan Africa (SSA) in particular, is ‘different’ and that it therefore requires ‘exceptional’ solutions to its development problems. In contrast, in this paper we argue that strong internal heterogeneity combined with general trends similar to those experienced elsewhere in the world make local economic development (LED) as likely to succeed in SSA as in other low- and middle-income countries. The likelihood of success depends mostly on place-specific conditions. Many of the most prosperous parts of the continent already have the basic enabling conditions for the design and implementation of LED strategies in place. Less favourable resource endowments, poor accessibility, and relatively weak civil societies can undermine the viability of LED outside the wealthier and most prosperous areas. In smaller urban areas and intermediate regions and city-regions, which lack only a few of the basic preconditions for LED, further capacity building may still enable the success of the approach. In contrast, LED may not be relevant for the poorest and most remote parts of SSA, where existing conditions do not provide a strong enough base on which to build LED strategies.

Socio-cultural inhibitors to use of modern contraceptive techniques in rural Uganda: a qualitative study

Introduction

Family planning is one of the cost-effective strategies in reducing maternal and child morbidity and mortality rates. Yet in Uganda, the contraceptive prevalence rate is only 30% among married women in conjunction with a persistently high fertility rate of 6.2 children per woman. These demographic indicators have contributed to a high population growth rate of over 3.2% annually. This study examines the role of socio-cultural inhibitions in the use of modern contraceptives in rural Uganda.

Methods

This was a qualitative study conducted in 2012 among men aged 15-64 and women aged 15-49 in the districts of Mpigi and Bugiri in rural Uganda. Eighteen selected focus group discussions (FGDs), each internally homogeneous, and eight in-depth interviews (IDIs) were conducted among men and women. Data were collected on sociocultural beliefs and practices, barriers to modern contraceptive use and perceptions of and attitudes to contraceptive use. All interviews were tape recoded, translated and transcribed verbatim. All the transcripts were coded, prearranged into categories and later analyzed using a latent content analysis approach, with support of ATLAS.ti qualitative software. Suitable quotations were used to provide in-depth explanations of the findings.

Results

Three themes central in hindering the uptake of modern contraceptives emerged: (i) persistence of socio-cultural beliefs and practices promoting births (such as polygamy, extending family lineage, replacement of the dead, gender-based violence, power relations and twin myths). (ii) Continued reliance on traditional family planning practices and (iii) misconceptions and fears about modern contraception.

Conclusion

Sociocultural expectations and values attached to marriage, women and child bearing remain an impediment to using family planning methods. The study suggests a need to eradicate the cultural beliefs and practices that hinder people from using contraceptives, as well as a need to scale-up family planning services and sensitization at the grassroots.

The Relationship between Partners' Family-Size Preferences in Southern Malawi

Studies of the relative influence of partners' fertility preferences on behaviors tend to treat preferences as fixed, largely independent traits despite existing theoretical arguments and empirical evidence suggesting that they are moving targets that may be jointly developed within relationships. In this study, we use couple-level panel data from married and unmarried young adults in southern Malawi to examine the relationship between partners' family-size preferences. We find evidence of assortative mating: young Malawians are more likely to partner with individuals who have similar family-size goals. Additionally, although partners' family-size preferences do not perfectly converge, changes among men's and women's preferences are significantly more likely to be "toward" than "away from" those of their partner. Our findings point to a need for studies regarding the relative influence of partners on reproductive outcomes to consider the interdependence of partners' preferences and the varied ways in which partners can influence shared reproductive behaviors.

