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Fotso JC, Cleland JG, Adje EO. Cameroon's slow fertility transition: A gender perspective. POPULATION STUDIES 2024; 78:79-91. [PMID: 38470717 DOI: 10.1080/00324728.2023.2297687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 10/09/2023] [Indexed: 03/14/2024]
Abstract
We interrogate the proposition that men's attitudes have constrained the fertility transition in Cameroon, where fertility remains high and contraceptive use low despite much socio-economic progress. We use five Demographic and Health Surveys to compare trends in desired family size among young women and men and analyse matched monogamous couple data from the two most recent surveys to examine wives' and husbands' desires to stop childbearing and their relative influence on current contraceptive use. In 2018, average desired family size was 5.6 and 5.1, for young men and women respectively, and this difference (half a child) has not changed since 1998. Among matched couples, the proportions wanting to stop childbearing were similar in wives and their husbands, but wives perceived husbands to be much more pronatalist than themselves. Surprisingly, men's own reported preferences were more closely associated with contraceptive use than wives' perceptions of husbands' preferences. We discerned little evidence that men's attitudes have impeded reproductive change.
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Sarnak D, Wood SN, Anglewicz P, Gummerson E, Gichangi P, Thiongo M, Moreau C. Differential discontinuation by covert use status in Kenya. Contracept X 2023; 5:100102. [PMID: 37928365 PMCID: PMC10625140 DOI: 10.1016/j.conx.2023.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023] Open
Abstract
Objectives Qualitative research suggests that covert users may be more likely to discontinue contraception due to the logistics of discretion and fear of disclosure. This study sought to quantify whether covert users are more likely to discontinue contraception than overt users. Study design We used a national longitudinal survey from Kenya conducted from November 2019/February 2020 to November 2020/April 2021 to test whether the time to discontinuation between covert and overt users still in need of contraception differed using survival analyses over a period of 5 years since method initiation. Results Multivariate Cox regression results showed there was an interaction with time and covert use on the risk of discontinuation; for every additional month of use, there was an increased risk of discontinuation of covert users compared to overt users (3% increased hazard, p = 0.02). At 1 and 2 years, there were no differences in the hazard of discontinuation (adjusted hazard ratio [aHR]1 year 0.95, 95% CI 0.54-1.65 and aHR2 years 1.37, 95% CI 0.85-2.21), yet at 3, 4, and 5 years, the hazard of discontinuation was higher for covert compared to overt users (aHR3 years 1.99, 95% 1.11-3.56; aHR4 years 2.89, 95% CI 2.0-6.40; aHR5 years 4.18, 95% CI 1.45-12.0). Conclusions These results suggest efforts are needed to support covert users in managing their contraceptive use and for improving contraceptive counseling surrounding covert use. Our findings shed light on the increasing challenge covert users face after approximately the first 2 years of use; covert users require additional follow-up in both research and care provision. Implications Covert users are at a higher risk of discontinuation of contraception while still trying to avoid pregnancy, particularly after the first 2 years of use. Family planning providers and programs must protect access to and maintain the privacy of reproductive services to this population, focusing on follow-up care provision and counseling.
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Affiliation(s)
- Dana Sarnak
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shannon N. Wood
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Phil Anglewicz
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Elizabeth Gummerson
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Peter Gichangi
- International Centre for Reproductive Health Kenya, Nairobi, Kenya
- Department of Public Health and Primary Care, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Mary Thiongo
- International Centre for Reproductive Health Kenya, Nairobi, Kenya
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
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Wood SN, Thomas HL, Thiongo M, Guiella G, Bazié F, Onadja Y, Mosso R, Fassassi R, Gichangi P, Decker MR. Intersection of reproductive coercion and intimate partner violence: cross-sectional influences on women's contraceptive use in Burkina Faso, Côte d'Ivoire and Kenya. BMJ Open 2023; 13:e065697. [PMID: 37164455 PMCID: PMC10173961 DOI: 10.1136/bmjopen-2022-065697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVES Among nationally representative cross-sections of women in need of contraception from Burkina Faso, Côte d'Ivoire and Kenya, we aimed to: (1) examine the intersection of past-year physical/sexual intimate partner violence (IPV), emotional IPV and reproductive coercion (RC) and (2) assess the impact of physical/sexual IPV, emotional IPV and RC on women's contraceptive use outcomes, including current contraceptive use, method type and covert use. DESIGN The present analysis uses cross-sectional female data collected in Burkina Faso (December 2020-March 2021), Côte d'Ivoire (October-November 2021) and Kenya (November-December 2020). SETTINGS Burkina Faso, Côte d'Ivoire and Kenya PARTICIPANTS: Analytical samples were restricted to partnered women with contraceptive