Early Sexual Debut and Its Associated Factors Among Young Women Aged 15-24 in Mali: A Multilevel Analysis.

Early sexual debut is associated with increased risk of several sexual and reproductive health problems, including unwanted pregnancies and sexually transmitted infections. Hence, determining factors that promote early sexual initiation is significant to guide policy and inform interventions aimed to promote the health of young people through to adulthood. This study examined the prevalence of early sexual debut and its associated factors among young women in Mali. Using cross-sectional nationally representative data from the 2018 Mali Demographic and Health Survey, a total of 4063 young women aged 15-24 were included in the study. Multilevel binary logistic regression analysis was done to determine the factors associated with early sexual debut. The results were presented using adjusted odds ratios (aOR) and 95% confidence intervals (CIs). The prevalence of early sexual debut in Mali was 17.8% (95% CI; 16-19.7%). Young women who attended higher school had lower odds of early sexual debut (aOR = 0.10, 95% CI; 0.01-0.82) compared to young women who had no formal education. Young women from richest households had lower odds of early sexual debut compared to those from the poorest households (aOR = 0.48, 95% CI; 0.27-0.82). Young women from households with large family size also had lower odds of experiencing early sexual debut compared to those in small family size (aOR = 0.81, 95% CI; 0.66-0.99). Furthermore, the odds of early sexual debut were lower among young women in Koulikoro (aOR = 0.59, 95% CI; 0.39-0.90), Sikasso (aOR = 0.35, 95% CI; 0.21-0.56), Segou (aOR = 0.40, 95% CI; 0.25-0.64), and Mopti (aOR = 0.44, 95% CI; 0.23-0.82) regions compared to young women in Kayes region. Higher odds of early sexual debut were found among currently employed compared to not currently employed young women (aOR = 1.74, 95% CI; 1.42-2.12) and currently married compared to not currently married young women (aOR = 4.64, 95% CI; 3.64-5.92). Young women from the Peulh ethnic groups compared to those from the Bambara ethnic groups were at a higher odds of early sexual debut (aOR = 1.43, 95% CI; 1.03-1.99). The findings suggest the need for interventions aimed at addressing early sexual debut among young women. These can include emphasizing the promotion and importance of female education, addressing the cultural practices that promote negative sexual norms/practices such as child marriages, and ensuring social change through efforts such as creating employment or economic opportunities for families.

High-risk fertility behaviours among women in sub-Saharan Africa.

BACKGROUND: High-risk fertility behaviours such as too early or advanced age at delivery, shorter birth interval, birth order and a higher number of live births to a woman often lead to adverse maternal and child health outcomes. We assessed high-risk fertility behaviours and their associated factors among women in sub-Saharan Africa (SSA). METHODS: Data on 200 716 women pooled from the demographic and health surveys of 27 countries conducted between 2010 and 2020 in SSA were analysed. High-risk fertility behaviour from four indicators, mother aged <18 years at the time of delivery; mother aged >34 years at the time of delivery; mother of a child born after a short birth interval (<24 months) and mother of high parity (>3 children), was derived. Multi-level multi-variable logistic regression analyses were carried out and the results were presented as adjusted odds ratios at 95% confidence interval. RESULTS: Women who were in polygamous marriages had higher odds of single and multiple high-risk fertility behaviour compared with their counterparts who were in monogamous marriages. Women with middle or high maternal decision-making power had higher odds of single and multiple high-risk fertility behaviours compared with those with low decision-making power. Single and multiple high-risk fertility behaviours were lower among women with access to family planning, those with at least primary education and those whose partners had at least primary education compared with their counterparts who had no access to family planning, those with no formal education and those whose partners had no formal education. CONCLUSION: Family structure, women's decision-making power, access to family planning, women's level of education and partners' level of education were identified as predictors of high-risk fertility behaviours in SSA. These findings are crucial in addressing maternal health and fertility challenges. Policy makers, maternal health and fertility stakeholders in countries with high prevalence of high parity and short birth intervals should organize programs that will help to reduce the prevalence of these high-risk factors, taking into consideration the factors that predispose women to high-risk fertility behaviours.

Association between women's household decision-making autonomy and health insurance enrollment in sub-saharan Africa.

