Spatial variation in contraceptive use in Bangladesh: looking beyond the borders

Geographic weighted regression analysis of hot spots of modern contraceptive utilization and its associated factors in Ethiopia

BACKGROUND

Utilization of modern contraceptives is a common healthcare challenge in Ethiopia. Prevalence of modern contraception utilization is varying across different regions. Therefore, this study aimed to investigate Geographic weighted regression analysis of hotspots of modern contraceptive utilization and its associated factors in Ethiopia, using Ethiopian Demographic and Health Survey 2016 data.

METHODS

Based on the 2016 Ethiopian Demographic Health Survey data, a total weighted sample of 8,673 women was included in this study. For the Geographic Weighted Regression analysis, Arc-GIS version 10.7 and SaTScan version 9.6, statistical software was used. Spatial regression was done to identify factors associated with the hotspots of modern contraceptive utilization and model comparison was carried out using adjusted R2 and AICc. Variables with a p-value < 0.25 in the bi-variable analysis were considered for the multivariable analysis. Multilevel robust Poisson regression analysis was fitted for associated factors since the prevalence of modern contraceptive was >10%. In the multilevel robust Poisson regression analysis, the adjusted prevalence ratio with the 95% confidence interval was reported to declare the statistical significance and strength of association.

RESULT

The prevalence of modern contraceptive utilization in Ethiopia was 37.25% (95% CI: 36.23%, 38.27%). Most of the hotspot areas were located in Oromia and Amhara regions, followed by the SNNPR region and Addis Ababa City administration. Single Women, poor Women, and more fertility preference were significant predictors of hotspots areas of modern contraceptive utilization. In the multivariable multilevel robust Poisson regression analysis, Women aged 25-34 years (APR = 0.88, 95% CI: 0.79, 0.98), 35-49 years (APR = 0.71, 95% CI: 0.61, 0.83), married marital status (APR = 2.59, 95% CI: 2.18, 3.08), Others religions (APR = 0.76, 95% CI: 0.65, 0.89), number of children 1-4 (APR = 1.18, 95% CI: 1.02, 1.37), no more fertility preference (APR = 1.21, 95% CI: 1.11, 1.32), Afar, Somali, Harari, and Dire Dawa: (APR = 0.42, 95% CI: 0.27, 0.67), (APR = 0.06, 95% CI: 0.03, 0.12), (APR = 0.78, 95% CI: 0.62, 0.98), and (APR = 0.75, 95% CI: 0.58, 0.98), respectively. Amhara region (APR = 1.34, 95% CI: 1.13, 1.57), rural residence (APR = 0.80, 95% CI: 0.67, 0.95) High community wealth index (APR = 0.78, 95% CI: 0.67, 0.91) were significantly associated with modern contraceptive utilization.

CONCLUSION AND RECOMMENDATION

There were significant spatial variations of factors affecting modern contraceptive use across regions in Ethiopia. Therefore, public health interventions targeting areas with low modern contraceptive utilization will help to increase modern contraception use considering significant factors at individual and community levels.The detailed map of modern contraceptive use cold spots among reproductive age group and its predictors could assist program planners and decision-makers to design targeted public health interventions.Government of Ethiopia must develop more geographic targeted strategies for improving socioeconomic status of women and availability & accessibility of health facilities in rural areas of the countries.

Small Area Estimation of Age-Specific and Total Fertility Rates in Bangladesh

Bangladesh has experienced a rapid national decline in fertility in recent decades, however, fertility rates vary considerably at the sub-national level (i.e., division). These variations are expected to be more pronounced at lower levels of geography (e.g., district level). However, routinely conducted demographic health surveys are designed for national estimates and do not have adequate samples to produce reliable estimate of fertility rates at lower levels of administrative units, particular when considering district level age-specific fertility rates. Data extracted from the Bangladesh Demographic Health Survey 2014 are used to derive direct estimates of age-specific fertility rates and associated smoothed standard errors. These are used as inputs for developing a small area model, which is expressed in a hierarchical Bayesian framework and fitted by Markov Chain Monte Carlo simulation. The model accounts for variation at different levels—women age-group, division, and district. The modeling results show large reductions in the estimated standards errors and provide consistent estimates of fertility at the detailed district age-specific level. There are significant differences in the fertility levels within and between districts and at the division level. Fertility rates are observed to be higher for Sylhet division and for women aged 20–24 years. We use geo-spatial maps of the fertility rates to visualize the variations over districts, and identify hot and cold-spots to have better targeted local level planning and policy decision making for further reductions in fertility rates in Bangladesh.