need who completed a violence module (Burkina Faso n=1863; Côte d'Ivoire n=1105; Kenya n=3390). PRIMARY AND SECONDARY OUTCOME MEASURES The exposures of interest-past-year emotional IPV, physical/sexual IPV and RC-were assessed using abridged versions of the Revised Conflict and Tactics Scale-2 and Reproductive Coercion Scale, respectively. Outcomes of interest included current contraceptive use, contraceptive method type (female controlled vs male compliant), and covert contraceptive use, and used standard assessments. RESULTS Across sites, 6.4% (Côte d'Ivoire) to 7.8% (Kenya) of women in need of contraception experienced RC; approximately one-third to one-half of women experiencing RC reported no other violence forms (31.7% in Burkina Faso to 45.8% in Côte d'Ivoire), whereas physical/sexual IPV largely occurred with emotional IPV. In multivariable models, RC was consistently associated with covert use (Burkina Faso: aOR 2.84 (95% CI 1.21 to 6.64); Côte d'Ivoire: aOR 4.45 (95% CI 1.76 to 11.25); Kenya: aOR 5.77 (95% CI 3.51 to 9.46)). Some IPV in some settings was also associated with covert use (emotional IPV, Burkina Faso: aOR 2.99 (95% CI 1.56 to 5.74); physical/sexual, Kenya: aOR 2.35 (95% CI 1.33 to 4.17)). CONCLUSIONS Across settings, covert use is a critical strategy for women experiencing RC. Country policies must recognise RC as a unique form of violence with profound implications for women's reproductive health.
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Affiliation(s)
- Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Haley L Thomas
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mary Thiongo
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population, Ouagadougou, Centre, Burkina Faso
| | - Fiacre Bazié
- Institut Supérieur des Sciences de la Population, Ouagadougou, Centre, Burkina Faso
| | - Yentéma Onadja
- Institut Supérieur des Sciences de la Population, Ouagadougou, Centre, Burkina Faso
| | - Rosine Mosso
- Ecole Nationale Superieure de Statistique et d'Economie Appliquee, Abidjan, Côte d'Ivoire
| | - Raimi Fassassi
- Ecole Nationale Superieure de Statistique et d'Economie Appliquee, Abidjan, Côte d'Ivoire
| | - Peter Gichangi
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
- Technical University of Mombasa, Mombasa, Kenya
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Michele R Decker
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
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Fabic MS, McDougal L, Raj A, Jadhav A. Is the Decision Not to Use Contraception an Indicator of Reproductive Agency? Stud Fam Plann 2023; 54:95-117. [PMID: 36790883 DOI: 10.1111/sifp.12235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Women's engagement in the decision to use contraception, an indicator captured in the Demographic and Health Surveys (DHS), is frequently used to assess women's reproductive agency. In 2014, DHS added a corollary question to the women's questionnaire on decision-making not to use contraception. Study authors hypothesize that women's engagement in decision-making not to use contraception is also indicative of reproductive agency. Analyzing DHS microdata from 30 countries collected between 2015 and 2020 (n = 292,141), this country-level study examines data quality in terms of missingness of data (t-tests), indicator utility in terms of response pattern variability (descriptive statistics), and construct validity in terms of associations between engagement in the decision not to use contraception and engagement in household decision-making (multivariable linear regression). Findings indicate the measure is of good quality, provides nuanced insight, and has construct validity. Importantly, the new measure deepens our understanding of women's reproductive agency.
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Affiliation(s)
- Madeleine Short Fabic
- Supervisory Public Health Advisor, United States Agency for International Development, Washington, DC, 20523, USA
| | - Lotus McDougal
- Assistant Professor, Center on Gender Equity and Health, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Anita Raj
- Professor, Director of the Center on Gender Equity and Health, University of California San Diego, San Diego, CA, USA
| | - Apoorva Jadhav
- Senior Technical Advisor for Demography and Health Policy, United States Agency for International Development, Washington, DC, 20523, USA
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Wood SN, Kennedy SR, Akumu I, Tallam C, Asira B, Zimmerman LA, Glass N, Decker MR. Understanding the Link Between Reproductive Coercion and Covert Use of Contraception as a Safety Strategy for Women Experiencing Violence in Nairobi's Urban Informal Settlements. Violence Against Women 2022; 29:1343-1367. [PMID: 36000323 DOI: 10.1177/10778012221108422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This mixed-methods study examined the relationship between reproductive coercion (RC) and covert contraceptive use among intimate partner violence survivors in Nairobi, Kenya. Quantitative analyses utilize baseline data from the myPlan Kenya trial (n = 321). Purposive in-depth interviews (IDIs) (n = 30) explored women's reproductive safety strategies. Multinomial analyses indicated increased covert use and decreased overt use compared to nonuse, for women experiencing RC; logistic models similarly report increased odds of covert use with RC experience. Qualitative data contextualize women's reasons for use and challenges faced. Integration of reproductive safety strategies into family planning and violence services can improve the safe use of contraception.