Safer conception needs for HIV prevention among female sex workers in Burkina Faso and Togo

Background. Reproductive health programming for female sex workers (FSW) may include contraceptive services but rarely addresses safer pregnancy planning. Methods. Adult FSW were enrolled into a cross-sectional study across four sites in Burkina Faso and Togo using respondent-driven sampling. Sociobehavioral questionnaires and HIV counseling and testing were administered. Sample statistics and engagement in HIV treatment were described and compared using Chi-squared statistics. Results. 1,349 reproductive-aged FSW were enrolled from January to July 2013. Overall, 267 FSW (19.8%) were currently trying to conceive. FSW trying to conceive were more likely to test positive for HIV at enrollment as compared to women not trying to become pregnant (24.5% versus 17.7%, P < 0.01); however awareness of HIV status was similar across groups. Among FSW trying to conceive, 79.0% (211/267) had previously received HIV testing, yet only 33.8% (23/68) of HIV-infected FSW reported a previous HIV diagnosis. Overall 25.0% (17/68) of HIV-infected FSW trying to conceive were on antiretroviral therapy. Conclusion. FSW frequently desire children. However engagement in the HIV prevention and treatment cascade among FSW trying to conceive is poor potentiating periconception transmission risks to partners and infants. Programs to facilitate earlier HIV diagnosis for FSW and safer conception counseling are needed as components of effective combination HIV prevention services.

Modern contraceptive use among sexually active men in Uganda: does discussion with a health worker matter?

Background

Family planning programs have recently undergone a fundamental shift from being focused on women only to focusing on men individually, or on both partners. However, contraceptive use among married men has remained low in most high-fertility countries including Uganda. Men’s role in reproductive decision-making remains an important and neglected part of understanding fertility control both in high-income and low-income countries. This study examines whether discussion of family planning with a health worker is a critical determinant of modern contraceptive use by sexually active men, and men’s reporting of partner contraceptive use.

Methods

The study used data from the 2011 Uganda Demographic and Health Survey comprising 2,295 men aged 15–54 years. Specifically, analyses are based on 1755 men who were sexually active 12 months prior to the study. Descriptive statistics, Pearson’s chi-square test, and logistic regression were used to identify factors that influenced modern contraceptive use among sexually active men in Uganda.

Results

Findings indicated that discussion of family planning with a health worker (OR =1.85; 95% CI: 1.29–2.66), region (OR = 0.41; 95% CI: 0.21–0.77), education (OR =2.13; 95% CI: 1.01–4.47), wealth index: richer (OR = 2.52; 95% CI: 1.58–4.01), richest (OR = 2.47; 95% CI: 1.44–4.22), surviving children (OR = 2.04; 95% CI:1.16–3.59) and fertility preference (OR = 3.50; 95% CI: 1.28–9.61) were most significantly associated with modern contraceptive use among men.

Conclusions

The centrality of the role of discussion with health workers in predicting men’s participation in family planning matters may necessitate creation of opportunities for their further engagement at health facilities as well as community levels. Men’s discussion of family planning with health workers was significantly associated with modern contraceptive use. Thus, creating opportunities through which men interact with health workers, for instance during consultations, may improve contraceptive use among couples.

Fistula and other adverse reproductive health outcomes among women victims of conflict-related sexual violence: a population-based cross-sectional study

BACKGROUND

Sexual violence (SV) is being used widely as a weapon of war. However, few studies have investigated its health effects. The objective of the present study is to investigate the relationship between sexual violence and several serious reproductive health conditions including fistula.

METHODS

We conducted a cross-sectional study among 320 women living in Goma, the Democratic Republic of Congo. We assessed the association of four outcomes: fistula, chronic pelvic pain, desire for sex, and desire for children, with SV in two contexts: conflict-related and nonconflict-related. Two groups of women: those who experienced conflict-related sexual violence (CRSV) and those who experienced nonconflict-related sexual violence (NCRSV), were compared with women who had not experienced SV. Data were collected by trained interviewers using a standard questionnaire.

RESULTS

Compared with women who did not experience SV, after adjustment for potential confounders, women who experienced CRSV were significantly more likely to have fistula (OR = 11.1, 95% CI [3.1-39.3]), chronic pelvic pain (OR = 5.1, 95% CI [2.4-10.9]), and absence of desire for sex (OR = 3.5, 95% CI [1.7-6.9]) and children (OR = 3.5, 95% CI [1.6-7.8]). Women who experienced NCRSV were more likely to report absence of desire for children (OR = 2.7, 95% CI [1.1-6.5]), and seemed more likely to report chronic pelvic pain (OR = 2.3, 95% CI [0.95-5.8]), although the difference was not statistically significant. Women who experienced NCRSV did not have higher odds for fistula and absence of sexual desire.

