Sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa: Evidence from demographic and health surveys

Unmet need for contraception among women in Benin: a cross-sectional analysis of the Demographic and Health Survey

BACKGROUND

The aim of the current study was to examine the prevalence and predictors of unmet need for contraception among women in sexual unions in Benin.

METHODS

Data for the study was extracted from the recent 2017-2018 Benin Demographic and Health Survey. A weighted sample of 9513 women of reproductive age was included in the study. We used multivariable multilevel binary logistic regression analysis to examine the factors associated with unmet need for contraception.

RESULTS

The prevalence of unmet need for contraception was 38.0% (36.7, 39.2). The odds of unmet need for contraception was higher among women with ≥4 births compared with those with no births, and among those who reported that someone else or others usually made decisions regarding their healthcare compared with those who make their own healthcare decisions. Wealth index was associated with a higher likelihood of unmet need for contraception. Also, the region of residence was associated with unmet need for contraception, with the highest odds being among women from the Mono region (adjusted odds ratio [aOR]=2.18, 95% CI 1.33 to 3.58).

CONCLUSIONS

Our study shows that the unmet need for contraception among women in Benin is relatively high. Our findings call on relevant stakeholders, including government and non-governmental organisations, to enhance women's empowerment as part of interventions that seek to prioritise contraceptive services for women.

Assessment of socio demographic factors on termination of pregnancy in Ghana

AIM

Assessing the socio-demographic factors on termination of pregnancy in Ghana.

DESIGN

Cross-sectional study, using data source from the Demographic Health Survey (DHS).

METHODS

Data pooled from the most recent DHS conducted in Ghana, with variables of interest with rural and urban population coverage. A systematic search of the literature was performed using PubMed, Google Scholar and Elsevier PubMed for the secondary data. Descriptive and logistic regression analysis was performed using Python Pandas' software to estimate the independent effects of the socio-demographic factors on termination of pregnancy in Ghana.

RESULTS

Reported using odds and adjusted OR AOR at 95% confidence level and statistical significance at a p-value of (p > 0.05). Age, place of residence, occupation, currently pregnant, woman's individual sample weight, completeness of current pregnancy, living children + current pregnancy, ethnicity and number of living children significantly predicted the outcome variable.

PATIENT OR PUBLIC CONTRIBUTION

Nurses have an important role to play in providing support, education and counselling to people, and must be equipped with the knowledge and skills (including non-judgmental and compassionate care) necessary to provide care that is sensitive to the diverse needs of people from different socio-demographic backgrounds.

Correlates of Unmet Need for Modern Contraception Among Reproductive-Aged Women Involved in New York City Criminal Legal Systems

Introduction

The population of women involved in criminal legal systems (WICL), a majority of whom are reproductive-aged, has risen steadily in the United States. They contend with numerous barriers to sexual and reproductive health services resulting in high rates of unmet need for contraception and unintended pregnancy.

Materials and Methods

This study included 132 non-pregnancy seeking reproductive-aged WICL enrolled in the baseline assessment of the HIV prevention intervention, "Women on the Road to Health" (WORTH). A multivariate generalized linear logistic regression model with robust estimation examined effects of past 6-month intimate partner violence (IPV; sexual and physical/injurious), past 3-month substance use (binge drinking, cannabis, other illegal drug use), and lifetime mental health diagnoses (anxiety, depression, bipolar disorder) on women's unmet need for modern contraception, adjusting for significant demographic and socioeconomic factors.

Results

Women who were younger in age (odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.63-0.88) and reporting lifetime diagnoses of anxiety disorders (OR: 13.64; 95% CI: 2.71-68.34) were significantly more likely to meet the criteria for unmet need for modern contraception. Women with a regular gynecologist (OR: 0.11; 95% CI: 0.01-0.86) reporting lifetime diagnoses of bipolar disorder and past 6-month sexual IPV histories (OR: 0.04; 95% CI: 0.002-0.86) were significantly less likely to meet the criteria for unmet need for modern contraception.

Conclusions

Distinct mental health diagnoses and experiences of IPV may uniquely impact unmet need for modern contraception among WICL. These findings emphasize the need for a more nuanced comprehension of these relationships to deliver comprehensive and holistic health services that address the intersecting needs of this population.

Trial registration: ClinicalTrials.gov NCT01784809. Registered 6 February 2013.