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Affiliation(s)
- Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Irene Akumu
- Mashinani Department, Ujamaa-Africa, Nairobi, Kenya
| | | | - Ben Asira
- Mashinani Department, Ujamaa-Africa, Nairobi, Kenya
| | - Linnea A Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nancy Glass
- Johns Hopkins School of Nursing, Baltimore, MD, USA.,Department of International Health, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Center for Global Health, 15851Johns Hopkins University, Baltimore, MD, USA
| | - Michele R Decker
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins School of Nursing, Baltimore, MD, USA.,Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Wood SN, Sarnak DO, Kibira SP, Zimmerman LA, Karp C, Makumbi F, Moreau C. Who uses covertly and what is the impact on contraceptive dynamics? Evidence from a national cohort of women in Uganda. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.13667.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Little is known regarding the specific role of covert use (i.e., use of contraception without partner knowledge) in contraceptive discontinuation and switching. Among a nationally representative cohort of women in Uganda, we sought to: 1) compare characteristics of covert, overt, and non-users of contraception at baseline; 2) assess the effect of using contraception covertly on switching and discontinuation over a one-year period. Methods: Analyses utilized PMA2020 Uganda Round 6 (April–May 2018), with longitudinal analyses incorporating data from a one-year follow-up survey (May–June 2019). Both cross-sectional (n=1,764) and longitudinal (n=616) samples included women in need of contraception. For cross-sectional analyses, multinomial regression compared risk of overt/covert use vs. non-use by user characteristics and logistic regression compared the odds of covert vs. overt use among contraceptive users. For longitudinal analyses, multinomial regression examined risk of contraceptive switching and discontinuation by baseline covert vs. overt use status. Results: Among contraceptive users, 14.1% reported using covertly. In cross-sectional analyses, higher wealth (aRRR=1.74; 95% CI=1.19-2.54), secondary or higher education (aRRR=2.52; 95% CI=1.42-4.49), and middle parity (aRRR=1.24; 95% CI=1.00, 2.28) were associated with an increased risk of overt use, and higher wealth (aRRR=2.08; 95% CI=1.09-3.98) and polygyny (aRRR=1.60; 95% CI=1.01-2.54) with covert use, compared to non-use. Among contraceptive users, women within polygynous unions had double the odds of using covertly compared to those with monogamous partners (aOR=1.97; 95% CI=1.28-3.03). Longitudinal analyses revealed large proportions of overt and covert users switched (30% overt, 26% covert) or discontinued methods (32% overt, 37% covert) at one-year follow-up, however, neither switching nor discontinuation was significantly related to overt/covert use status at baseline. Conclusions: Though significant differences by covert use status were not detected, approximately 33% of users discontinued over one year; these women represent important beneficiaries of family planning programming as they may remain at risk for unintended pregnancy.
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Wood SN, Magalona S, Zimmerman LA, OlaOlorun F, Omoluabi E, Akilimali P, Guiella G, Gichangi P, Anglewicz P. Self-injected contraceptives: does the investment reflect women's preferences? BMJ Glob Health 2022; 7:bmjgh-2022-008862. [PMID: 35835480 PMCID: PMC9289037 DOI: 10.1136/bmjgh-2022-008862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/25/2022] [Indexed: 11/04/2022] Open
Abstract
Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is an innovative contraceptive method aimed at meeting women's unique circumstances and needs, largely due to its ability to be self-injected. Substantial research and advocacy investments have been made to promote roll-out of DMPA-SC across sub-Saharan Africa. To date, research on the demand for DMPA-SC as a self-injectable method has been conducted largely with healthcare providers, via qualitative research, or with highly specific subsamples that are not population based. Using three recent rounds of data from Performance Monitoring for Action, we examined population-representative trends in demand, use, and preference for self-injection among current non-users in Burkina Faso, the Democratic Republic of Congo (Kinshasa and Kongo Central regions), Kenya, and Nigeria (Lagos and Kano States). We found that while over 80.0% of women had heard of injectables across settings, few women had heard of self-injection (ranging from 13.0% in Kenya to 24.8% in Burkina Faso). Despite initial increases in DMPA-SC prevalence, DMPA-SC usage began to stagnate or even decrease in all settings in the recent three years (except in Nigeria-Kano). Few (0.0%-16.7%) current DMPA-SC users were self-injecting, and the majority instead were relying on a healthcare provider for administration of DMPA-SC. Among current contraceptive non-users wishing to use an injectable in the future, only 1.5%-11.4% preferred to self-inject. Our results show that self-injection is uncommon, and demand for self-injection is very limited across six settings, calling for further qualitative and quantitative research on women's views on DMPA-SC and self-injection and, ultimately, their contraceptive preferences and needs.