Positive deviance in health and medical research on individual level outcomes - a review of methodology

BACKGROUND

Positive deviance as a methodology is increasing in application yet there is high variability in how this approach is applied in health services research.

METHODS

We conducted a scoping review of the literature for positive deviance applied to health outcomes informed by PRISMA-ScR. We searched the literature from 1945 to 2020, including articles on positive deviance or positive outliers, and restricted to examining individual rather than organizational outcomes. We analyzed the methodology applied including the process of identifying deviants, the use of control groups, and the degree of community engagement.

RESULTS

Our initial search identified 1140 manuscripts; we included 104 papers describing 98 studies, 11 topical and one miscellaneous category. Most studies used objective measures of health or survey-based responses to identify deviants from a sub-set of the population at risk. The use of controls was less common in some topics (hospital infections), whereas controls were universally applied in other topics (malnutrition). The degree of community engagement varied widely.

CONCLUSIONS

Positive deviance would benefit from improvements in reporting and standardized approaches to defining deviance. Studies could be improved through clarified definitions of deviance/risk, explicit descriptions of community engagement, and more consistent use of controls.

Geographic variation and associated factors of long-acting contraceptive use among reproductive-age women in Ethiopia: a multi-level and spatial analysis of Ethiopian Demographic and Health Survey 2016 data

Background

High fertility rates and unintended pregnancies are public health concerns of lower and middle income countries such as Ethiopia. Long acting contraceptives (LACs) take the lion’s share in reducing unintended pregnancies and high fertility rates. Despite their numerous advantages, the utilization of LACs remains low in Ethiopia. This study is aimed to explore the geographic variation and associated factors of long acting contraceptive use among reproductive-age women in Ethiopia.

Methods

This is a secondary data analysis of 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total of weighted sample sizes of 10,439 reproductive-age women were included in the final analysis. To clean and analyze the none-spatial data Stata 14 was used while ArcGIS 10.6 and SaTScanTM version 9.6 software were used for spatial analysis. Multilevel Mixed-effect Logistic regression model was used to identify associated factors of LACs utilization. An Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was reported to identify significant variables.

Results

Long acting contraceptive utilization was non-random (Moran’s I: 0.30, p-value < 0.01). Statistically, clusters with significant low utilization of LACs were found in Somali, Afar, Gambela, northern Amhara, eastern Oromia and western part of Southern Nations Nationalities and Peoples (SNNP) regions. Adjusting for other factors such as being married (AOR = 2.51, 95% CI: 1.29–4.87), having one to two (AOR = 2.14, 95% CI: 1.43–3.22), and three to four children (AOR = 1.68, 95% CI: 1.02–2.76), urban (AOR = 1.59, 95% CI: 1.16–2.19), want no more children (AOR = 1.40, 95% CI: 1.08–1.83), working status of women (AOR = 1.33, 95% CI: 1.07–1.65) increased the odds of LACs utilization. While previous history of abortion (AOR = 0.56, 95% CI: 0.39–0.80), and living in the pastoralist community (AOR = 0.22, 95% CI: 0.14–0.35) reduced the odds of LACs utilization in Ethiopia

Conclusions

Significant geographic variation of LACs utilization was observed in Ethiopia. Spots with Low LACs utilization were found in the eastern, north eastern and western part of the country. Socio-demographic and pregnancy related factors were significant determinants of LACs utilization. Designing intervention programs targeting the identified hot spot clusters, and variables that can hinder the utilization of LACs is very important to increase the utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01171-2.