CONCLUSION

Conflict-related sexual violence can contribute to women's adverse reproductive health outcomes. Its impact is more devastating than that of NCRSV.

Impact of long-term contraceptive promotion on incident pregnancy: a randomized controlled trial among HIV-positive couples in Lusaka, Zambia

OBJECTIVES

To evaluate the impact of family planning promotion on incident pregnancy in a combined effort to address Prongs 1 and 2 of prevention of mother-to-child transmission of HIV.

DESIGN

We conducted a factorial randomized controlled trial of 2 video-based interventions.

METHODS

"Methods" and "Motivational" messages promoted long-term contraceptive use among 1060 couples with HIV in Lusaka, Zambia.

RESULTS

Among couples not using contraception before randomization (n = 782), the video interventions had no impact on incident pregnancy. Among baseline contraceptive users, viewing the "Methods video" which focused on the intrauterine device and contraceptive implant was associated with a significantly lower pregnancy incidence [hazard ratio (HR) = 0.38; 95% confidence interval (CI): 0.19 to 0.75] relative to those viewing control and/or motivational videos. The effect was strongest in concordant positive couples (HR = 0.22; 95% CI: 0.08 to 0.58) and couples with HIV-positive women (HR = 0.23; 95% CI: 0.09 to 0.55).

CONCLUSIONS

The "Methods video" intervention was previously shown to increase uptake of long-acting contraception and to prompt a shift from daily oral contraceptives to quarterly injectables and long-acting methods such as the intrauterine device and implant. Follow-up confirms sustained intervention impact on pregnancy incidence among baseline contraceptive users, in particular couples with HIV-positive women. Further work is needed to identify effective interventions to promote long-acting contraception among couples who have not yet adopted modern methods.

Religion, contraception, and method choice of married women in Ghana

Using pooled data from the 1998 and 2003 Demographic and Health Surveys, this paper investigates the association between religion and contraceptive behavior of married women in Ghana. Guided by the particularized theology and characteristics hypotheses, multinomial logit and complementary log-log models are used to explore denominational differences in contraceptive adoption among currently married women and assess whether the differences could be explained through other characteristics. We found that while there were no differences between women of different Christian faiths, non-Christian women (Muslim and Traditional) were significantly more likely to have never used contraception compared with Christian women. Similar observations were made on current use of contraception, although the differences were greatly reduced in the multivariate models.

A study of psychological symptoms, family function, marital and life satisfactions of polygamous and monogamous women: the Palestinian case

BACKGROUND

Polygamy is defined as a marriage in which a spouse of either gender has more than one mate at the same time. Polygamy is considered a valid form of marriage in many countries and communities around the globe.

AIM

The purpose of this study is to examine the psychological symptoms, family function, marital satisfaction, life satisfaction and the degree of agreement with the practice of polygamy among 'senior wives' - the first wife in the polygamous marriage - and women in monogamous marriages in the West Bank, Palestine.

METHOD

A convenience sample of 309 women, 187 from polygamous and 122 from monogamous families, participated in this study. All women from polygamous families were senior wives. The following instruments were deployed: the McMaster Family Assessment Device (FAD), the ENRICH marital satisfaction questionnaire, the SCL-90 mental health symptoms checklist, the Rosenberg self-esteem (SE) scale, the Diener et al. (1985), a life satisfaction scale, and a basic socio-demographic scale, including the degree of agreement of the practice of polygamy.

RESULTS

The findings revealed significant differences between senior wives in polygamous marriages and wives in monogamous marriages with regard to family functioning, marital satisfaction, self-esteem and life satisfaction. Likewise, many of the mental health symptoms were different. Particularly noteworthy were somatization, depression, hostility psychotism and the General Severity Index (a global index of distress). More women in polygamous marriages agreed with the practice of polygamy than their monogamous counterparts.

CONCLUSION

Practitioners and policy makers need to be aware of the consequences of polygamy on first wives and on society as whole.