Effects of a clinic-based reproductive empowerment intervention on proximal outcomes of contraceptive use, self-efficacy, attitudes, and awareness and use of survivor services: a cluster-controlled trial in Nairobi, Kenya

This study was undertaken to evaluate the effect of a reproductive empowerment contraceptive counselling intervention (ARCHES) adapted to private clinics in Nairobi, Kenya on proximal outcomes of contraceptive use and covert use, self-efficacy, awareness and use of intimate partner violence (IPV) survivor services, and attitudes justifying reproductive coercion (RC) and IPV. We conducted a cluster-controlled trial among female family planning patients (N = 659) in six private clinics non-randomly assigned to ARCHES or control in and around Nairobi, Kenya. Patients completed interviews immediately before (baseline) and after (exit) treatment and at three- and six-month follow-up. We use inverse probability by treatment weighting (IPTW) applied to difference-in-differences marginal structural models to estimate the treatment effect using a modified intent-to-treat approach. After IPTW, women receiving ARCHES contraceptive counselling, relative to controls, were more likely to receive a contraceptive method at exit (86% vs. 75%, p < 0.001) and had a significantly greater relative increase in awareness of IPV services at from baseline to three- (beta 0.84, 95% CI 0.13, 1.55) and six-month follow-up (beta 0.92, 95% CI 0, 1.84) and a relative decrease in attitudes justifying RC from baseline to six-month follow-up (beta -0.34, 95% CI -0.65, -0.04). In the first evaluation of a clinic-based approach to address both RC and IPV in a low- or middle-income country (LMIC) context, we found evidence that ARCHES contraceptive counselling improved proximal outcomes related to contraceptive use and coping with RC and IPV. We recommend further study and refinement of this approach in Kenya and other LMICs.Plain Language Summary Reproductive coercion (RC) and intimate partner violence (IPV) are two forms of gender-based violence that are known to harm women's reproductive health. While one intervention, ARCHES - Addressing Reproductive Coercion in Health Settings, has shown promise to improve contraceptive use and help women cope with RC and IPV in the United States, no approach has been proven effective in a low- or middle-income country (LMIC) context. In the first evaluation of a reproductive empowerment contraceptive counselling intervention in an LMIC setting, we found that ARCHES contraceptive counselling, relative to standard contraceptive counselling, improved proximal outcomes on contraceptive uptake, covert contraceptive use, awareness of local violence survives, and reduced attitudes justifying RC among women seeking contraceptive services in Nairobi, Kenya. Distal outcomes will be reported separately. Findings from this study support the promise of addressing RC and IPV within routine contraceptive counselling in Kenya on women's proximal outcomes related to contraceptive use and coping with violence and coercion and should be used to inform the further study of this approach in Kenya and other LMICs.

Women empowerment domains and unmet need for contraception among married and cohabiting fecund women in Sub-Saharan Africa: A multilevel analysis based on gender role framework

BACKGROUND

Low women empowerment, is a known contributing factor to unmet needs for contraception by limiting access to health services through negative cultural beliefs and practices. However, little is known about the association between unmet needs and domains of women empowerment in Sub-Saharan African (SSA) countries. Hence, this study aimed at assessing the influence of women empowerment domains on the unmet need for contraception in the region using the most recent Demographic and Health Survey (DHS) data (2016-2021).

METHODS

The data for the study was derived from the appended women's (IR) file of eighteen SSA countries. A weighted sample of 128,939 married women was analyzed by STATA version 16. The Harvard Institute's Gender Roles Framework, which comprised of influencer, resource, and decision-making domains was employed to identify and categorize the covariates across three levels. The effects of each predictor on the unmet need for spacing and limiting were examined using a multivariable multilevel mixed-effect multinomial logistic regression analysis. Adjusted relative risk ratio (aRRR) with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

RESULTS

The pooled prevalence of unmet needs for contraception was 26.36% (95% CI: 24.83-30.40) in the region, with unmet needs for spacing and limiting being 16.74% (95% CI: 16.55, 17.02) and 9.62% (95% CI: 9.45, 12.78), respectively. Among variables in the influencer domain, educational level, family size of more than five, parity, number of children, attitude towards wife beating, and media exposure were substantially linked with an unmet need for spacing and limiting. Being in the poorest wealth quintile and enrollment in health insurance schemes, on the other hand, were the two variables in the resource domain that had a significant influence on unmet needs. The overall decision-making capacity of women was found to be the sole significant predictor of unmet needs among the covariates in the decision-making domain.

