Family Planning for Strangers: An Experiment on the Validity of Reported Contraceptive Use

Sterilization levels reported in the Dominican Republic appear well above what we would normally expect given prevailing patterns in the region. We suspect that the use of strangers as interviewers—the normative approach in data collection in both developed and developing country settings—may be partly responsible for this result, and may underlie a long history of bias in family planning data. We present findings from a field experiment conducted in a Dominican town in 2010, where interviewer assignment was randomized by level of preexisting level of familiarity between interviewer and respondent. In our data, sterilization use is higher when the interviewer is an outsider, as opposed to someone known to the respondent or from the same community. In addition, high sterilization use is correlated with a propensity of respondents to present themselves in a positive light to interviewers. These results call into question the routine use of strangers and outsiders as interviewers in demographic and health surveys.

Understanding the socio-economic and sexual behavioural correlates of male circumcision across eleven voluntary medical male circumcision priority countries in southeastern Africa

BACKGROUND

Male circumcision (MC) has been demonstrated to be effective and cost-effective for HIV/AIDS prevention. Global guidance to adopt this intervention was announced in 2007 for countries with high HIV/AIDS prevalence and low MC prevalence. However, scale up of voluntary medical male circumcision (VMMC) programs in MC priority countries have been slow. Many of these countries have particular cultural barriers that impede uptake of this effective intervention. This analysis explored correlates of MC status among men and their socio-economic, health and sexual behaviour factors using DHS data (2006-2011) from 11 MC priority countries.

METHODS

Our analysis included univariate unadjusted analyses for individual countries and the region (by combining all countries into one dataset) and a multiple logistic regression model.

RESULTS

Individual country results vary widely but alignment was mostly found between unadjusted analyses and multiple logistic regression model. The model found that men who are of the Muslim faith, reside in urban areas, have higher or secondary education attainment, hold professional occupations, and be in the richest wealth quintile are more likely to be circumcised. Circumcision is also positively correlated with lower reports of STIs, safe sexual behaviour, and HIV/AIDS prevention knowledge.

CONCLUSIONS

Since the data collected predate VMMC program launch in these countries, results can only indicate baseline associations. However, characteristics of these existing circumcision practices may be utilized for better population targeting and program management to achieve higher impact with this effective prevention strategy.

The converging burdens of infectious and non-communicable diseases in rural-to-urban migrant Sub-Saharan African populations: a focus on HIV/AIDS, tuberculosis and cardio-metabolic diseases

Africa has the unenviable challenge of dealing with a double burden of disease: infectious diseases (IDs) such as HIV/AIDS and tuberculosis are high while non-communicable diseases (NCDs) are rapidly rising in the region. Populations with increased susceptibility to both include migrants. This review highlights the susceptibility of rural-to-urban migrants in Sub-Saharan Africa to the IDs of HIV/AIDS and tuberculosis, and to NCDs, particularly cardiovascular diseases. The disruption that occurs with migration is often accompanied by unhealthy exposures and environments. These include partaking in risky sexual practices and a subsequent greater risk for HIV infection in migrants than the general populations which contributes to the spread of the disease. Migrants frequently work and live in conditions that are poorly ventilated and overcrowded with suboptimal sanitation which increases their risk for tuberculosis. Considering that migrants have an increased risk of acquiring both HIV/AIDS and tuberculosis, and in view of the interaction between these diseases, they are likely to be at high risk for co-infection. They are also likely to facilitate the geographical spread of these infections and serve as conduits of disease dissemination to rural areas. Changes in lifestyle behaviours that accompany migration and urbanisation are exemplified primarily by shifts in physical activity and dietary patterns which promote the development of obesity, diabetes, hypertension and cardiovascular diseases. Urban living and employment is generally less physically exerting than rural routines; when migrants relocate from their rural residence they adapt to their new environment by significantly reducing their physical activity levels. Also, nutritional patterns among migrants in urban centres change rapidly with a shift to diets higher in fat, sugar and salt. Consequently, increases in weight, blood pressure and glucose levels have been reported within a year of migration. Interactions between IDs and NCDs are common; considering that migrants have an increased susceptibility to IDs and demonstrate a rapid rise in their risk for NCDs, the concurrent prevalence of both is likely in this population. There is a need for a combined strategy to combat IDs and NCDs with screening and treatment programmes geared towards this high risk group.