Determinants of fertility in rural Ethiopia: the case of Butajira Demographic Surveillance System (DSS)

Background

Fertility is high in rural Ethiopia. Women in the reproductive age group differed in various characteristics including access to food and encounter to drought which requisite the assessment of determinants of fertility.

Methods

Reproductive age women were recruited from a DSS, the Butajira DSS database. A DHS maternity history questionnaire was administered on 9996 participants. Data quality was assured besides ethical clearance. Poisson regression crude and adjusted Incidence Rate Ratio with 95 Confidence Interval were used to identify determinants of fertility.

Results

Delayed marriage, higher education, smaller family, absence of child death experience and living in food-secured households were associated with small number of children. Fertility was significantly higher among women with no child sex preference. However, migration status of women was not statistically significant.

Conclusions

Policy makers should focus on hoisting women secondary school enrollment and age at first marriage. The community should also be made aware on the negative impact of fertility on household economy, environmental degradation and the country's socio-economic development at large.

A qualitative study of women in polygynous marriages

Polygyny, the practice of taking more than one wife at the same time is a common practice in several countries including Africa. This study, conducted in Ghana, West Africa, investigated married women's experiences in polygyny and their ways of coping.

METHODS

Using exploratory qualitative methodology, data were collected from 15 married women who consented to in-depth interviews. The study was conducted in the summer of 2005 with approval from an institutional review board and permission from community leaders from the study site.

FINDINGS

Three themes emerged from the study: infertility, co-wives' relationships and ways of coping. The findings indicated that infertility was the number one reason that women allowed for co-wives in their marriages because this was necessary to protect the marriage rather than divorce. Unhappiness, loneliness, sense of competition and jealousy, and lack of intimacy with the spouse were identified as disadvantages of polygyny. The perceived advantages of polygyny included sharing of house chores and child rearing. The women's ways of coping included the use of religion, faith and a strong sisterly bond formed with the co-wives. Though the majority of the women disapproved of polygyny unions, divorce was not an option.

CONCLUSION

These findings have implications for nursing and policy-makers. Nurses can provide education and implement programmes that teach coping mechanisms and stress management. Policy-makers should be made aware of the implications of polygynous marriages on women's health and well-being. There is the need to conduct more research to investigate the effects of polygyny on women's mental health and the need to develop programmes to support women.

Polygynous marital structure and child survivorship in sub-Saharan Africa: some empirical evidence from Ghana

Although studies have found children in married families to have better health outcomes than those in other family types, this strand of research implicitly views marriage as monolithic and, by default, monogamous as found in western industrialized societies. In polygynous cultures, there is a need to make a distinction between polygynous and monogamous families, because these marital arrangements might imply varying levels of parental support necessary for optimum child outcomes. Using pooled children's data from the 1998 and 2003 (N=4938) Ghana Demographic and Health Surveys, this study investigates the effects of polygynous marital structure on child survivorship and assesses whether the effect is uniform over the entire childhood period. In models that did not allow for age-specific effects of polygyny, children in polygynous marriages were found to have an elevated risk of death. Further analysis revealed that only older children experienced the survival disadvantages associated with polygyny.

Cohabitation, marriage, and 'sexual monogamy' in Nairobi's slums

The current study investigates the extent to which sexual exclusivity--the restriction of one's sexual engagements to a single partner--prevails across various marital status, union type, and co-residence categories among Nairobi's poorest residents, slum dwellers. This question is central to the spread of HIV in the increasingly urban and poor, high prevalence countries of sub-Saharan Africa, where transmission is primarily via heterosexual sex. In many circles, sexual exclusivity is considered a prominent feature of the marriage institution. Yet, marriage and cohabitation are often not easily distinguishable in sub-Saharan Africa, meaning that the frequent use, as a proxy, of the "in union" category, which includes married as well as cohabiting persons can, at best, be considered tenuous. Using the 2000 Nairobi Cross-Sectional Slum Survey (NCSS), this paper confirms that marriage is associated with higher reports of sexual exclusivity even in settings where poverty provokes risky behavior. The finding, here, is of lower risk of HIV infection for married respondents, with a smaller effect observed among non-married cohabiters. Converse to the implied benefits of marriage, though, women with co-wives are more likely to report multiple partners. The implications of these findings are discussed.