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Affiliation(s)
- Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sophia Magalona
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Linnea A Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Funmilola OlaOlorun
- Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Elizabeth Omoluabi
- Department of Statistics and Population Studies, University of the Western Cape, Bellville, South Africa
| | - Pierre Akilimali
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population/University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Peter Gichangi
- International Centre for Reproductive Health - Kenya (ICRHK), Mombasa, Kenya
| | - Philip Anglewicz
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Sarnak DO, Gemmill A. Perceptions of Partners' Fertility Preferences and Women's Covert Contraceptive Use in Eight sub-Saharan African Countries. Stud Fam Plann 2022; 53:527-548. [PMID: 35767464 PMCID: PMC9545344 DOI: 10.1111/sifp.12206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Covert use of contraception is a common but underreported and understudied phenomenon where one partner uses contraception without the other's knowledge. We used Demographic and Health Survey couple data to examine the relationship between wives’ perceptions of husbands’ fertility preferences and type of contraceptive use (overt vs. covert) in Benin, Ethiopia, Kenya, Mali, Nigeria, Sierra Leone, Uganda, and Zambia using logistic regression. Wives who perceived that their husbands wanted more children than them had increased odds of using covertly, compared to those who perceived that husbands wanted the same number of children in all countries except Benin, and the strength of the relationships ranged from adjusted odds ratio (aOR) 2.89 (95 percent confidence interval (CI) 1.75–4.76) in Zambia to aOR 4.01 (95 percent CI 1.68–9.58) in Mali. Wives who reported not knowing their husbands’ fertility preferences had increased odds of using covertly compared to wives who perceived that their husbands wanted the same number of children in all countries except Zambia, ranging from aOR 2.02 (95 percent CI 1.11–3.69) in Ethiopia to aOR 3.82 (95 percent CI 2.29–6.37) in Kenya. Our findings indicate that efforts to increase partner engagement to align couple's fertility preferences may encourage overt use.
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Affiliation(s)
- Dana O Sarnak
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alison Gemmill
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Sarnak DO, Gummerson E, Wood SN, OlaOlorun FM, Kibira SPS, Zimmerman LA, Anglewicz P. Prevalence and characteristics of covert contraceptive use in the Performance Monitoring for Action multi-country study. Contracept X 2022; 4:100077. [PMID: 35620730 PMCID: PMC9127266 DOI: 10.1016/j.conx.2022.100077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/26/2022] Open
Abstract
Objectives A more nuanced understanding of contributors to covert contraceptive use remains critical to protecting covert users and reducing its necessity. This study aimed to examine the overall prevalence of covert use, and sociodemographic characteristics associated with covert vs overt use across multiple geographies in sub-Saharan Africa and Asia. Study Design Performance Monitoring for Action (PMA) is one of the few nationally representative surveys that measures covert use across socially diverse contexts via a direct question. Utilizing PMA 2019-2020 phase 1 data from Burkina Faso, Côte D'Ivoire, Kenya, Democratic Republic of Congo (DRC; Kinshasa and Kongo Central regions), Uganda, Nigeria (Kano and Lagos), Niger, and Rajasthan, we estimated overall prevalence of covert use. We conducted bivariate analyses and multivariate logistic regressions for 6 sites, comparing the odds of covert use with overt use among users of contraception by sociodemographic characteristics. Results Covert use ranged from 1% in Rajasthan to 16% in Burkina Faso. Marital status was the only sociodemographic characteristic consistently associated with type of use across sites. Specifically, polygynous marriage (compared to monogamous) increased odds of using covertly, ranging from adjusted odds ratio (aOR) of 1.8 [95% confidence interval (CI) 1.2-2.7] in Burkina Faso to 6.2 [95% CI 2.9-13.3] in Kinshasa. Unmarried women with partners or boyfriends were also more likely to be using covertly compared with their monogamously married counterparts in all sites (aORs ranged from 2.2 [95% CI 1.0-4.7] in Uganda to 4.4 [95% CI 1.7-11.0] in Kinshasa). Conclusion Understanding factors associated with covert use has programmatic and policy implications for women's reproductive autonomy. Implications Covert use is a common phenomenon across most sites, representing a small but programmatically important contingent of users. Family planning providers and programs must protect access to and maintain privacy of reproductive services to this population, but should also focus on creating interventions and environments that support overt use.