Lower and middle-income countries such as Ethiopia face a challenge of an ever increasing population with high maternal mortality. In Ethiopia, the population is estimated to be more than 110 million. High fertility rates, unintended pregnancy, maternal and child mortalities are the main concerns of the country. Accordingly, it is required of the country to make a robust intervention to limit these public concerns. In relation to this, LACs utilization happens to be one of the solutions to solving the concerns. Despite their efficacy, availability, and acceptability the utilization of LACs remains low and varies among different geographic areas. However, the reason is still undefined and geographic variation was not assessed before.

In our study, we analyze the Ethiopian demographic and health survey 2016 data to assess the presence of significant geographic variation and associated factors of long-acting contraceptive utilization. Hence, a spatial and multilevel analysis were employed to assess the geographic variation and associated factors of LACs utilization in Ethiopia.

A statistically significant geographic variation was observed among different clusters. Clusters with significantly low utilization of LACs were found in the pastoralist (Afar, Gambela, and Somalia) regions of the country. Thus, more organized efforts need to be made to increase the utilization of LACs. Controlling for others: Marital statuses, occupation, future pregnancy interest, urban residence, previous history of abortion, living in the pastoralist community were statistically significant determinant factors of LACs utilization.

In conclusion, significant geographic variation of LACs utilization was observed among different clusters. Besides, different socio-demographic, pregnancy, and child health-related variables were significant determinants of LACs utilization.

Reading the geography of India’s district-level fertility differentials: a spatial econometric approach

India has gradually progressed into fertility transition over the last few decades. However, the timing and pace of this transition has varied notably in terms of both its geography and the demographic groups most affected by it. While much literature exists on the relationships between fertility level and its influence on demographic, economic, socio-cultural and policy-related factors, the potential spatial variations in the effects of these factors on the fertility level remain unaddressed. Using the most recent district-level census data (of 2011) for India, this nationwide study has identified plausible spatial dependencies and heterogeneities in the relationships between the district-wise Total Fertility Rates (TFRs) and their respective demographic, socioeconomic and cultural factors. After developing a geocoded database for 621 districts of India, spatial regression and Geographically Weighted Regression (GWR) models were used to decipher location-based relationships between the district-level TFR and its driving forces. The results revealed that the relationships between the district-level TFR and the considered selected predictors (percentage of Muslims, urbanization, caste group, female mean age at marriage, female education, females in the labour force, net migration, sex ratio at birth and exposure to mass media) were not spatially invariant in terms of their respective strength, magnitude and direction, and furthermore, these relationships were conspicuously place- and context-specific. This study suggests that such locality-based variations and their complexities cannot be explained simply by a single narrative of either socioeconomic advancement or government policy interventions. It therefore contributes to the ongoing debate on fertility research in India by highlighting the spatial dependence and heterogeneity of the impacts made by demographic, socioeconomic and cultural factors on local fertility levels. From a methodological perspective, the study also discerns that the GWR local model performs better, in terms of both model performance and prediction accuracy, compared with the conventional global model estimates.

Rural-urban differentials in fertility levels and fertility preferences in West Bengal, India: a district-level analysis

Fertility in West Bengal is one of the lowest in India, and this relies heavily on the use of traditional methods of contraception. Social scientists and demographers have pointed to the historical role of the diffusion process of adhering to a small family size. The Total Fertility Rate (TFR) in Kolkata district, the state capital, is the lowest in the country, and has been a centre of low fertility historically. However, stark differences in rural-urban fertility rates have existed over the last few decades in West Bengal, but these have now started to narrow. This study aimed to capture the macro-level rural-urban differences in fertility levels and preferences in the West Bengal, and understand how socioeconomic factors affect these. Data were drawn from the Census of India (2011) and NFHS-4 (2015-16). Using census data and the Reverse-Surviving Method, the TFR of West Bengal was estimated to be 1.9, varying between 2.1 and 1.7 in rural and urban areas. The rural-urban gap in the district-level fertility rates was prominent, specifically in districts with higher levels of fertility. Kolkata, Hugli and North Twenty-Four Parganas had the lowest-low fertility (TFR = <1.5). Fewer than half of women with only one living child wanted further children, and this was somewhat higher in rural areas. Around 40% of women had achieved their desired number of children. However, a substantial proportion (43.1%) had a lower number of children than desired, varying between 45.9% and 41.7% in urban and rural areas, respectively. Contraception use, female education and age at marriage, along with the other socioeconomic factors, had a greater influence on rural fertility rates than on urban counterparts in the districts of West Bengal. Further research should be directed at understanding the contemporary fertility decline as well as the gap between ideal and desired number of children, specifically in those districts with very low fertility rates.