Which African men promote smaller families and why? Marital relations and fertility in a Pare community in Northern Tanzania

This research comes in the wake of increasing interest in men's roles in childbearing decisions in sub-Saharan Africa. While some of the findings indicate that men tend to hinder fertility decline, we aimed to identify which men desire fewer children, under what circumstances, and why. The research was done in a Pare community in Northern Tanzania. It is our hypothesis that differences in men's fertility desires and decisions are to be sought in the context of their conjugal union. This paper, based on data from a case study from two Pare villages, attempts to examine the relationship between male attitudes toward reproduction and marital relations. The methodology consisted of a combination of an ethnographic study and in-depth interviews. A subsequent survey, the questions for which were derived from the qualitative work, was administered in order to verify the generalisability of the findings of the qualitative work. Findings show that those men who desire fewer children are younger, educated at least to the primary and often to the secondary level, their wives have also completed at least primary school, they are more affluent, and they are likely to be Christian. They are in a marital relationship where the partners chose each other, they communicate with their wives about important issues, and make joint decisions, including the number of children they should have. The discussion relates the differences in the marital patterns and fertility preferences to differences in the life plans of Christians and Muslims in this community.

Spousal communication and family planning behavior in Navrongo: a longitudinal assessment

The poor performance of most family planning programs in the 1980s, especially in sub-Saharan Africa, generated concern among researchers and led to a quest for explanations. In most countries, the alienation of men from participation in these programs was subsequently identified as one of the major causes, a finding that led researchers to redirect their attention to couples instead of individuals as the focus of such programs. Lack of spousal communication about family planning was identified as one reason for the low level of contraceptive use among women. Subsequent research has persistently demonstrated a positive relationship between spousal communication and contraceptive use. Most prior studies on this topic have been based on cross-sectional data, so that whether the identified relationships are causal remains unclear. Does communication, in fact, predict contraceptive use, or does the use of contraceptives generate communication among couples? This study addresses the question of causality by using longitudinal data from the Navrongo Health Research Centre panel survey. Results from both cross-sectional and longitudinal analysis demonstrate that spousal communication does, indeed, predict contraceptive behavior, even when other factors are controlled.

Ethnic variations in observance and rationale for postpartum sexual abstinence in Malawi

Using quantitative and qualitative data from three culturally heterogeneous ethnic groups in Malawi, I show that differences in postpartum sexual abstinence are closely associated with community-specific rationales for the practice, particularly differences in the definition and timing of child-strengthening rituals that couples are required to perform before resuming intercourse. Contrary to conventional wisdom, the primary rationale for abstinence in the study areas is not linked to child spacing. Among Tumbukas in the north, most women perform the ritual immediately after resuming menstruation. Among the other ethnic groups, the rituals can be performed at any time after the end of postpartum bleeding. The study underscores the utility of the complementary micro-level approach in understanding reproductive behavior in sub-Saharan Africa.

Household organization, women's autonomy, and contraceptive behavior in southern Ethiopia

The Southern Nations, Nationalities, and People's Region of Ethiopia (SNNPR) is home to 11 million people constituting more than 45 language and ethnic groups, most of whom live in extremely poor rural communities. Data for currently married, fecund women aged 15-49 from demographic surveys conducted in the SNNPR in 1990 and 1997 are used to investigate contraceptive knowledge and communication, and the use and future need for family planning services in this population. This study focuses on how these processes are affected by household organization and women's status, and on their implications for population policies and programs. Considerations of the implications of these results for understanding the fertility transition of a highly diverse African population under severe stress are presented. Although household extension and polygamy characterize one-third of the women sampled, they do not affect the women's contraceptive behavior. Women's literacy and autonomy are, by far, the most significant forces in the movement toward lower fertility in the region.

