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Cotton C. Child Fostering and Family Size Preferences in Uganda. Stud Fam Plann 2024; 55:23-43. [PMID: 38351477 DOI: 10.1111/sifp.12259] [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: 03/24/2024]
Abstract
Mothers who exceed their ideal family size (IFS) may find themselves caring for more children than desired. In the absence of reliable and desirable prenatal controls of family size, mothers may foster-out children to reduce burdens of childrearing, particularly in contexts where fostering is common. Using six rounds of Demographic and Health Surveys collected in Uganda between 1988 and 2016, I explore the relationship between exceeding IFS and child out-fostering, proposing that fostering-out may serve to manage excess fertility and that this relationship may change as actual and desired fertility declines. Models are run separately for mothers and children aged 0-17 to explore mothers' overall out-fostering behavior versus out-fostering strategies for children. Results at the mother level suggest a strong positive relationship between exceeding IFS and out-fostering that remains relatively stable over time, but results at the child level indicate children's age explains the relationship between mothers' exceeding IFS and being fostered-out, demonstrating the nuances of how family size preferences might impact family life in practice. Though mothers report a desire for smaller families over time, childbearing and childrearing behaviors, including high fertility and child out-fostering, remain consistent over the course of Uganda's fertility transition, signifying the central role out-fostering plays in Ugandan families.
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Affiliation(s)
- Cassandra Cotton
- School of Social and Family Dynamics, Arizona State University, Tempe, AZ, 85287, USA
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Awoonor‐Williams JK, Phillips JF. Developing organizational learning for scaling-up community-based primary health care in Ghana. Learn Health Syst 2022; 6:e10282. [PMID: 35036554 PMCID: PMC8753302 DOI: 10.1002/lrh2.10282] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Achieving effective community-based primary health care requires evidence for guiding strategic decisions that must be made. However, research processes often limit data collection to particular organizational levels or disseminate results to specific audiences. Decision-making that emerges can fail to account for the contrasting perspectives and needs of managers at each organizational level. The Ghana Health Service (GHS) addressed this problem with a multilevel and sequential research and action approach that has provided two decades of implementation learning for guiding community-based primary health care development. METHOD The GHS implementation research initiatives progressed from (i) a participatory pilot investigation to (ii) an experimental trial of strategies that emerged to (iii) replication research for testing scale-up, culminating in (iv) evidence-based scale-up of a national community-based primary health care program. A reform process subsequently repeated this sequence in a manner that involved stakeholders at the community, sub-district, district, and regional levels of the system. The conduct, interpretation, and dissemination of results that emerged comprised a strategy for achieving systems learning by conducting investigations in phases in conjunction with bottom-up knowledge capture, lateral exchanges for fostering peer learning at each system level, and top-down processes for communicating results as policy. Continuous accumulation of qualitative data on stakeholder reactions to operations at each organizational level was conducted in conjunction with quantitative monitoring of field operations. RESULTS Implementation policies were enhanced by results associated with each phase. A quasi-experiment for testing the reform process showed that scale-up of community-based primary health care was accelerated, leading to improvements in childhood survival and reduced fertility. CONCLUSION Challenges to system learning were overcome despite severe resource constraints. The integration of knowledge generation with ongoing management processes institutionalized learning for achieving evidence-driven program action.