Using geographical analysis to identify child health inequality in sub-Saharan Africa

One challenge to achieving Millennium Development Goals was inequitable access to quality health services. In order to achieve the Sustainable Development Goals, interventions need to reach underserved populations. Analyzing health indicators in small geographic units aids the identification of hotspots where coverage lags behind neighboring areas. The purpose of these analyses is to identify areas of low coverage or high need in order to inform effective resource allocation to reduce child health inequity between and within countries. Using data from The Demographic and Health Survey Program surveys conducted in 27 selected African countries between 2010 and 2014, we computed estimates for six child health indicators for subnational regions. We calculated Global Moran's I statistics and used Local Indicator of Spatial Association analysis to produce a spatial layer showing spatial associations. We created maps to visualize sub-national autocorrelation and spatial clusters. The Global Moran's I statistic was positive for each indicator (range: 0.41 to 0.68), and statistically significant (p <0.05), suggesting spatial autocorrelation across national borders, and highlighting the need to examine health indicators both across countries and within them. Patterns of substantial differences among contiguous subareas were apparent; the average intra-country difference for each indicator exceeded 20 percentage points. Clusters of cross-border associations were also apparent, facilitating the identification of hotspots and informing the allocation of resources to reduce child health inequity between and within countries. This study exposes differences in health indicators in contiguous geographic areas, indicating that specific regional and subnational, in addition to national, strategies to improve health and reduce health inequalities are warranted.

Identifying factors influencing contraceptive use in Bangladesh: evidence from BDHS 2014 data

Background

Birth control is the conscious control of the birth rate by methods which temporarily prevent conception by interfering with the normal process of ovulation, fertilization, and implantation. High contraceptive prevalence rate is always expected for controlling births for those countries that are experiencing high population growth rate. The factors that influence contraceptive prevalence are also important to know for policy implication purposes in Bangladesh. This study aims to explore the socio-economic, demographic and others key factors that influence the use of contraception in Bangladesh.

Methods

The contraception data are extracted from the 2014 Bangladesh Demographic and Health Survey (BDHS) data which were collected by using a two stage stratified random sampling technique that is a source of nested variability. The nested sources of variability must be incorporated in the model using random effects in order to model the actual parameter effects on contraceptive prevalence. A mixed effect logistic regression model has been implemented for the binary contraceptive data, where parameters are estimated through generalized estimating equation by assuming exchangeable correlation structure to explore and identify the factors that truly affect the use of contraception in Bangladesh.

Results

The prevalence of contraception use by currently married 15–49 years aged women or their husbands is 62.4%. Our study finds that administrative division, place of residence, religion, number of household members, woman’s age, occupation, body mass index, breastfeeding practice, husband’s education, wish for children, living status with wife, sexual activity in past year, women amenorrheic status, abstaining status, number of children born in last five years and total children ever died were significantly associated with contraception use in Bangladesh.

Conclusions

The odds of women experiencing the outcome of interest are not independent due to the nested structure of the data. As a result, a mixed effect model is implemented for the binary variable ‘contraceptive use’ to produce true estimates for the significant determinants of contraceptive use in Bangladesh. Knowing such true estimates is important for attaining future goals including increasing contraception use from 62 to 75% by 2020 by the Bangladesh government’s Health, Population & Nutrition Sector Development Program (HPNSDP).

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5098-1) contains supplementary material, which is available to authorized users.