Men matter: Additive and interactive gendered preferences and reproductive behavior in kenya

The extent of men’s roles in reproductive decision-making in Africa is a subject of contention. Despite the volume of work on the roles men play in fertility decisions, there have been few attempts to derive direct empirical estimates of the effect of men’s preferences on reproductive behavior. I employ 1989 and 1993 Kenya Demographic and Health Surveys to examine the relative roles of the reproductive preferences of males and females on contraceptive use. Additive and interactive measures of preferences document a significant effect of men’s preferences, which may eclipse women’s preferences. The implications of these findings are discussed.

Polygyny and reproductive behavior in sub-saharan Africa: A contextual analysis

In this paper I examine the effect of polygyny on aggregate reproductive behavior. I argue that within countries there exist different polygyny regimes, each exhibiting a unique reproductive pattern. Using the 1988/1989 Kenya Demographic and Health Survey (KDHS1) data, I identify three distinct regimes: low-polygyny, mid polygyny, and high-polygyny regimes. The results of the bivariate and multivariate analyses reveal strong differences in reproductive preferences and behaviors across polygyny regimes. High-polygyny regimes, for instance, maintain a value orientation that favors and encourages high reproductive performance. The force of this pronatalism operates equally for men and women; but whereas men in this regime attain their reproductive goals by marrying multiple wives, women attain theirs by maximizing their reproductive capabilities. This maximization occurs through early initiation of sexual/reproductive activity, universal marriage and minimal interruption of marriage, nonuse of contraception within a union, and a positive attitude toward high fertility.

A community study of child spacing, fertility and contraception in West Pokot District, Kenya

Kenya is well known for its high fertility rate and West Pokot District has the highest population growth rate in Kenya. This study was designed to examine the community's perceptions of fertility dynamics. It looks at traditional methods of family planning and the recent changes in child spacing, fertility and contraception and the attitudes behind them. This study also examines what the community (particularly women), want in the way of family planning services. The study used randomly selected groups throughout the district and employed a quasi-anthropological group discussion method.

Human ecology and behavior and sexually transmitted bacterial infections

The three direct determinants of the rate of spread of sexually transmitted diseases (STDs) are sexual behaviors, the mean duration of infectiousness, and the mean efficiency of sexual transmission of each STD. Underlying ecological and behavioral factors that operate through one or more of these direct determinants lie on a continuum, ranging from those most proximate back to those more remote (in time or mechanism) from the direct determinants. Most remote and least modifiable are the historical stages of economic development that even today conspicuously influence patterns of sexual behavior. Next are the distribution and changing patterns of climate, hygiene, and population density; the global population explosion and stages of the demographic transition; and ongoing changes in human physiology (e.g., menarche at younger age) and culture (e.g., later marriage). More proximate on the continuum are war, migration, and travel; and current policies for economic development and social welfare. Most recent or modifiable are technologic and commercial product development (e.g., oral contraceptives); circumcision, condom, spermicide, and contraception practices; patterns of illicit drug use that influence sexual behaviors; and the accessibility, quality, and use of STD health care. These underlying factors help explain why the curable bacterial STDs are epidemic in developing countries and why the United States is the only industrialized country that has failed to control bacterial STDs during the AIDS era.

Pregnancy and contraception use among urban Rwandan women after HIV testing and counseling

OBJECTIVES

This study examined hormonal contraceptive use and pregnancy in urban Rwandan women, following human immunodeficiency virus (HIV) antibody testing and counseling.

METHODS

A sample of 1458 childbearing urban Rwandan women aged 18 to 35 years was tested and followed for 2 years.

RESULTS

At enrollment, 17% of 998 HIV-negative women and 11% of 460 HIV-positive women were pregnant, and 17% vs 23%, respectively, were using hormonal contraceptives. One year later, half of the HIV-positive and one third of the HIV-negative hormonal-contraceptive users had discontinued use. The 2-year incidence of pregnancy was 43% in HIV-positive and 58% in HIV-negative women. HIV-positive women with fewer than four children were more likely to become pregnant than those with four or more; this association persisted in multivariate analyses but was not noted among HIV-negative women. At the end of the study, over 40% of non-users said that they would use hormonal contraception if it was provided at the study clinic, but 40% of HIV-positive women desired more children.