BACKGROUND: Out of pocket payment for healthcare remains a barrier to accessing health care services in sub-Saharan Africa (SSA). Women's decision-making autonomy may be a strategy for healthcare access and utilization in the region. There is a dearth of evidence on the link between women's decision-making autonomy and health insurance enrollment. We, therefore, investigated the association between married women's household decision making autonomy and health insurance enrollment in SSA. METHODS: Demographic and Health Survey data of 29 countries in SSA conducted between 2010 and 2020 were analyzed. Both bivariate and multilevel logistic regression analyses were carried out to investigate the relationship between women's household decision-making autonomy and health insurance enrollment among married women. The results were presented as an adjusted odds ratio (AOR) and the 95% confidence interval (CI). RESULTS: The overall coverage of health insurance among married women was 21.3% (95% CI; 19.9-22.7%), with the highest and lowest coverage in Ghana (66.7%) and Burkina Faso (0.5%), respectively. The odds of health insurance enrollment was higher among women who had household decision-making autonomy (AOR = 1.33, 95% CI; 1.03-1.72) compared to women who had no household decision-making autonomy. Other covariates such as women's age, women's educational level, husband's educational level, wealth status, employment status, media exposure, and community socioeconomic status were found to be significantly associated with health insurance enrollment among married women. CONCLUSION: Health insurance coverage is commonly low among married women in SSA. Women's household decision-making autonomy was found to be significantly associated with health insurance enrollment. Health-related policies to improve health insurance coverage should emphasize socioeconomic empowerment of married women in SSA.

Exploring health insurance and knowledge of the ovulatory cycle: evidence from Demographic and Health Surveys of 29 countries in Sub-Saharan Africa.

BACKGROUND: Unplanned pregnancy continues to be a major public health concern in Sub-Saharan Africa (SSA). Understanding the ovulatory cycle can help women avoid unplanned pregnancy. Though a wide range of factors for ovulatory cycle knowledge in SSA countries has not been well assessed, the influence of health insurance on ovulatory cycle knowledge is largely unknown. As a result, we set out to investigate the relationship between health insurance enrollment and knowledge of the ovulatory cycle among women of childbearing age. This study aims to investigate the relationship between health insurance enrollment and knowledge of the ovulatory cycle among women of childbearing age in sub-Saharan Africa (SSA). METHODS: Demographic and Health Surveys (DHSs) data from 29 SSA countries were analyzed. The association between health insurance and ovulatory cycle knowledge was investigated using bivariate and multivariate multilevel logistic regression models among 372,692 women of reproductive age (15-49). The findings were presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). A p-value of 0.05 was considered statistically significant. RESULTS: The pooled result shows that the prevalence of knowledge of ovulatory cycle in the studied 29 SSA countries was 25.5% (95% CI; 24.4%-26.6%). Findings suggest higher odds of ovulatory cycle knowledge among women covered by health insurance (AOR = 1.27, 95% CI; 1.02-1.57), with higher education (higher-AOR = 2.83, 95% CI; 1.95-4.09), from the richest wealth quintile (richest-AOR = 1.39, 95% CI; 1.04-1.87), and from female headed households (AOR = 1.16, 95% CI; 1.01-1.33) compared to women who had no formal education, were from the poorest wealth quintile and belonged to male headed households, respectively. We found lower odds of ovulatory cycle knowledge among women who had 2-4 parity history (AOR = 0.80, 95% CI; 0.65-0.99) compared to those with history of one parity. CONCLUSIONS: The findings indicate that the knowledge of the ovulatory cycle is lacking in SSA. Improving health insurance enrollment should be considered to increase ovulatory cycle knowledge as an approach to reduce the region's unplanned pregnancy rate. Strategies for improving opportunities that contribute to women's empowerment and autonomy as well as sexual and reproductive health approaches targeting women who are in poorest quintiles, not formally educated, belonging to male headed households, and having high parity should be considered.

Association between women's empowerment and diarrhoea in children under five years: evidence from the 2017/18 Benin Demographic and Health Survey.