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Affiliation(s)
- Dana O Sarnak
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Elizabeth Gummerson
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Funmilola M OlaOlorun
- Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Simon Peter Sebina Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Linnea A Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Philip Anglewicz
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Le Voir R. Measuring contraceptive use in a displacement-affected population using the Multiple Indicator Cluster Survey: The case of Iraq. J Migr Health 2022; 6:100114. [PMID: 35677661 PMCID: PMC9168485 DOI: 10.1016/j.jmh.2022.100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 04/19/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
Access to safe, effective, affordable, and acceptable contraceptive methods of choice is a basic right for displaced people. Yet displaced people are typically invisible in national sample surveys on population health, and quantitative evidence on their reproductive health outcomes is limited. This study focuses on the case of Iraq, a country with widespread displacement and where contraceptive use is a government policy priority. Using displacement screening questions in the Iraq 2018 Multiple Indicator Cluster Survey questionnaires, I construct two displacement-related indicators based on reason for last move and previous household residence. Descriptive statistics and binary logistic regression are used to test associations between modern contraceptive use and displacement, demographic, and socioeconomic factors. Controlling for the variables in the models, factors significantly associated with modern contraceptive use among married women aged 15-49 in Iraq are Federal Iraq region (reference Kurdish Region of Iraq, OR 1.78), upper secondary and primary education (reference pre-primary or no education, OR 1.50 and 1.20, respectively), parity, age, and exposure to television. The association between displacement (reason for last move) and modern contraceptive use significantly depends on a woman's level of education and whether they live in an urban or rural area. Women who previously lived in a camp are almost half as likely to use modern contraception compared to other previous residence types. This paper highlights the methodological potential and substantive value of using national household surveys to analyse reproductive health outcomes through a displacement lens. It also critically examines the limitations of these data and measures, drawing on total survey error and feminist theory.
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Affiliation(s)
- Rosanna Le Voir
- Department of Methodology, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom
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Vishwakarma M, Shekhar C. Covert use of reversible contraceptive methods and its association with husband's egalitarian gender attitude in India. BMC Public Health 2022; 22:460. [PMID: 35255867 PMCID: PMC8903557 DOI: 10.1186/s12889-022-12882-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 02/28/2022] [Indexed: 12/04/2022] Open
Abstract
Background In a patriarchal society, women often keep their use of contraceptives secret in order to meet their reproductive goals and satisfy their reproductive preferences. Nevertheless, to our knowledge, women’s covert contraceptive use and its association with husband’s gender attitude have not been studied in the Indian settings. The present study estimates the extent of covert modern contraceptive use (CCU) among women and its linkage with husbands’ gender attitudes in India. Methods The study is based on fecund and monogamous couples using modern, reversible contraceptive methods. The numbers of such couples were 4,825 and 7,824 in the national family health surveys 2005–06 and 2015–16 respectively. The outcome variable in the study was CCU, while the independent variables were husband’s gender attitude, women’s education, freedom of mobility, freedom to spend money independently, surviving number of children, concordance regarding additional children, couple-level information such as age and educational gap between spouses, and some socioeconomic status (SES) variables. We used latent class analysis to measure the gender attitude and used bivariate descriptive analysis and multivariate binary logistic regression to assess the linkages between husband’s gender attitude and CCU. Results This study found that the prevalence of CCU increased from 15% in 2005–06 to 27% in 2015–16. In both the time periods, contraceptive pills were the most preferred covert method, followed by intrauterine device (IUD). The results of the multivariate logistic regression show that women with husbands of moderate and low egalitarian gender attitudes were, respectively, 50% and 40% more likely to hide their contraceptive use than those with husbands of a high gender attitude. Women’s education, wealth index, number of living children, and region of residence were also found to be significantly associated with CCU. Conclusion The study reveals that husband’s low egalitarian gender attitude can be a potential barrier between spouses, preventing them from opening up about their fertility preferences and contraceptive needs to each other. A couple-oriented approach to family planning is needed so that both members of a couple can satisfy their fertility desires and preferences eventually. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12882-x.