CONCLUSIONS

Research is needed to identify the practical and psychosocial obstacles to effective long-term contraception among HIV-positive women. HIV counseling programs must specifically address the issue of childbearing.

A Sceptical Argument concerning the Value of a Behavioural Solution for AIDS

A thought experiment was developed in which it is demonstrated that frequently recurring temptations are hard to resist even if the risks of succumbing to the temptation are well understood. Behavioural programmes against AIDS are primarily concerned with making the risks of unprotected sex known to groups of people at risk of contracting HIV. But these target groups are also shown to engage in very frequent sex and this, combined with the thought experiment suggest that behavioural programmes may be less effective than desired. Structural interventions may be more successful than behavioural programmes. Some limitations of the thought experiment are considered.

Macroepidemiology of the HIVs-AIDS (HAIDS) pandemic. Insufficiently considered zoological and geopolitical aspects

The human immunodeficiency viruses (HIVs)-acquired immunodeficiency syndrome (AIDS) or HAIDS pandemic originated from lentiviruses of nonhuman primates (thus qualifying as a zoonosis) that moved into humans in Africa. The HAIDS patients eventually die of opportunistic infections, all potentially zoonotic. The HAIDS infection remained parochial, first endemically and then epidemically, until the African urbanization that occurred in each of the countries postindependence. The latter included wars and the massive movement of soldiers (virologically naive) from the American continent to Africa and back. The HAIDS viral ecology coincided with African swine fever (ASF) in the Americas. Haiti became the focal point for both infections. Some infected Haitians also became, together with some infected drug addicts in the United States, a source of contaminated human blood for transfusions and production of plasma derivatives.

Gender, education, and fertility: a cross-national analysis of Sub-Saharan African nations

According to the demographic transition theory and the wealth flows model, it is expected that fertility will decline with socioeconomic development, manifested in part through increasingly greater proportions of the population with formal education. Since their independence in the 1960s, most sub-Saharan African nations have experienced rapid changes in educational levels. However, recent estimates indicate that high levels of fertility are being maintained as reflected in the high rates of population increase of approximately 3%/year. Controlling for socioeconomic development as measured by per capita energy consumption and percentage of labor force in agriculture, this article examines the relationship between education and fertility for men and women in 37 sub-Saharan nations. Results indicate that primary school enrollment in 1960 and 1980 for both males and females had a weak negative and nonsignificant relationship with the total fertility rate 15-30 years later. Secondary school enrollment in 1960 for both males and females had weak relationships with the total fertility rate. However, secondary school enrollment for males in 1980 had a significant negative effect on the total fertility rate 10-25 years later. Implications are discussed.

African women and AIDS: negotiating behavioral change

Trends in the incidence of HIV/AIDS infection among women in Sub-Saharan Africa suggest this population is increasingly at risk. Many of the same factors that have predisposed rural African women to ill health in the past now increase their vulnerability to AIDS, including poverty and malnutrition, uncontrolled fertility, and complications of childbirth. As men travel out from rural communities to urban centers in search of employment, their sexual contacts multiply; many will acquire the HIV virus and carry it back to infect wives at home. Women, too, are leaving rural areas for the promise of a better life in cities and commercial centers along the way. Their struggle for economic survival and personal autonomy has led many to form relationships with new sexual partners, with a consequent increase in HIV seroprevalence among women once considered at low risk of infection. This paper argues that AIDS prevention campaigns have not yet taken into account the cultural, social, and economic constraints on most African women's ability to comply with advice to limit partners and use condoms. The author proposes a research agenda to explore the meaning of AIDS and AIDS prevention in the sociocultural context of women's lives. A better understanding of how women, themselves, perceive and respond to current attempts to prevent the transmission of AIDS is an increasingly critical factor in the intervention process. Most important, it is a necessary first step toward their effective participation with men in the development of culturally relevant strategies for protecting themselves and their families.