CONCLUSION

Unmet needs for contraception in SSA countries were found to be high. Reproductive health program planners and contraceptive service providers should place due emphasis on women who lack formal education, are from low-income families, and have large family sizes. Governments should collaborate with insurance providers to increase health insurance coverage alongside incorporating family planning within the service package to minimize out-of-pocket costs. NGOs, government bodies, and program planners should collaborate across sectors to pool resources, advocate for policies, share best practices, and coordinate initiatives to maximize the capacity of women's decision-making autonomy.

"I fear those things": non-uptake of contraceptives, and barriers to use among adolescent girls and young women at high risk of HIV infection in Kampala, Uganda

Background

Adolescent girls and young women involved in risky behaviors are vulnerable to multiple health problems, yet sexual and reproductive health services remain underutilized. We evaluated factors associated with non-uptake of contraceptives and barriers to use among adolescent girls and young women (14-24 years old) at high risk of HIV infection in an environment where contraceptives were provided at no cost.

Methods

We conducted a mixed methods study, utilizing data from a baseline cross sectional survey and qualitative in-depth interviews. Survey participants tested negative for pregnancy and reported willingness to use contraception. Non-uptake of contraceptives was defined as not taking contraception at any study visit (baseline and throughout the study). Logistic regression model was used to assess factors associated with non-uptake of contraceptives. We purposively selected participants for interviews to discuss their knowledge and experiences with contraceptives and make suggestions to improve uptake. Qualitative data were analyzed thematically.

Results

All 285 participants were included in the analysis. Out of the 285 participants 127 were not using contraceptives and of the 127, 44 (34.6%) did not take up any method throughout the study while 43 of the 83 remaining participants (who took up a method) chose male condoms only. Non-uptake of contraceptives was less likely among older women (20-24 years) (aOR = 0.32, 95% CI 0.16-0.89) compared to younger women (less than 20 years). Qualitative data showed that concerns about future fertility, fear of associated side effects and influence from close relations contributed to non-uptake of contraception.

Conclusion

Non-uptake of contraceptives was common despite the promotion and provision of contraceptives in the context of a research study mainly because adolescents lack autonomy while making contraceptive decisions. Identifying and addressing their concerns and continued counselling on contraceptive use alongside condom promotion may improve uptake and utilization of contraceptives.

Women's marital status and use of family planning services across male- and female-headed households in low- and middle-income countries

Background

As more households are being led by women, who are often seen as disadvantaged, more attention is being given to the potential association of female household headship with health. We aimed to assess how demand for family planning satisfied by modern methods (mDFPS) is associated with residence in female or male headed households and how this intersects with marital status and sexual activity.

Methods

We used data from national health surveys carried out in 59 low- and middle-income countries between 2010 and 2020. We included all women aged 15 to 49 years in our analysis, regardless of their relationship with the household head. We explored mDFPS according to household headship and its intersectionality with the women's marital status. We identified households as male-headed households (MHH) or female-headed households (FHH), and classified marital status as not married/in a union, married with the partner living in the household, and married with the partner living elsewhere. Other descriptive variables were time since the last sexual intercourse and reason for not using contraceptives.

Results

We found statistically significant differences in mDFPS by household headship among reproductive age women in 32 of the 59 countries, with higher mDFPS among women living in MHH in 27 of these 32 countries. We also found large gaps in Bangladesh (FHH = 38%, MHH = 75%), Afghanistan (FHH = 14%, MHH = 40%) and Egypt (FHH = 56%, MHH = 80%). mDFPS was lower among married women with the partner living elsewhere, a common situation in FHH. The proportions of women with no sexual activity in the last six months and who did not use contraception due to infrequent sex were higher in FHH.

Conclusions

Our findings indicate that a relationship exists between household headship, marital status, sexual activity, and mDFPS. The lower mDFPS we observed among women from FHH seems to be primarily associated with their lower risk of pregnancy; although women from FHH are married, their partners frequently do not live with them, and they are less sexually active than women in MHH.