Contraceptive adoption in the extended postpartum period is low in Northwest Ethiopia

Background

The extended postpartum period is a one year period after delivery which is critical for women to prevent unintended pregnancy and to reduce the risk of maternal and child mortality by ensuring safe birth intervals. Studies indicate that birth intervals of three to five years reduce maternal mortality and provide health benefits to newborn babies, infants, and children. As a result, assessing postpartum contraceptive use and its determinants are an increasingly important component of global health. The objectives of the study were to determine postpartum contraceptive use and identify the variables which affect postpartum contraceptive use among women of Dabat district.

Methods

All women aged 15 to 49 years who delivered a child between January 1, 2012 and December 31, 2012 in the Debat district were interviewed by house-to- house survey.

Results

A total of 10.3 % of the mothers reported adopting contraception in the extended postpartum period. Women who delivered with the assistance of a skilled attendant [AOR = 1.88, 95 % CI (1.01-3.51)] and attended postnatal care services [AOR = 2.19, 95 % CI (1.06-4.52)] were more likely to use contraceptives. Secondary and above level of the husband’s education was also a variable that significantly affected postpartum contraceptive use [AOR = 2.98, 95 % CI (1.49-5.97)].

Conclusions

Contraceptive use in the extended postpartum period was found to be low placing women at risk for a pregnancy in the extended postpartum period. Advice about contraceptives during postnatal clinic visits was limited. Improving utilization of institutional delivery by a skilled attendant and enhancing postnatal care services are important to increase contraceptive use in the extended postpartum period.

Dependent or Productive? A New Approach to Understanding the Social Positioning of Older South Africans Through Living Arrangements

South Africa's population is aging. Most of the older Black South Africans continue to live in extended household structures with children, grandchildren, and other kin. They also constitute a source of income through a means-tested noncontributory state-funded pension available at age 60. Using census data from the Agincourt Health and Demographic Surveillance System in 2000, 2005, and 2010, we develop a typology of living arrangements that is reflective of the social positioning of elderly persons as dependent or productive household members and analyze changes in the distribution over time. Older persons, in general, live in large, complex, and multigenerational households. Multigenerational households with "productive" older persons are increasing in proportion over the period, although there are few differences by gender or pension eligibility at any time point.

Determinants of maternal health services utilization in Uganda

Background

Uganda’s poor maternal health indicators have resulted from weak maternal health services delivery, including access to quality family planning, skilled birth attendance, emergency obstetric care, and postnatal care for mothers and newborns. This paper investigated the predictors of maternal health services (MHS) utilization characterized as: desirable, moderate and undesirable.

Methods

We used a sample of 1728 women of reproductive ages (15–49), who delivered a child a year prior to the 2011 UDHS survey. A multinomial logistic regression model was used to analyze the relative contribution of the various predictors of ideal maternal health services package utilization. Andersen’s Behavioral Model of Health Services Utilization guided the selection of covariates in the regression model.

Results

Women with secondary and higher education were more likely to utilize the desirable maternal health care package (RRR = 4.5; 95 % CI = 1.5-14.0), compared to those who had none (reference = undesirable MHS package). Women who lived in regions outside Kampala, Uganda’s capital, were less likely to utilize the desirable package of maternal health services (Eastern – RRR = 0.2, CI = 0.1-0.5; Western – RRR = 0.3, CI = 0.1-0.8; Central – RRR = 0.3, CI = 0.1-0.8; Northern – RRR = 0.4, CI = 0.2-1.0). Women from the richest households were more likely to utilize the desirable maternal health services package (RRR = 1.9; 95 % CI = 1.0-3.7). Residence in rural areas, being Moslem and being married reduced a woman’s chances of utilizing moderate maternal health care services.

Conclusions

Utilization of maternal health services varied greatly by demographic and socio-economic characteristics. Women with a secondary and higher education, and those of higher income levels, were more likely to utilize the ideal maternal health services package. Therefore, there is need to formulate policies and design maternal health services programs that target the socially marginalized women.

Excess Mortality Associated with Influenza among Tuberculosis Deaths in South Africa, 1999-2009

Background

Published data on the interaction between influenza and pulmonary tuberculosis (PTB) are limited. We aimed to estimate the influenza-associated mortality among individuals with PTB in South Africa from 1999–2009.

Methods

We modelled the excess influenza-associated mortality by applying Poisson regression models to monthly PTB and non-tuberculosis respiratory deaths, using laboratory-confirmed influenza as a covariate.