The cultural evolution of fertility decline

Cultural evolutionists have long been interested in the problem of why fertility declines as populations develop. By outlining plausible mechanistic links between individual decision-making, information flow in populations and competition between groups, models of cultural evolution offer a novel and powerful approach for integrating multiple levels of explanation of fertility transitions. However, only a modest number of models have been published. Their assumptions often differ from those in other evolutionary approaches to social behaviour, but their empirical predictions are often similar. Here I offer the first overview of cultural evolutionary research on demographic transition, critically compare it with approaches taken by other evolutionary researchers, identify gaps and overlaps, and highlight parallel debates in demography. I suggest that researchers divide their labour between three distinct phases of fertility decline--the origin, spread and maintenance of low fertility--each of which may be driven by different causal processes, at different scales, requiring different theoretical and empirical tools. A comparative, multi-level and mechanistic framework is essential for elucidating both the evolved aspects of our psychology that govern reproductive decision-making, and the social, ecological and cultural contingencies that precipitate and sustain fertility decline.

ROLE OF COMMUNITY AND CONTEXT IN CONTRACEPTIVE BEHAVIOUR IN RURAL WEST BENGAL, INDIA: A MULTILEVEL MULTINOMIAL APPROACH

Studies examining the influence of community-level interactions and contextual/supply-side factors in determining contraceptive choices have yielded mixed results in the context of rural India. Using small-scale survey data of 1348 women from rural West Bengal and by employing multilevel multinomial logit models, this study tested the influence of these factors after controlling for various socio-demographic and individual-level socioeconomic factors. The study reveals that supply-side intervention strategies, i.e. addressing outreach and advocacy activities and socio-religious needs at the community level, are essential prerequisites to breaking away from the predominance of sterilization in the contraceptive method-mix and enhancing the adoption of modern reversible contraceptives for improved spacing of births - a crucial factor in maternal and child health outcomes.

State variations in women's socioeconomic status and use of modern contraceptives in Nigeria

BACKGROUND

According to the 2014 World Population Data Sheet, Nigeria has one of the highest fertility and lowest contraceptive prevalence rates around the world. However, research suggests that national contraceptive prevalence rate overshadows enormous spatial variations in reproductive behavior in the country.

OBJECTIVE

I examined the variations in women's socioeconomic status and modern contraceptive use across states in Nigeria.

METHODS

Using the 2013 Nigeria Demographic and Health Survey data (n = 18,910), I estimated the odds of modern contraceptive use among sexually active married and cohabiting women in a series of multilevel logistic regression models.

RESULTS

The share of sexually active, married and cohabiting women using modern contraceptives widely varied, from less than one percent in Kano, Yobe, and Jigawa states, to 40 percent in Osun state. Most of the states with low contraceptive prevalence rates also ranked low on women's socioeconomic attributes. Results of multilevel logistic regression analyses showed that women residing in states with greater shares of women with secondary or higher education, higher female labor force participation rates, and more women with health care decision-making power, had significantly higher odds of using modern contraceptives. Differences in women's participation in health care decisions across states remained significantly associated with modern contraceptive use, net of individual-level socioeconomic status and other covariates of modern contraceptive use.

CONCLUSION

Understanding of state variations in contraceptive use is crucial to the design and implementation of family planning programs. The findings reinforce the need for state-specific family planning programs in Nigeria.

Social network- and community-level influences on contraceptive use: evidence from rural Poland

The diffusion of 'modern' contraceptives-as a proxy for the spread of low-fertility norms-has long interested researchers wishing to understand global fertility decline. A fundamental question is how local cultural norms and other people's behaviour influence the probability of contraceptive use, independent of women's socioeconomic and life-history characteristics. However, few studies have combined data at individual, social network and community levels to simultaneously capture multiple levels of influence. Fewer still have tested if the same predictors matter for different contraceptive types. Here, we use new data from 22 high-fertility communities in Poland to compare predictors of the use of (i) any contraceptives-a proxy for the decision to control fertility-with those of (ii) 'artificial' contraceptives-a subset of more culturally taboo methods. We find that the contraceptive behaviour of friends and family is more influential than are women's own characteristics and that community level characteristics additionally influence contraceptive use. Highly educated neighbours accelerate women's contraceptive use overall, but not their artificial method use. Highly religious neighbours slow women's artificial method use, but not their contraceptive use overall. Our results highlight different dimensions of sociocultural influence on contraceptive diffusion and suggest that these may be more influential than are individual characteristics. A comparative multilevel framework is needed to understand these dynamics.