Sexual violence and self-reported sexually transmitted infections among women in sub-Saharan Africa

Sexual violence has proven to be associated with sexually transmitted infections (STIs) in sub-Saharan Africa (SSA). We examined the association between sexual violence and self-reported STIs (SR-STIs) among women in sexual unions in 15 sub-Saharan African countries. This was a cross-sectional study involving the analysis of data from the Demographic and Health Surveys (DHS) from 15 countries in SSA. A total sample of 65,392 women in sexual unions were included in the final analysis. A multilevel binary logistic regression analysis was carried out and the results were presented using adjusted odds ratios (aOR) at 95% Confidence Interval (CI). Women who experienced sexual violence in the last 12 months were more likely to self-report STIs compared to those who did not experience sexual violence [aOR = 1.76, 95% CI = 1.59-1.94]. Compared to women in Angola, those who were in Mali, Nigeria, Sierra Leone, Uganda, and Liberia were more likely to self-report STIs while those in Burundi, Cameroon, Chad, Ethiopia, Malawi, Rwanda, South Africa, Zambia, and Zimbabwe were less likely to self-report STIs. The study has revealed variations in the country level regarding the prevalence of sexual violence and SR-STI in the last 12 months among women in sexual unions in the selected countries. This study has demostrated that sexual violence in the last 12 months is associated with SR-STIs among women in sexual unions. Moreover, factors that predict SR-STIs were observed in this study. Policymakers and agencies that matter could consider the factors identified in this study when designing policies or strengthening existing ones to tackle STIs among women in SSA. To accelerate the progress towards the achievement of Sustainable Development Goal 3, its imperative efforts and interventions must be intensified in SSA to reduce sexual violence which will go a long way to reduce SR-STIs among women.

Intimate Partner Violence and Unmet Need for Family Planning in Selected South Asian Countries

This article analyzes the relationship between various forms of intimate partner violence (IPV) and unmet need for family planning (FP) in South Asia. The data were obtained from the latest wave of the Demographic and Health Survey in Afghanistan, India, Maldives, Nepal, and Pakistan. Binary logistic regression analyses show mixed results, with a significant association between at least one type of IPV and unmet need for FP in all countries under study, except Maldives. There were also contrasting findings on the IPV-unmet need nexus, with a positive sign in some but negative sign in others. Women who experienced physical violence were associated with a higher odds of having an unmet need in Pakistan, but the opposite was true in Afghanistan and Nepal. The odds of having an unmet need were higher among Indian women who experienced IPV (sexual and emotional). In Afghanistan, women who experienced IPV (physical and emotional) have lower odds of having an unmet need. However, the interaction analysis of IPV (physical and sexual) and partners' controlling behavior showed a positive association with unmet need. Policymakers need to develop policies and strategies to prevent IPV and reduce unmet need for FP, in line with the Sustainable Development Goals.

Women’s healthcare decision-making and unmet need for contraception in Mali

Background

Contraception plays a significant role in fertility regulation. Evidence suggests that reproductive health rights influence contraception use. Women of Mali are noted to have limited control over their healthcare decisions. As a result, this study aimed at investigating the association between women’s healthcare decision-making capacity and unmet need for contraception in Mali.

Methods

This study comprised 6593 women who participated in the 2018 Mali Demographic and Health Survey. Two binary logistic regression models were built. Whilst the first model (crude) involved healthcare decision-making capacity and unmet need for contraception, the second one was a complete model which controlled for all the socio-demographic characteristics. Sample weight was applied and Stata version 13.0 was used for all analyses.

Results

Most of the women were not taking their healthcare decisions alone (92.8%). Nearly four out of ten of them indicated that they had unmet need for contraception (35.7%). Unmet need for contraception was high among women aged 45–49 (50.9%) and low among those aged 15–19 (19.2%). Unmet need for contraception was more probable among women who took their healthcare decisions alone compared to those who did not take their healthcare decisions alone [AOR = 1.35; CI = 1.08–1.70]. Compared with women aged 15–19, unmet need was higher among women aged 45–49 [AOR = 4.58, CI = 3.05–6.86]. Richer women had lower odds of unmet need for contraception compared with poorest women [AOR = 0.77, CI = 0.61–0.97].

Conclusion

Women who took their healthcare decisions alone had higher odds of unmet need for contraception. To increase contraceptive use in Mali, it is imperative to take women’s healthcare decisions into consideration to strengthen existing policies geared towards fertility control and improvement in maternal health to achieve Sustainable Development Goals 3 and 5. Sustainable Development Goal 3 seeks to ensure healthy lives and promote well-being for all at all ages whilst Goal 5 aims at achieving gender equality and empower all women and girls.