Results

PTB deaths increased each winter, coinciding with influenza virus circulation. Among individuals of any age, mean annual influenza-associated PTB mortality rate was 164/100,000 person-years (n = 439). The rate of non-tuberculosis respiratory deaths was 27/100,000 (n = 1125) for HIV-infected and 5/100,000 (n = 2367) for HIV-uninfected individuals of all ages. Among individuals aged <65 years, influenza-associated PTB mortality risk was elevated compared to influenza-associated non-tuberculosis respiratory deaths in HIV-infected (relative risk (RR): 5.2; 95% CI: 4.6–5.9) and HIV-uninfected individuals (RR: 61.0; CI: 41.4–91.0). Among individuals aged ≥65 years, influenza-associated PTB mortality risk was elevated compared to influenza-associated non-tuberculosis respiratory deaths in HIV-uninfected individuals (RR: 13.0; 95% CI: 12.0–14.0).

Conclusion

We observed an increased risk of influenza-associated mortality in persons with PTB compared to non-tuberculosis respiratory deaths. If confirmed in other settings, our findings may support recommendations for active inclusion of patients with TB for influenza vaccination and empiric influenza anti-viral treatment of patients with TB during influenza epidemics.

Estimating the absolute wealth of households

Objective

To estimate the absolute wealth of households using data from demographic and health surveys.

Methods

We developed a new metric, the absolute wealth estimate, based on the rank of each surveyed household according to its material assets and the assumed shape of the distribution of wealth among surveyed households. Using data from 156 demographic and health surveys in 66 countries, we calculated absolute wealth estimates for households. We validated the method by comparing the proportion of households defined as poor using our estimates with published World Bank poverty headcounts. We also compared the accuracy of absolute versus relative wealth estimates for the prediction of anthropometric measures.

Findings

The median absolute wealth estimates of 1 403 186 households were 2056 international dollars per capita (interquartile range: 723–6103). The proportion of poor households based on absolute wealth estimates were strongly correlated with World Bank estimates of populations living on less than 2.00 United States dollars per capita per day (R² = 0.84). Absolute wealth estimates were better predictors of anthropometric measures than relative wealth indexes.

Conclusion

Absolute wealth estimates provide new opportunities for comparative research to assess the effects of economic resources on health and human capital, as well as the long-term health consequences of economic change and inequality.

Levels, trends and reasons for unmet need for family planning among married women in Botswana: a cross-sectional study

OBJECTIVES

The objectives of this study are: (1) to estimate the prevalence of unmet need for family planning among married women using Botswana Family Health Survey 2007 data and (2) to identify risk factors for unmet need for family planning among married women.

DESIGN

This study used secondary data from a cross-sectional survey that was conducted to provide a snapshot of health issues in Botswana.

SETTING

Nationally representative population survey data.

PARTICIPANTS

2601 married or in union women aged 15-49 years who participated in the 2007 Botswana Family Health Survey were included in the analysis.

PRIMARY OUTCOME

Unmet need for family planning, which was defined as the percentage of all fecund married women who are not using a method of contraception even though they do not want to get pregnant.

RESULTS

Married women who had unmet need for family planning were 9.6% in 2007. Most of the unmet need was for limiting (6.7%) compared to spacing (2.9%). Unmet need for family planning was more likely to be among women whose partners disapproved of family planning, non-Christians, had one partner and had never discussed family planning with their partner. Women of low parity, aged 25-34 years, and greater exposure to mass media, were less likely to have experienced unmet need. The patterns and magnitude of covariates differed between unmet need for limiting and for spacing.

CONCLUSIONS

The prevalence of unmet need for family planning was low in Botswana compared to other sub-Saharan African countries. The findings from this study reemphasise the importance of women's empowerment and men's involvement in women's sexual and reproductive healthcare needs and services. Different approaches are needed to satisfy the demand for family planning for spacing and limiting.

Association between wanting circumcision and risky sexual behaviour in Zimbabwe: evidence from the 2010-11 Zimbabwe demographic and health survey

BACKGROUND

Zimbabwe adopted voluntary medical male circumcision (VMMC) as an additional HIV prevention strategy in 2009. A number of studies have been conducted to understand the determinants of VMMC uptake but few studies have examined the characteristics of men who are willing to get circumcised or the link between wanting circumcision and risky sexual behaviour. This study investigated the relationship between wanting male circumcision and engaging in risky sex behaviours. This was based on the assumption that those who are willing to undergo circumcision are already engaging in risky sexual behaviours.