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Affiliation(s)
| | - James F. Phillips
- Heilbrunn Department of Population and Family Health, Mailman School of Public HealthColumbia UniversityNew YorkNew YorkUSA
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Remera E, Chammartin F, Nsanzimana S, Forrest JI, Smith GE, Mugwaneza P, Malamba SS, Semakula M, Condo JU, Ford N, Riedel DJ, Nisingizwe MP, Binagwaho A, Mills EJ, Bucher H. Child mortality associated with maternal HIV status: a retrospective analysis in Rwanda, 2005-2015. BMJ Glob Health 2021; 6:e004398. [PMID: 33975886 PMCID: PMC8118007 DOI: 10.1136/bmjgh-2020-004398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Child mortality remains highest in regions of the world most affected by HIV/AIDS. The aim of this study was to assess child mortality rates in relation to maternal HIV status from 2005 to 2015, the period of rapid HIV treatment scale-up in Rwanda. METHODS We used data from the 2005, 2010 and 2015 Rwanda Demographic Health Surveys to derive under-2 mortality rates by survey year and mother's HIV status and to build a multivariable logistic regression model to establish the association of independent predictors of under-2 mortality stratified by mother's HIV status. RESULTS In total, 12 010 live births were reported by mothers in the study period. Our findings show a higher mortality among children born to mothers with HIV compared with HIV negative mothers in 2005 (216.9 vs 100.7 per 1000 live births) and a significant reduction in mortality for both groups in 2015 (72.0 and 42.4 per 1000 live births, respectively). In the pooled reduced multivariable model, the odds of child mortality was higher among children born to mothers with HIV, (adjusted OR, AOR 2.09; 95% CI 1.57 to 2.78). The odds of child mortality were reduced in 2010 (AOR 0.69; 95% CI 0.59 to 0.81) and 2015 (AOR 0.35; 95% CI 0.28 to 0.44) compared with 2005. Other independent predictors of under-2 mortality included living in smaller families of 1-2 members (AOR 5.25; 95% CI 3.59 to 7.68), being twin (AOR 4.93; 95% CI 3.51 to 6.92) and being offspring from mothers not using contraceptives at the time of the survey (AOR 1.6; 95% CI 1.38 to 1.99). Higher education of mothers (completed primary school: (AOR 0.74; 95% CI 0.64 to 0.87) and secondary or higher education: (AOR 0.53; 95% CI 0.38 to 0.74)) was also associated with reduced child mortality. CONCLUSIONS This study shows an important decline in under-2 child mortality among children born to both mothers with and without HIV in Rwanda over a 10-year span.
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Affiliation(s)
- Eric Remera
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Global Health Equity, Kigali, Rwanda
| | - Frédérique Chammartin
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Sabin Nsanzimana
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
- University of Global Health Equity, Kigali, Rwanda
| | - Jamie Ian Forrest
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
| | | | - Placidie Mugwaneza
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
| | | | - Muhammed Semakula
- Institute of HIV, Disease Prevention and Control, Rwanda Biomedical Center, Gasabo, City of Kigali, Rwanda
- Center for Excellence in Data Science, University of Rwanda - Kigali Campus, Kigali, Rwanda
- Centre for Statistics, Hasselt University Faculty of Business Economics, Hasselt, Limburg, Belgium
| | - Jeanine U Condo
- National University of Rwanda School of Public Health, Kigali, Rwanda
- Tulane University, New Orleans, Louisiana, USA
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - David J Riedel
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marie Paul Nisingizwe
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
| | | | - Edward J Mills
- Cytel, Vancouver, British Columbia, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Heiner Bucher
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics Department of Clinical Research, University Hospital Basel, Basel, Switzerland
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Yargawa J, Machiyama K, Ponce Hardy V, Enuameh Y, Galiwango E, Gelaye K, Mahmud K, Thysen SM, Kadengye DT, Gordeev VS, Blencowe H, Lawn JE, Baschieri A, Cleland J. Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study. Popul Health Metr 2021; 19:6. [PMID: 33557851 PMCID: PMC7869206 DOI: 10.1186/s12963-020-00227-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes. METHODS The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight. RESULTS Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention. CONCLUSIONS We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.