Evidence suggests that reproductive health rights influence contraception use. In Mali, women are noted to have limited control over their healthcare decisions. Due to that, this current study explored the relationship between women’s healthcare decision-making capacity and unmet need for contraception in Mali. The sample was 6593 women aged 15–49. About nine out of ten of the women were not taking their healthcare decisions alone and 35.7% indicated that they had unmet need for contraception. Unmet need for contraception dominated among those aged 45–49 (50.9%) but was low among those aged 15–19 (19.2%). Women who took their healthcare decisions alone had high odds of unmet need for contraception. Compared with women aged 15–19, unmet need was nearly five times likely among women aged 45–49. Richer women had lower odds of unmet need for contraception compared with poorest women. To increase contraceptive use in Mali, it is important to take into consideration the variations revealed in this study. This will help to strengthen existing policies geared towards fertility control and improvement in maternal health.

Intimate partner violence and unmet need for family planning in Afghan women: the implication for policy and practice

BACKGROUND

Intimate Partner Violence (IPV) is a serious public health issue and has been linked to a range of adverse health outcomes. This study explored the prevalence of IPV and its relationship with the unmet need for family planning among a sample of married Afghan women aged 18-49 years.

METHODS

This study used the data from Afghanistan Demographic and Health Survey (DHS) conducted in 2015. The data relating to IPV, unmet need for family planning, and sociodemographic characteristics of Afghan women aged 18-49 (n = 20,593) were extracted and analyzed accounting for the sampling weights and survey design in bivariate and multivariate analyses using the STATA software version 14.

RESULTS

An estimated 55.89% experienced some type of IPV during the last 12 months. Unmet need for family planning was documented in less than a third of the population. Illiterate employed women from poorer families who were living in the rural areas were more likely to suffer from any type of IPV. Moreover, those from Pashtun, Tajik, and Pashai ethnic groups had a higher odds of any type of violence compared to the reference group (Turkmen). Illiterate women (OR = 1.37, 95% CI 1.02-1.83) with more than 5 pregnancy experiences (OR = 1.44, 95% CI 1.19-1.74) had more unmet needs for family planning compared to the reference group. The unmet needs were almost 40% and 30% less likely to be observed among women from Pashtun and Tajik ethnic backgrounds compared to the reference group (Turkmen), respectively. The likelihood of having unmet needs was 30% less in those women who suffered from any type of violence.

CONCLUSION

IPV is an important predictor of several adverse health outcomes. The findings portray the disastrous situation of Afghan women's rights violation and violence against them and communicate an important message to the international communities and human rights advocate to take immediate actions in order to mitigate the current situation and prevent the violence against Afghan women to improve the integrity of their reproductive health.

Socio-demographic determinants of pregnancy termination among adolescent girls and young women in selected high fertility countries in sub-Saharan Africa

BACKGROUND

Most of the unintended pregnancies that occur among adolescent girls and young women (AGYW) in sub-Saharan Africa (SSA) end up in pregnancy termination. In this study, the socio-demographic determinants of pregnancy termination among AGYW (aged 15-24) in selected countries with high fertility rates in SSA were examined.

METHODS

This was a cross-sectional analysis of data from the most recent Demographic and Health Surveys of nine countries in SSA. The countries included are Angola, Burkina Faso, Burundi, Chad, Gambia, Mali, Niger, Nigeria, and Uganda. A total of 62,747 AGYW constituted the sample size for the study. Fixed and random effects models were used to examine the determinants of pregnancy termination with statistical significance at p < 0.05.

RESULTS

Higher odds of pregnancy termination were found among AGYW aged 20-24, those who were cohabiting and married, those who listened to radio and watched television at least once a week and those who lived in communities with high literacy level. Conversely, the odds of pregnancy termination were lower among AGYW with three or more births and those with secondary/higher education.

CONCLUSION

The socio-demographic determinants of pregnancy termination among AGYW in this study were age, level of education, marital status, exposure to radio and television, parity, and community literacy level. The findings provide the needed information for designing health interventions to reduce unwanted pregnancies and unsafe abortions in countries with high fertility rates in SSA. It is recommended that governments and non-governmental organisations in these countries should enhance sexuality education and regular sensitization of adolescent sexual and reproductive health programmes targeted at AGYW who are at risk of pregnancy termination.