DATA AND METHODS

Data from men age 15-45 years who were interviewed during the 2010-11 Zimbabwe Demographic and Health Survey of 2010-11 was used. A total of 7480 men were included in the sample for this study. Logistic regression was used to assess the association between wanting circumcision and risky sexual behaviours.

FINDINGS

Men in the highest wealth tercile were significantly more likely to want circumcision compared to men in lower wealth terciles (OR=1.36, p<0.01). Wanting circumcision was also significantly associated with age. Men in the 25-34 age category reported wanting circumcision more (OR=1.21, p < 0.05) while older men were significantly less likely to want circumcision (OR=0.63, p<0.01). Christian men and those residing in rural areas were also less likely to want circumcision (OR=0.74, p<0.05 and OR = 0.75, p < 0.001 respectively). The findings of this study indicate a strong association between wanting circumcision and having had risky sex (OR=1.36, p<0.01), having multiple partners (OR=1.35, p<0.01) and having paid for sex (OR=1.42, p < 0.001) However, wanting circumcision was negatively associated with having used a condom at the last risky sex (OR=0.76, p<0.001).

CONCLUSIONS

The association between demand for VMMC and risky sexual behaviour need continuous monitoring. We emphasise that the promotion of VMMC for HIV prevention should not overshadow the promotion of existing methods of HIV prevention such as condoms and reduction of sexual partners.

BIOSOCIAL CORRELATES OF AGE AT FIRST SEXUAL INTERCOURSE: THE CASE OF GRADE 9 AND GRADE 11 PUPILS IN THE NORTH WEST PROVINCE OF SOUTH AFRICA

Survival analysis – specifically the actuarial life-table method and the Cox Proportional Hazards model – was used to assess Bronfenbrenner's bio-ecological model with regards to the onset of sexual intercourse in a random sample of 1697 grade 9 and grade 11 pupils in the North West Province of South Africa. Data were collected in July and August 2007. Of the contextual factors examined, only academic performance and community disorganization were found to be statistically significantly associated with age at first sexual intercourse amongst girls. High academic performance by girls is positively associated with age at first sexual intercourse, while girls who live in disorganized communities initiate sexual intercourse earlier than their counterparts in other communities. Age is negatively associated with the timing of first sexual debut among both girls and boys. Males initiate sexual intercourse earlier than females, while youths with at least one sexual partner are much more likely to initiate sexual intercourse earlier than those without sexual partners.

Unmet need and fertility decline: a comparative perspective on prospects in sub-Saharan Africa

This study assesses how changes in unmet need for family planning have contributed to contemporary fertility declines, and the implications of this historical record for further fertility decline, especially in sub-Saharan Africa. We examine joint trends at the national level in fertility, unintended fertility, and unmet need. We bring unintended fertility into the analysis because the underlying rationale for reducing unmet need is to avert unintended pregnancies and births. The association over time between unmet need and fertility is investigated using survey data from 45 countries in Africa, Asia, and Latin America and the Caribbean from the mid-1970s to the present. The empirical analysis finds that reduction in unmet need, especially unmet need for limiting, is strongly associated with fertility decline in Latin America and the Caribbean and in Asia and North Africa. Fertility decline in sub-Saharan Africa is weakly associated with trends in unmet need (and satisfaction of demand). We propose that the stark regional difference is due to measurement problems and to the fundamentally different character of fertility decline in sub-Saharan Africa, itself reflective of basic differences in pretransition reproductive regimes.

Disparities in modern contraception use among women in the Democratic Republic of Congo: a cross-sectional spatial analysis of provincial variations based on household survey data