An exploratory spatial analysis of geographical inequalities of birth intervals among young women in the Democratic Republic of Congo (DRC): a cross-sectional study

BACKGROUND

The length of time between two successive live births (birth interval), is associated with child survival in the developing world. Short birth intervals (<24 months) contribute to infant and child mortality risks. Contraceptive use contributes to a reduction in short birth intervals, but evidence is lacking in the DRC. We aimed to investigate the proportion of short birth intervals at the provincial level among young women in the DRC.

METHODS

Data from the Demographic and Health Survey undertaken in the DRC in 2007 were analyzed. Logistic regression and Bayesian geo-additive models were used to explain provincial inequalities in short birth intervals among women of reproductive age and young women. Posterior odds ratio (OR) and 95% credible region (CR) were estimated via Markov chain Monte Carlo (MCMC) techniques. Posterior spatial effects and the associated posterior probability maps were produced at the provincial-level to highlight provinces with a significant higher risk of short birth interval.

RESULTS

The overall proportion of short birth intervals among all women of reproductive age (15-49 years) and young women (15-24 years) were 30.2% and 38.7% respectively. In multivariate Bayesian geo-additive regression analyses, among the whole sample of women, living in rural areas [OR = 1.07, 95% CR: (0.97, 1.17)], exclusive breastfeeding [1.08 (1.00, 1.17)] and women with primary education [1.06 (1.00, 1.16)], were consistently associated with a higher risk of short birth intervals. For the young women, none of the factors considered were associated with the risk of short birth interval except a marginal effect from the lack of education. There was a spatial variation in the proportion of women reporting short birth intervals and among all women of reproductive age across provinces, with Nord-Kivu [1.12 (1.02, 1.24)], Sud Kivu [1.17 (1.05, 1.29)] and Kasai Occidental [1.18 (1.06, 1.32)] reporting a higher risk of short birth intervals. For young women, the higher risk provinces were Nord-Kivu [1.22 (1.00, 1.54)] and Sud Kivu [1.34 (1.14, 1.63)].

CONCLUSIONS

This study suggests distinct geographic patterns in the proportion of short birth intervals among Congolese women, as well as the potential role of demographic and geographic location factors driving the ongoing higher youth fertility, higher childhood and maternal mortality in the DRC.

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

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

Microcredit and domestic violence in Bangladesh: an exploration of selection bias influences

This article explores the relationship between women's participation in microcredit groups and domestic violence in Bangladesh. Several recent studies have raised concern about microcredit programs by reporting higher levels of violence among women who are members. These results, however, may be attributable to selection bias because members might differ from nonmembers in ways that make them more susceptible to violence to begin with. Using a sample of currently married women from the 2007 Bangladesh Demographic Health Survey (BDHS) (N = 4,195), we use propensity score matching (PSM) as a way of exploring selection bias in this relationship. Results suggest that the previously seen strong positive association between membership and violence does not hold when an appropriate comparison group, generated using PSM, is used in the analyses. Additional analyses also suggest that levels of violence do not differ significantly between members and nonmembers and instead could depend on context-specific factors related to poverty. Members for whom a match is not found report considerably higher levels of violence relative to nonmembers in the unmatched group. The background characteristics of members and nonmembers who do not match suggest that they are more likely to be younger and from relatively well-to-do households.