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Affiliation(s)
- Minakshi Vishwakarma
- Research Scholar, Department of Fertility and Social Demography, International Institute for Population Sciences, Mumbai, India, 400088
| | - Chander Shekhar
- Professor, Department of Fertility and Social Demography, International Institute for Population Sciences, Mumbai, India, 400088
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Dozier JL, Zimmerman LA, Ejigu BA, Shiferaw S, Seme A, Yihdego M, Yirgu R, Wood SN. Pregnancy coercion and partner knowledge of contraceptive use among Ethiopian women. Contracept X 2022; 4:100084. [PMID: 36193281 PMCID: PMC9525805 DOI: 10.1016/j.conx.2022.100084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jessica L. Dozier
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Corresponding author.
| | - Linnea A. Zimmerman
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Bedilu A. Ejigu
- Department of Statistics, College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mahari Yihdego
- Performance Monitoring for Action Ethiopia, Addis Ababa, Ethiopia
| | - Robel Yirgu
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Shannon N. Wood
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Sarnak DO, Tsui A, Makumbi F, Kibira SPS, Ahmed S. A Panel Study of Fertility Preferences and Contraceptive Dynamics in the Presence of Competing Pregnancy Risks in Uganda. Demography 2021; 58:295-320. [PMID: 33834246 DOI: 10.1215/00703370-8937285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although many studies have examined the influence of women's fertility preferences on subsequent fertility behavior and the role of contraceptive use intentions on unmet need, very few have explored their concurrent effects on contraceptive use dynamics. This study examines the independent concurrent effects of women's fertility preferences and contraceptive intentions on subsequent adoption and discontinuation, treating pregnancy as a competing risk factor that may alter contraceptive need. The data are derived from a 2018 follow-up survey of a 2014 national sample of 3,800 Ugandan female respondents of childbearing age. The survey included a contraceptive calendar that recorded pregnancy, birth, and contraceptive event episodes, including reasons for discontinuation. We use competing risk regression to estimate the effect of fertility preferences and contraceptive intentions on the cumulative incidence function of contraceptive behaviors, accounting for intervening pregnancy, female background covariates, loss to follow-up, and complex survey design. We find that women's contraceptive intentions significantly increase the rate of contraceptive adoption. After having adopted, women's contraceptive intentions have been realized and do not prolong use. The risk of discontinuation among women who adopted after baseline was significantly higher than for those using at baseline, irrespective of their initial intentions. The effectiveness of the type of contraceptive method chosen significantly lowered discontinuation risk. Fertility preferences were not significantly associated with either time to adoption or discontinuation. The pace of the fertility transition in this sub-Saharan African setting is likely being shaped by reproductive regulation through the intentional use of contraception that enables spacing births.
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Affiliation(s)
- Dana O Sarnak
- Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy Tsui
- Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Fredrick Makumbi
- Epidemiology and Biostatistics Department, School of Public Health, Makerere University, Kampala, Uganda
| | - Simon Peter Sebina Kibira
- Community Health and Behavioral Sciences Department, School of Public Health, Makerere University, Kampala, Uganda
| | - Saifuddin Ahmed
- Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Sarnak DO, Wood SN, Zimmerman LA, Karp C, Makumbi F, Kibira SPS, Moreau C. The role of partner influence in contraceptive adoption, discontinuation, and switching in a nationally representative cohort of Ugandan women. PLoS One 2021; 16:e0238662. [PMID: 33434205 PMCID: PMC7802956 DOI: 10.1371/journal.pone.0238662] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/09/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Understanding contraceptive use dynamics is critical to addressing unmet need for contraception. Despite evidence that male partners may influence contraceptive decision-making, few studies have prospectively examined the supportive ways that men influence women's contraceptive use and continuation. OBJECTIVE This study sought to understand the predictive effect of partner influence, defined as partner's fertility intentions and support for contraception, and discussions about avoiding pregnancy prior to contraceptive use, on contraceptive use dynamics (continuation, discontinuation, switching, adoption) over a one-year period. METHODS This study uses nationally representative longitudinal data of Ugandan women aged 15-49 collected in 2018-2019 (n = 4,288 women baseline; n = 2,755 women one-year follow-up). Two analytic sub-samples of women in union and in need of contraception at baseline were used (n = 618 contraceptive users at baseline for discontinuation/switching analysis; n = 687 contraceptive non-users at baseline for adoption analysis). Primary dependent variables encompassed contraceptive use dynamics (continuation, discontinuation, switching, and adoption); three independent variables assessed partner influence. For each sub-sample, bivariate associations explored differences in sociodemographic and partner influences by contraceptive dynamics. Multinomial regression models were used to examine discontinuation and switching for contraceptive users at baseline; logistic regression identified predictors of contraceptive adoption among non-users at baseline. RESULTS Among users at baseline, 26.3% of women switched methods and 31.5% discontinued contraceptive use by follow-up. Multinomial logistic regression, adjusting for women's characteristics, indicated the relative risk of contraceptive discontinuation doubled when women did not discuss pregnancy avoidance with their partner prior to contraceptive use. Partner influence was not related to method switching. Among non-users at baseline, partner support for future contraceptive use was associated with nearly three-fold increased odds of contraceptive adoption. SIGNIFICANCE These results highlight the potentially supportive role of male partners in contraceptive adoption. Future research is encouraged to elucidate the complex pathways between couple-based decision-making and contraceptive dynamics through further prospective studies.