This study investigates inequalities at the province level of the use of modern contraception and the proportion of short birth intervals among women in the DRC using data from the 2007 Demographic and Health Survey. Logistic regression and Bayesian geo-additive models were used. The posterior odds ratio and the associated 95% credible interval (95% CI) were estimated using Markov Chain Monte Carlo (MCMC) techniques. Posterior spatial effects were mapped at the province level with the associated posterior probability maps showing statistical significance at 5%. The overall rates of modern contraception use among the entire sample of women (15-49 years old; N = 7172) and youth (15-24 years old; N = 1389) were 5.7% and 6.0% respectively. However, there was striking variation in contraceptive use between the two groups across provinces with a clear east-to-west gradient. The highest use in the total sample was in Nord-Kivu (OR 1.32; 95% CI 1.12, 1.55) and Bas Congo provinces (1.47; 1.22, 1.78). For the youth, the highest use was observed in Nord-Kivu (1.19; 0.92, 1.65). In multivariate Bayesian geo-additive regression analyses among the entire sample of women, factors consistently associated with lower use of modern contraception were living in rural areas (0.71; 0.62, 0.82), living in low-income households (0.67; 0.54, 0.80) and having no education (0.83; 0.67, 0.97). For the youth sample, living in low-income households (0.57; 0.41, 0.84) and no breast-feeding (0.64; 0.47, 0.86) were consistently associated with a lower use of modern contraception. The study shows a distinct geographic pattern in the use of modern contraception in youth and the entire sample of women in the DRC, suggesting a potential role for socioeconomic factors, such as accessibility, affordability and availability, as well as environmental factors at the province level beyond individual-level risk factors.

Migration and the epidemiological transition: insights from the Agincourt sub-district of northeast South Africa

BACKGROUND

Migration and urbanization are central to sustainable development and health, but data on temporal trends in defined populations are scarce. Healthy men and women migrate because opportunities for employment and betterment are not equally distributed geographically. The disruption can result in unhealthy exposures and environments and income returns for the origin household.

OBJECTIVES

The objectives of the paper are to describe the patterns, levels, and trends of temporary migration in rural northeast South Africa; the mortality trends by cause category over the period 2000-2011; and the associations between temporary migration and mortality by broad cause of death categories.

METHOD

Longitudinal, Agincourt Health and Demographic Surveillance System data are used in a continuous, survival time, competing-risk model.

FINDINGS

In rural, northeast South Africa, temporary migration, which involves migrants relocating mainly for work purposes and remaining linked to the rural household, is more important than age and sex in explaining variations in mortality, whatever the cause. In this setting, the changing relationship between temporary migration and communicable disease mortality is primarily affected by reduced exposure of the migrant to unhealthy conditions. The study suggests that the changing relationship between temporary migration and non-communicable disease mortality is mainly affected by increased livelihood benefits of longer duration migration.

CONCLUSION

Since temporary migration is not associated with communicable diseases only, public health policies should account for population mobility whatever the targeted health risk. There is a need to strengthen the rural health care system, because migrants tend to return to the rural households when they need health care.

ENDURING ECONOMIC HARDSHIP, WOMEN'S EDUCATION, MARRIAGE AND FERTILITY TRANSITION IN KINSHASA

This paper examines fertility transition in Kinshasa, capital of the Democratic Republic of the Congo (DRC) and second-largest city in sub-Saharan Africa. Shapiro (1996) documented the onset of fertility transition in the city, using data from 1990. Women's education was strongly inversely related to fertility, beginning with secondary schooling, and increases in women's education were important in initiating fertility transition in the city. The paper uses data from the 2007 Demographic and Health Survey in the DRC to examine fertility in Kinshasa and assess fertility transition since 1990, a period characterized by severe adverse economic conditions in the DRC. Fertility transition has continued at a strong pace. In part this reflects increased educational attainment of women, but it appears also to be largely a consequence of enduring economic hardship. The ongoing fertility decline has been accompanied by substantial delays in entry to marriage and childbearing, reflecting adverse economic conditions, which in turn have contributed to continuing declines in fertility.

Variations socio-économiques de la fécondité en Côte d’Ivoire : quels groupes ont commencé à réguler leurs naissances ?

Cet article analyse les différences socio-économiques de la fécondité en Côte d’Ivoire. Il met en évidence deux modèles de fécondité dont l’un traditionnel est caractérisé par une fécondité élevée et stable, tandis que l’autre de transition indique une réduction de la fécondité. Ces modèles révèlent l’hétérogénéité des comportements reproductifs, car après contrôle des effets des variables socio-économiques et des déterminants proches, les différences de fécondité continuent d’exister entre les groupes socio-économiques. La progression de la contraception chez les femmes « modernes », explique la diminution de leur fécondité. Il s’agit de femmes qui exercent une activité professionnelle, s’informent sur la planification familiale et lui sont favorables, de même que leurs partenaires. Celles qui n’utilisent pas la contraception manquent surtout d’informations du fait de l’inaccessibilité des centres de planification familiale. Étant donné que ces femmes manifestent la volonté d’espacer les naissances, elles pourraient changer de comportement si elles étaient mieux informées.