Routes to low mortality in poor countries revisited

In June 1986, Population and Development Review published a highly influential article by John Caldwell entitled “Routes to Low Mortality in Poor Countries.” Amid growing anxiety over decelerating world mortality decline, Caldwell explored social and political pathways to mortality success on the basis of two lists of superior mortality achievers and exceptionally poor mortality achievers, countries whose mortality rankings drastically differed from their income rankings. To mark the quarter-century since Caldwell's study and chart new pathways, this article looks at the subsequent performance of Caldwell's original exceptional achievers and develops an updated list of achievers. Analysis highlights the presence of many more poor achievers today; the rising importance of adult mortality as a marker of exceptional achievement; the increasing success of countries in Latin America and the Muslim world; the continued success of China, Vietnam, Cuba, and Costa Rica. dramatic improvements in schooling outcomes, particularly for women, have reduced the importance of education as a determinant of superior achievement. Reinforcing Caldwell's original assertions, the synthesis highlights how interactions between social consensus, health care systems, and human capital dependence offer a pathway to superior achievement. These forces may be especially powerful at moments of national crisis.

Contextual influences on contraceptive use in the Eastern Cape, South Africa

This paper uses linked individual and health facility data from the 1998 South Africa Demographic and Health Survey and the 1998 Eastern Cape Facility Survey to explore community and health facility influences on modern contraceptive use. Several pathways of influence between the community and individual contraceptive adoption are identified, centering primarily on the community climate of female autonomy. Few significant effects of the health facility environment on contraceptive adoption are identified. The residual variation in contraceptive use highlights the deficits that exist in current datasets for capturing community influences on contraceptive behavior.

Contextual influences on modern contraceptive use in sub-Saharan Africa

OBJECTIVES

We examined the role of community-level factors in explaining geographic variations in modern contraceptive use in 6 African countries.

METHODS

We analyzed Demographic and Health Survey and contextual data sources with multilevel modeling techniques to identify factors contributing to geographic variations in women's use of modern contraceptives.

RESULTS

We found significant associations between several community-level factors and reported use of modern contraceptive methods. We also identified several pathways of influence between the community and the individual.

CONCLUSIONS

Aspects of a community's sociocultural and economic environment appear to influence a woman's use of modern contraceptive methods.

Contextual influences on the use of health facilities for childbirth in Africa

OBJECTIVES

Previous studies of maternal health-seeking behavior focused on individual- and household-level factors. We examined community-level influences on the decision to deliver a child in a health facility across 6 African countries.

METHODS

Demographic and Health Survey data were linked with contextual data, and multilevel models were fitted to identify the determinants of childbirth in a health facility in the 6 countries.

RESULTS

We found strong community-level influences on a woman's decision to deliver her child in a health facility. Several pathways of influence between the community and individual were identified.

CONCLUSIONS

Community economic development, the climate of female autonomy, service provision, and fertility preferences all exert an influence on a woman's decision to seek care during labor, but significant community variation remains unexplained.

Popular perceptions of emerging influences on mortality and longevity in Bangladesh and West Bengal

Relatively little is known about how environmental and pathological threats to human survival and longevity are perceived by the public. In this study in rural Bangladesh and West Bengal, India, which used individual interviews and focus-group discussions to investigate the changing costs of and motivations for reproduction, respondents were questioned about their perceptions of changes in mortality. The findings show that, while child mortality levels are perceived to have fallen dramatically in recent times, the health and survival prospects of the middle aged and the elderly are seen to have been better in the past. The perceived decline in adult health is attributed to environmental deterioration and lifestyle changes accompanying modernization. This paper explores people's reasons for this unexpected worldview. References to pesticides and chemical fertilizers as causes of death abound in their explanations and are seen to be associated with unhealthy agricultural practices and impiety.

Women's status and domestic violence in rural Bangladesh: individual- and community-level effects

We explore the determinants of domestic violence in two rural areas of Bangladesh. We found increased education, higher socioeconomic status, non-Muslim religion, and extended family residence to be associated with lower risks of violence. The effects of women's status on violence was found to be highly context-specific. In the more culturally conservative area, higher individual-level women's autonomy and short-term membership in savings and credit groups were both associated with significantly elevated risks of violence, and community-level variables were unrelated to violence. In the less culturally conservative area, in contrast, individual-level women's status indicators were unrelated to the risk of violence, and community-level measures of women's status were associated with significantly lower risks of violence, presumably by reinforcing nascent normative changes in gender relations.