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Affiliation(s)
- Judith Yargawa
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Kazuyo Machiyama
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Ponce Hardy
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Yeetey Enuameh
- Kintampo Health Research Centre, Kintampo, Ghana
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Edward Galiwango
- IgangaMayuge Health and Demographic Surveillance System, Makerere University Centre for Health and Population Research, Makerere, Uganda
| | - Kassahun Gelaye
- Dabat Research Centre Health and Demographic Surveillance System, Dabat, Ethiopia
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Kaiser Mahmud
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Sanne M. Thysen
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Centre for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Research Open Patient data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
| | - Damazo T. Kadengye
- Data, Measurement and Evaluation Unit, African Population and Health Research Centre, Nairobi, Kenya
| | - Vladimir Sergeevich Gordeev
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E. Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Angela Baschieri
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - John Cleland
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
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Biney AAE, Wright KJ, Kushitor MK, Jackson EF, Phillips JF, Awoonor-Williams JK, Bawah AA. Being ready, willing and able: understanding the dynamics of family planning decision-making through community-based group discussions in the Northern Region, Ghana. GENUS 2021; 77:1. [PMID: 33456069 PMCID: PMC7788016 DOI: 10.1186/s41118-020-00110-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 12/11/2020] [Indexed: 11/29/2022] Open
Abstract
Regional contraceptive use differentials are pronounced in Ghana, with the lowest levels occurring in the Northern Region. Community-based health services, intended to promote maternal and child health and family planning use, may have failed to address this problem. This paper presents an analysis of qualitative data on community perspectives on family planning "readiness," "willingness," and "ability" compiled in the course of 20 focus group discussions with residents (mothers and fathers of children under five, young boys and girls, and community elders) of two communities each in two Northern Region districts that were either equipped with or lacking direct access to community health services. The study districts are localities where contraceptive use is uncommon and fertility is exceptionally high. Results suggest that direct access to community services has had no impact on contraceptive attitudes or practice. Widespread method knowledge is often offset by side-effect misperceptions. Social constraints are prominent owing to opposition from men. Findings attest to the need to improve the provision of contraceptive information and expand method choice options. Because societal acceptance and access in this patriarchal setting is critical to use, frontline worker deployment should prioritize strategies for outreach to men and community groups with prominent attention to social mobilization themes and strategies that support family planning.
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Affiliation(s)
- Adriana A. E. Biney
- Regional Institute for Population Studies (RIPS), University of Ghana, P. O. Box LG 96, Legon, Accra, Ghana
| | - Kalifa J. Wright
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
| | - Mawuli K. Kushitor
- Regional Institute for Population Studies (RIPS), University of Ghana, P. O. Box LG 96, Legon, Accra, Ghana
| | - Elizabeth F. Jackson
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
| | - James F. Phillips
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
| | - John Koku Awoonor-Williams
- Policy, Planning, Monitoring and Evaluation (PPME) Division, Ghana Health Service, Private Mail Bag, Ministries, Accra, Ghana
| | - Ayaga A. Bawah
- Regional Institute for Population Studies (RIPS), University of Ghana, P. O. Box LG 96, Legon, Accra, Ghana
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Cleland J, Machiyama K, Casterline JB. Fertility preferences and subsequent childbearing in Africa and Asia: A synthesis of evidence from longitudinal studies in 28 populations. Population Studies 2019; 74:1-21. [DOI: 10.1080/00324728.2019.1672880] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Yeatman S, Smith-Greenaway E. Birth Planning and Women's and Men's Health in Malawi. Stud Fam Plann 2018; 49:10.1111/sifp.12060. [PMID: 29998555 PMCID: PMC6414279 DOI: 10.1111/sifp.12060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite the frequency with which it occurs, we know little about unintended fertility in sub-Saharan Africa and even less about its implications for the health of the women and men who experience it. We use longitudinal data from southern Malawi to explore how young adults report on the planning of their births and to identify changes in their self-rated health and subjective well-being associated with having more- or less-planned births. Our data feature a comprehensive scale of pregnancy planning, the London Measure of Unplanned Pregnancy (LMUP), that extends beyond the conventional focus on timing-based pregnancy intentions to incorporate information about contraception, desires, intentions, partner discussion, and preconception preparations. Women and men have similar bimodal distributions on the LMUP, with the majority of births clearly unplanned or planned but a sizeable minority that falls in the middle. Change score models demonstrate that, for women, an unplanned birth is associated with a decline in self-rated health. In contrast, men whose births were ambivalently-planned experience a decline in subjective well-being. Our findings highlight the value of considering the full spectrum of birth planning and demonstrate the health consequences of unplanned fertility for both women and men in this sub-Saharan context.
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Affiliation(s)
- Sara Yeatman
- Department of Health and Behavioral Sciences, University of Colorado Denver
- Institute of Behavioral Science, University of Colorado Boulder
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