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Affiliation(s)
- Dana O Sarnak
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shannon N Wood
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Linnea A Zimmerman
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Celia Karp
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Simon P S Kibira
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.,Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
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From non-use to covert and overt use of contraception: Identifying community and individual factors informing Nigerian women's degree of contraceptive empowerment. PLoS One 2020; 15:e0242345. [PMID: 33206705 PMCID: PMC7673533 DOI: 10.1371/journal.pone.0242345] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/01/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE In Nigeria, unmet need for contraception is high despite improved access to modern contraception. To identify factors that support Nigerian women's contraceptive decisions to achieve their reproductive goals, in the presence or absence of their partner's support, we seek to identify individual/couple and community level determinants of a spectrum of contraceptive practices, from non-use to covert and overt use of contraception. METHODS Data were drawn from a national probability survey conducted by Performance Monitoring and Accountability 2020 in Nigeria in 2017-2018. A sample of 12,948 women 15-49 years was included, 6433 of whom were in need of contraception at the time of the survey. We conducted bivariate and multivariate analysis to identify individual/couple and community level factors associated with covert use relative to non-use and to overt use of contraception. RESULTS Altogether, 58.0% of women in need of contraception were non-users, 4.5% were covert users and 37.5% used contraception overtly. Covert users were more educated and wealthier than non-users, but less educated and less wealthy than overt users. Covert users were less likely to cohabitate with their partner compared to non-users [AOR = 4.60 (95%CI: 3.06-6.93)] and overt users [AOR = 5.01 (95%CI: 3.24-7.76)] and more likely to reside in urban areas. At the community level, covert users were more likely to live in communities with higher contraceptive prevalence and higher levels of female education relative to non-users. They were also more likely to live in communities with higher female employment [AOR = 1.62, (95%CI: 0.96-2.73)] compared to overt users. CONCLUSION By identifying individual and community level factors associated with the spectrum from non-use to covert use and overt use of contraception, this study highlights the importance of integrating individual and community interventions to support women's realization of their reproductive goals.
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Concordance in spousal reports of current contraceptive use in India. J Biosoc Sci 2020; 53:606-622. [PMID: 32799934 DOI: 10.1017/s0021932020000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Couple-level reports of contraceptive use are important as wives and husbands may report their use differently. Using matched couple data (N = 63,060) from India's NFHS-4 (2015-16), this study examined concordance in spousal reports of current contraceptive use and its differentials. Reporting of contraceptive use was higher among wives (59.0%) than husbands (25.2%). Concordance was low; 16.5% of couples reported the current use of the same method, while 20.4% reported the current use of any method. Many husbands did not report female sterilization as a means of contraception being used by their wives. Reconstruction of contraceptive use among men, based on the 'ever-use of sterilization' question asked to men, increased concordance by 10%. Multivariate analyses showed that concordance was low in urban and southern India, among younger women and among women with a lower wealth index. Men's control over household decision-making and negative attitudes towards contraception were associated with lower concordance. The findings highlight the importance of using couple-level data to estimate contraceptive prevalence, and the role of education programmes to inculcate positive attitudes towards contraception, fostering gender equality and involving men in family planning efforts. The results also raise the issue of data quality as the survey questions were asked differently to men and women, which might have contributed to the wide observed discordance.
