Associations between women's perceptions of domestic violence and contraceptive use in seven countries in West and Central Africa

Gender ideology and fertility: evidence for a curvilinear hypothesis

Research on the relationship between fertility and gender ideology revealed inconsistent results. In the present study, we argue that inconsistencies may be due to the fact that such a relationship may be nonlinear. We hypothesize a U-shaped relationship between two dimensions of gender ideology (i.e., primacy of breadwinner role and acceptance of male privilege) and fertility rates. We conducted a cross-national analysis of 60 countries using data from the World Values Survey as well as the World Population Prospects 2019. Controlling for gross domestic product, we found support for a U-shaped relationship between gender ideology and fertility. Higher levels of fertility rates were found at lower and especially higher levels of traditional gender ideology, while a medium level of gender ideology was associated with the lowest fertility rate. This curvilinear relationship is in agreement with the phase of the gender revolution in which the country is located.

Collective norms and modern contraceptive use in men and women: A multilevel analysis of DHS Program data in Nigeria and Zambia

Background: Social norms have long been understood as essential for demographic preferences, intentions and behavior, despite a lack of consistent definitions and measures in the field. Recent work has more clearly defined these norms, both at the individual and community/collective levels. However, past research on the effect of social norms on contraceptive use has focused mainly on the influence of individual-level norms, largely among women only, contributing to mixed findings. Methods: This study addresses this gap through the use of multilevel models to identify associations between collective gender, fertility, and family planning norms and individual use of modern contraceptives for both men and women, using recent Demographic and Health Survey (DHS) data from Nigeria and Zambia. Multiple measures of variation, including community-level random effects and the intraclass correlation, are calculated, providing evidence of the general effect of community factors on behavior. Results: Our findings support the importance of social, demographic and economic context on how collective gender, fertility, and family planning norms relate to modern contraceptive use. Different social norms are associated with use in the two countries, and, even within the same country, men and women’s use are influenced by different norms. Among the examined norms, only collective fertility norms were associated with use for all the groups examined, consistently associated with lower use of modern contraception. Overall, clustering at the community level explained a larger proportion of variance in individual use in men compared to women, suggesting that men’s behavior was more consistently associated with the measured social norms than women’s. Conclusions: These findings suggest that careful attention should be paid to understanding and measuring social norms when considering programs or policy around the provision of modern contraception and that these should not assume that social norms influence men and women’s behaviors in the same way.

A cross-sectional study of women's autonomy and modern contraception use in Zambia

BACKGROUND

Modern contraceptive use effectively prevents unwanted pregnancies, promoting maternal and child health and improving the socio-economic well-being of women and their families. Women's autonomy has been shown to increase the uptake of modern contraception use. This research aimed to investigate the relationship between measures of women's autonomy and modern contraception use among partnered women in Zambia.

METHODS

This cross-sectional survey study used data from the health census, the 2018 Zambia Demographic Health Survey. We measured women's autonomy using three indices: women's participation in decision-making, women's attitude towards wife-beating and women's household status. Information from 6727 women in a relationship, not pregnant, not planning pregnancy and aged between 15 and 49 years old were analyzed using descriptive statistics and adjusted odds ratios (AOR).

RESULTS

The mean age of respondents was 32 years. Most women lived in rural areas (65%), and 81% were protestant. Current modern contraception use among partnered women was 8.8%. Women's autonomy was significantly associated with modern contraception use. Women with moderate autonomy (AOR = 1.054, P value = 0.004, 95% CI 1.048-1.312) and high autonomy (AOR = 1.031, P value = 0.001, 95% CI 1.013-1.562) had higher odds of using modern contraception compared to those with low autonomy. Other factors related to modern contraception use included a higher level of education (AOR = 1.181, P value = 0.012, 95% CI 1.091-1.783), increased wealth index (AOR = 1.230, P value = 0.006, 95% CI 1.105-1.766) and age, 15-24 (AOR = 1.266, P value = 0.007, 95% CI 1.182-2.113,) and 25-34 (AOR = 1.163, P value = 0.002, 95% CI 1.052-1.273).

CONCLUSION

This study argues that increasing women's assertiveness to make independent decisions within the household is cardinal to enhancing the uptake of modern contraception in Zambia and other low-and-middle-income countries. Governments and other stakeholders must therefore consider rolling out programs to boost women's autonomy, which in turn would support gender equality and reproductive health.

Randomized Controlled Trials of Interventions Addressing Intimate Partner Violence in Sub-Saharan Africa: A Systematic Review

BACKGROUND

Intimate partner violence (IPV) perpetrated by males is the most prevalent form of violence against women across the globe. A systematic review was carried out to identify published randomized controlled trials of interventions aiming to prevent or reduce IPV in Sub-Saharan Africa. Details were sought on the interventions, outcomes, and risk of bias in evaluations.

METHODS

Articles were identified by searching MEDLINE, Embase, Web of Science, and PsycInfo. The search included terms pertaining to IPV, the research design, and the target geographical region. To be included, studies needed to have assessed the impact of an intervention on reported incidence, prevalence of IPV, or measures of related attitudes and behaviors. Fifteen papers were included in the final review. Risk of bias was evaluated using the Cochrane Library "Risk of Bias" tool.

RESULTS

Findings suggest that interventions have the potential to reduce IPV-related behaviors and attitudes. Certain types of IPV were more amenable to change than others. Higher levels of efficacy were identified in interventions that had longer follow-up, addressed IPV as a main aim, and occurred at the community level or multiple levels of the social ecology.

CONCLUSIONS

Findings should be interpreted in light of varying risks of bias. Suggestions are made for future research and practice.

Prevalence and factors associated with modern contraceptive use among women of reproductive age in 20 African countries: a large population-based study

OBJECTIVE

To assess the prevalence and factors associated with modern contraceptive (CP) use among women of the reproductive age.

DESIGN

Cross-sectional study.

SETTING

We used data from the Multiple Indicator Cluster Surveys (MICSs) from 20 African countries collected between 2013 and 2018.

PARTICIPANTS

Data on 1 177 459 women aged 15-49 years old.

METHODS

Multivariable logistic regression was used to identify factors associated with modern CP use, while controlling simultaneously for independent variables, and accounting for clustering, stratification and sample weights from the complex sampling design. We used random effects meta-analysis to pool adjusted estimates across the 20 countries.

RESULTS

The overall prevalence of modern CP use was 26% and ranged from 6% in Guinea to 62% in Zimbabwe. Overall, injectable (32%) was the most preferred method of CP, followed by oral pill (27%) and implants (16%). Women were more likely to use a modern CP if they: had a primary (adjusted prevalence odds ratios (aPORs): 1.68, 95% CI: 1.47 to 1.91)) or secondary/higher education (aPOR: 2.16, 95% CI: 1.80 to 2.59) compared with women with no formal education; had no delivery in the last 2 years (aPOR: 3.89, 95% CI: 2.76 to 5.47) compared with women who delivered in the last 2 years; were aged 25-34 years (aPOR: 1.33, 95% CI: 1.20 to 1.47) compared with women aged 15-24 years; were of middle-income status (aPOR: 1.25, 95% CI: 1.11 to 1.39) or rich (aPOR: 1.53, 95% CI: 1.27 to 1.84) compared with poor women and had two or more antenatal care visits compared with women without a visit. Perceived domestic violence was not associated with modern CP use (aPOR: 0.98, 95% CI: 0.92 to 1.05).

CONCLUSION

Our findings are relevant in a global context, particularly in the African region, and improve our understanding on relevant factors essential to increasing modern CP use.

Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries

BACKGROUND

There is ample evidence that gender norms affect contraceptive practice; however, data are mostly qualitative with limited geographical scope. We investigated that association quantitatively using collective community-level attitudes towards premarital sex and wife-beating as proxies for gender norms.