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Karp C, Wood SN, Galadanci H, Sebina Kibira SP, Makumbi F, Omoluabi E, Shiferaw S, Seme A, Tsui A, Moreau C. 'I am the master key that opens and locks': Presentation and application of a conceptual framework for women's and girls' empowerment in reproductive health. Soc Sci Med 2020; 258:113086. [PMID: 32521413 PMCID: PMC7369639 DOI: 10.1016/j.socscimed.2020.113086] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/30/2020] [Accepted: 05/22/2020] [Indexed: 11/18/2022]
Abstract
RATIONALE A renewed focus on women's and girls' empowerment in the era of Sustainable Development Goals reflects the belief that empowerment is central to health and development. Sexual and reproductive health (SRH) outcomes, including pregnancy and contraceptive use, may contribute to and result from empowerment. However, enhanced understanding of how women become empowered for SRH requires clear conceptualization of empowerment. OBJECTIVE We aimed to assess the applicability of a proposed framework for women's and girls' SRH empowerment (WGE-SRH) in sub-Saharan Africa. We sought to understand what shapes and motivates preferences for childbearing and contraception, exploring how women and girls navigate external pressures or rewards to exercise and achieve their reproductive goals. METHODS Grounded in the WGE-SRH framework, we conducted a qualitative study in four distinct contexts (Ethiopia, Kano and Anambra States in Nigeria, and Uganda). We implemented and analyzed 120 in-depth interviews and 38 focus group discussions with 440 women and men and translated results to refine the WGE-SRH framework. RESULTS Findings demonstrate the salience of women's internal motivations, including the social value and joys of motherhood, in shaping existence of reproductive choices. However, existence of choice was limited by couples' economic situations, pressures from providers, partners, and family members, and women's fears of contraceptive side effects or relationship dissolution. Despite these constraints, many found ways to exercise their reproductive choices through negotiation with partners, third party involvement in reproductive discussions, non-verbal communication, and covert use of contraception. CONCLUSIONS The WGE-SRH framework is useful for exploring SRH empowerment, embracing the multilevel, dynamic nature of empowerment, as a process transitioning from existence of choice (autonomy) to exercise of choice (self-efficacy, decision-making, negotiation), and, ultimately, to achievement of choice. Future research and programs related to SRH empowerment should distinguish between existence and exercise of choices to promote the health and well-being of women and girls.
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Affiliation(s)
- Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA.
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Hadiza Galadanci
- Center for Advanced Medical Research and Training, Bayero University Kano, Nigeria
| | - Simon Peter Sebina Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University, Uganda
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Uganda
| | | | - Solomon Shiferaw
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Ethiopia
| | - Assefa Seme
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Ethiopia
| | - Amy Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA; Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, F-94805, Villejuif, France
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Kibira SPS, Karp C, Wood SN, Desta S, Galadanci H, Makumbi FE, Omoluabi E, Shiferaw S, Seme A, Tsui A, Moreau C. Covert use of contraception in three sub-Saharan African countries: a qualitative exploration of motivations and challenges. BMC Public Health 2020; 20:865. [PMID: 32503485 PMCID: PMC7275340 DOI: 10.1186/s12889-020-08977-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The balance between increasing men's participation in family planning and rights-based initiatives favoring women's empowerment is highlighted with the issue of covert use of contraception. While covert use has been documented in low- and middle-income countries as a way for women to obtain contraception in light of partner opposition, little is known about women's decision-making processes, actions, and potential consequences of discreet contraceptive use. We aimed to understand women's choices to use contraception covertly and the challenges they faced in concealing their use across three sub-Saharan African countries. METHODS Women aged 15-49 and their male partners were purposively sampled from urban and rural sites in Ethiopia, Northern and Southern Nigeria, and Uganda for 120 in-depth interviews and 38 focus group discussions. Semi-structured interviews explored women's and girls' empowerment surrounding sex, childbearing, and contraception. Interviews were conducted in local languages, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data; covert use codes were reviewed and matrices were created based on themes and sub-themes. RESULTS Findings comprised three thematic areas: the practice of covert contraceptive use and reasons for using covertly; challenges for women who use contraception covertly; and consequences of disclosure or being discovered. While some women initiated using contraception covertly due to tensions within relationships or to keep peace within the home due to known partner opposition, others did not consider family planning to be a male responsibility. Though covert use was commonly discussed, it was also socially sanctioned, and portrayed as an act of female disobedience that questioned the social order of patriarchy. Further challenges of using covertly included lack of financial and social support, and suspicions surrounding delayed fertility and contraceptive-related side effects. Repercussions comprised increased suspicion, threats, or violence, though some women reported improved couple communication with disclosure. CONCLUSIONS Results indicate that while covert use of contraception is common, continued covert use is challenging, especially when side effects manifest. Covert use may further suggest women taking independent action, symbolizing some level of empowerment. Results underscore the importance of disentangling unique reasons for covert use and the severity of repercussions of disclosure.
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Affiliation(s)
- Simon P S Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Selamawit Desta
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Hadiza Galadanci
- Center for Advanced Medical Research and Training, Bayero University Kano, Kano State, Nigeria
| | - Fredrick E Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Elizabeth Omoluabi
- Centre for Research Evaluation Resources and Development, Ile-Ife Osun State, Nigeria
| | - Solomon Shiferaw
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Amy Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, F-94807, Le Kremlin-Bicêtre, France
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