METHODS

Data came from nationally representative Demographic and Health Surveys (2005-2009) for women of reproductive age (15-49 years) in nine sub-Saharan African countries. Using multilevel logistic models, controlling for individual covariates and community-level indicators of women's empowerment, we assessed the community-level association of gender norms regarding premarital sex and wife-beating with individual contraception uptake and demand satisfied among fecund sexually active women. Norms were approximated as 'collective attitudinal norms' from female/male residents (aged 15-49 years) from the same community. We assessed the magnitude and significance of the community-level effects and attributed variance across communities. The same analysis was replicated for each country.

RESULTS

In a fully-adjusted model with a pooled sample of 24 404 adolescent women, the odds of contraception use increased with a 1 standard deviation (SD) increase in the variation of collective permissive attitudes towards premarital sex of female (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.02-1.15) and male (OR = 1.11, 95% CI = 1.05-1.17) peers (15-24 years), while odds of contraceptive use declined by 10% (OR = 0.90, 95% CI = 0.85-0.96) with collective accepting attitudes towards wife-beating of women aged 15-49 years. Similar results were found in separate models that controlled for adults' permissive attitudes towards premarital sex. The community-level attributed variance (V2 = 1.62, 95% CI = 1.45-1.80) represented 33% (intra-class correlation (ICC) = 33.0, 95% CI = 30.0-35.4) of the total variation of contraception use, and attitudes towards premarital sex and violence jointly explained nearly 26% of that V2 variance. The community-level shared of attributed variation of contraceptive use varied significantly across countries, from 3.5% in Swaziland (ICC = 3.5, 95% CI = 0.8-13.7) to 60.2% in Nigeria (OR = 60.2, 95% CI = 56.0-64.2).

CONCLUSIONS

Overall, significant positive associations of collective permissive attitudes of both adolescent and adult women towards premarital sex were found for use of, and demand for, contraception, whereas collective accepting attitudes towards wife-beating were negatively associated with the use and demand for contraception. Ours is the first study to define quantitatively the influence of proxies for gender norms at the community level on women's family planning decisions. These findings offer new insights for understanding the role of sex-related attitudes and norms as important factors in shaping contraceptive practices and improving the effectiveness of family planning policies by targeting individuals as well as their groups of influence.

Women's empowerment in Egypt: the reliability of a complex construct

Women’s empowerment, defined as the process where women acquire enabling resources that enhance their agency, is a strategy employed to improve women’s reproductive health. Agency is conceptualised as the ability to define life choices. However, measures of women’s agency, such as household decision-making, are thought to be unreliable. Null and negative associations between women’s empowerment and reproductive health are often attributed to weak measures of empowerment that are perceived to lack validity and reliability. This study uses the 2006 and 2012 Egyptian Labor Market Panel Survey and the 2008 and 2014 Egyptian Demographic and Health Survey to examine the reliability of measures of women’s agency by considering the effects of women’s individual and household characteristics on women’s agency. Both surveys are nationally representative, from similar time periods and include the same measures of agency – household decision-making and attitudes towards intimate partner violence (IPV). Negative binomial regression models of individual and household determinants of agency demonstrate the degree to which the measures secure consistent results upon repeated application. Results show that the same individual, household, and spousal characteristics were consistently associated with decision-making and attitudes towards IPV in the two surveys. Findings support the conceptualisation of women’s empowerment as household decision-making and attitudes towards IPV in Egypt. This also offers promising evidence for use of these measures in reproductive health research, in women's health programmes, and as part of strategies to improve women’s empowerment.

Factors associated with health facility delivery in West and Central Africa: A multilevel analysis of seven countries

We examined associations between individual and community socioeconomic status (SES) and childbirth in a health facility in West and Central Africa using data from the 2009-2011 United Nations Children's Fund (UNICEF) Multiple Indicator Cluster Survey for women in seven countries (n = 34,487). Individual SES measures were education and wealth; community SES was low or high poverty index. In adjusted results, women residing in communities with high poverty had significantly lower odds of facility delivery than those who lived in more affluent communities in five countries (all p < 0.001). Reducing out-of-pocket healthcare costs may improve women's access to delivery in health facilities.

Integrated Intimate Partner Violence and Human Immunodeficiency Virus Interventions in Sub-Saharan Africa: A Systematic Review Targeting or Including Adolescents

Adolescents in Sub-Saharan Africa are at disproportionately high risk for intimate partner violence (IPV) and human immunodeficiency virus (HIV). The interconnected risks for IPV and HIV present the opportunity for interventions to concurrently seek to reduce violence and sexual risk behaviors among young people. Accordingly, the present systematic review evaluates interventions that concomitantly address IPV and HIV risk among adolescents in Sub-Saharan Africa. The authors systematically reviewed electronic databases for studies meeting the following criteria: use of randomized control trials (RCT) or quasi-RCT in Sub-Saharan African countries; inclusion of adolescents aged 13-18 years; use of a comparison group (wait listed, designated to a comparative treatment, or treatment as usual); and incorporation of IPV and HIV outcome assessments. Results suggested that six studies have utilized rigorous research methodologies to evaluate integrated IPV/HIV interventions; however, few have targeted adolescents. The six studies meeting inclusion criteria indicate that current research on IPV/HIV is conducted with rigorous study designs among target populations with high IPV/HIV risk, using gender-specific risk reduction activities. The authors' findings indicate there is also the need for consistent application of valid and reliable outcome measurements of IPV and HIV risk. Additional research is needed to identify best practices for reducing IPV and HIV incidence among vulnerable adolescent populations in Sub-Saharan Africa.

The prevalence of modern contraceptive use and its associated socio-economic factors in Ghana: evidence from a demographic and health survey of Ghanaian men

OBJECTIVE

This study estimated the prevalence of modern contraceptive use (MCU) and the sociodemographic factors associated with MCU among sexually active men in Ghana. The study is informed by the Health Belief Model, which is used as a conceptual framework for understanding MCU.

STUDY DESIGN

This was a cross-sectional study of 2014 Ghana Demographic and Health Survey data.

METHODS

Analysis was limited to 3373 men who reported being sexually active within the 24-months prior to the survey data collection. Descriptive statistics, Chi-squared test, and multivariable logistic regression analyses were used to estimate the prevalence of MCU and the associated factors affecting contraception use.

RESULTS

The sexually active men ranged in age from 15 to 59 years of whom 26.20% used modern contraceptives. Men who had discussed family planning with a health worker were more likely to use contraceptives compared with men who did not (adjusted odds ratio [AOR] = 1.54; 95% confidence interval [CI] = 1.14-2.08). Men who were undecided about having additional children were more likely to be using modern contraception compared with men who wanted more children (AOR = 1.85; 95% CI = 1.06-3.22). Men with at least a primary education were more likely to use contraception compared with men with no education (AOR = 1.80; 95% CI = 1.23-2.63). Finally, men with multiple sexual partners were more likely to use contraception compared with men with a single sexual partner (AOR = 1.42; 95% CI = 1.09-1.85).

CONCLUSION

There was a low prevalence of MCU among sexually active Ghanaian men. MCU was associated with factors such as education and age.

Intimate partner violence and current modern contraceptive use among married women in Uganda: a cross-sectional study

Introduction

This paper examined the relationship between Intimate Partner Violence (IPV) and current modern contraceptive use (MCU) among married women in Uganda.

Methods

We used the 2011 Uganda Demographic and Health Survey (UDHS) data, selecting a weighted sample of 1,307 married women from the domestic violence module. Chi-squared tests and multivariate complementary log-log (clog-log) regressions were used to examine the relationship between IPV and current MCU, controlling for women's socio-demographic factors.

Results

Significant predictors of current MCU (25.3%) among married women were: women's reported ability to ask a partner to use a condom, number of living children and wealth index. The odds of current MCU were higher among women who could ask their partners to use a condom (aOR = 1.87, 95% CI: 1.26-2.78), had more than one child (aOR = 2.05, 95% CI: 1.07,3.93) and were from better wealth indices for example the richest (aOR = 2.52, 95% CI: 1.25-5.08). IPV was not associated with current MCU independently and after adjusting for women's socio-demographic factors.

Conclusion

In Uganda's context, IPV was not associated with current MCU. Interventions to promote MCU should enhance women's capacity to negotiate MCU within union and target women of lower socio-economic status.

Age-specific factors related to institutional delivery in Nigeria: Insights from the 2011 Multiple Indicator Cluster Survey

With 814 maternal deaths per 100,000 live births, maternal mortality remains a significant public health problem in Nigeria. We examined associations between maternal age and institutional delivery among 9,485 women, using data from the 2011 Nigeria Multiple Indicator Cluster Survey. We used multiple logistic regression to identify enabling factors and barriers to institutional delivery. Older maternal age was positively associated with institutional delivery. In age-stratified, adjusted analyses, secondary/higher education and living in wealthy households were consistently associated with increased odds of institutional delivery among the youngest (15-19 years) and the oldest (40-49 years) women. Higher parity was associated with significantly reduced odds of institutional delivery among women <40 years, but was not associated among women aged 40-49 years. Among women of 40-49 years, attending at least four antenatal care (ANC) visits was associated with increased odds of institutional delivery; among women of ages 15-19 years, the association was not significant. Similarly, having a skilled ANC provider was not significantly associated with institutional delivery among women aged 15-19 and 40-49 years. These findings suggest that women at the highest risk for maternal death may face barriers to institutional delivery services. Focused policies and programs are needed to address women's reproductive health vulnerabilities.

Choice of contraceptive methods by women's status: Evidence from large-scale microdata in Nepal

OBJECTIVE

We aimed to investigate how improvement in women's status affects the choice of contraceptive methods in Nepal.

STUDY DESIGN

We regressed the choice of contraceptive methods on women's status and other controlling variables by employing large-scale microdata representing over 12,000 married women aged 15-49 years in Nepal. Years of schooling and literacy were defined as women's status variables. We estimated how educational attainment affects the choice of contraceptive methods. We also analyzed how fear of their partners affected women's choices.

RESULTS

Female sterilization was the most common choice among the contraceptive methods (25.5% of contraceptive users) in Nepal, followed by injections (19.9%). However, our estimation results showed that these options change with an improvement in women's status. An additional year of education increased the probability that women would choose condoms by 1.2 percentage points (95% confidence interval [CI]: 0.7, 1.6) and decreased the probability of choosing female sterilization by 1.4 percentage points (95% CI: -1.9, -0.8). For the well-educated women, injections and condoms became the first and second choices (29.5% and 21.5%), respectively, while female sterilization was the third option (17.9%) for contraceptive methods. Women's fear of their partners also affected the choice of contraceptive methods. The women who feared their partners were 7.0 percentage points more likely to choose female sterilization than condoms.

CONCLUSION

Improvement in women's status (more education and less fear of their partners) changed their contraceptive behaviors by increasing the probability of choosing condoms and decreasing the probability of choosing female sterilization in Nepal.

Reproductive Health and Bodily Integrity in Tanzania

Several policy initiatives support the empowerment of women to improve their reproductive health. Little is known, however, about the inverse effect that reproductive health might have on women's empowerment. Women are pressured to conform to their reproductive role, and an inability to do so might affect their empowerment, including control over their own body. Using a panel dataset of 504 married women in Northern Tanzania, we find that women who experienced a pregnancy loss show more tolerant views of partner violence and that child mortality lowers their perceived control over the sexual relationship with their spouse. The number of living children did not affect bodily integrity. These results confirm that women's bodily integrity is partly dependent on the ability to fulfill their reproductive role. They strengthen the case for policies and programs that improve women's reproductive health and underline the importance of counselling after pregnancy or child loss.