Globally, diarrhoea is the third leading cause of death for under five-children. Women's empowerment can significantly reduce under-five mortality due to diarrhoea. This study investigated the association between women's empowerment and childhood diarrhoea in Benin using data from the 2017/18 Benin Demographic and Health Survey. A total of 7979 currently married women were included in the study. A logistic regression model was used to control for possible confounders. The prevalence of diarrhoea among children under five years of age was 13.6%. About 36.3% of the currently married women decided either alone or together with their husband on their own health, purchase of large household items and visiting family/relatives. Close to 65.4% of currently married women disagreed with all five reasons to justify wife-beating. The children of mothers who had decision-making power were less likely to have diarrhoea (aOR = 0.74, 95% CI: 0.57-0.96) than the children of mothers who had no decision-making power. Moreover, the children of mothers who disagreed with all five reasons to justify wife-beating (aOR = 0.79, 95% CI: 0.65-0.96) were less likely to have diarrhoea than the children of mothers who accepted wife-beating as a part of life. Women's age, educational level, wealth index and region were associated with childhood diarrhoea in Benin. The role of women's empowerment, as determined by decision-making power and wife-beating attitude, was found to be significantly associated with the risk of childhood diarrhoea in Benin, after adjusting for other variables. Therefore, it is essential for policymakers in Benin to reinforce strategies and interventions focusing on women's empowerment to avert childhood mortality caused by diarrhoea. This includes improving household economic status, women's education and decision-making power and enhancing awareness of women's human and democratic rights.

Disparities in use of skilled birth attendants and neonatal mortality rate in Guinea over two decades.

BACKGROUND: Maternal mortality remains high in sub-Saharan African countries, including Guinea. Skilled birth attendance (SBA) is one of the crucial interventions to avert preventable obstetric complications and related maternal deaths. However, within-country inequalities prevent a large proportion of women from receiving skilled birth attendance. Scarcity of evidence related to this exists in Guinea. Hence, this study investigated the magnitude and trends in socioeconomic and geographic-related inequalities in SBA in Guinea from 1999 to 2016 and neonatal mortality rate (NMR) between 1999 and 2012. METHODS: We derived data from three Guinea Demographic and Health Surveys (1999, 2005 and 2012) and one Guinea Multiple Indicator Cluster Survey (2016). For analysis, we used the 2019 updated WHO Health Equity Assessment Toolkit (HEAT). We analyzed inequalities in SBA and NMR using Population Attributable Risk (PAR), Population Attributable Fraction (PAF), Difference (D) and Ratio (R). These summary measures were computed for four equity stratifiers: wealth, education, place of residence and subnational region. We computed 95% Uncertainty Intervals (UI) for each point estimate to show whether or not observed SBA inequalities and NMR are statistically significant and whether or not disparities changed significantly over time. RESULTS: A total of 14,402 for SBA and 39,348 participants for NMR were involved. Profound socioeconomic- and geographic-related inequalities in SBA were found favoring the rich (PAR = 33.27; 95% UI: 29.85-36.68), educated (PAR = 48.38; 95% UI: 46.49-50.28), urban residents (D = 47.03; 95% UI: 42.33-51.72) and regions such as Conakry (R = 3.16; 95% UI: 2.31-4.00). Moreover, wealth-driven (PAF = -21.4; 95% UI: -26.1, -16.7), education-related (PAR = -16.7; 95% UI: -19.2, -14.3), urban-rural (PAF = -11.3; 95% UI: -14.8, -7.9), subnational region (R = 2.0, 95% UI: 1.2, 2.9) and sex-based (D = 12.1, 95% UI; 3.2, 20.9) inequalities in NMR were observed between 1999 and 2012. Though the pattern of inequality in SBA varied based on summary measures, both socioeconomic and geographic-related inequalities decreased over time. CONCLUSIONS: Disproportionate inequalities in SBA and NMR exist among disadvantaged women such as the poor, uneducated, rural residents, and women from regions like Mamou region. Hence, empowering women through education and economic resources, as well as prioritizing SBA for these disadvantaged groups could be key steps toward ensuring equitable SBA, reduction of NMR and advancing the health equity agenda of "no one left behind."

Individual and community-level determinants of knowledge of ovulatory cycle among women of reproductive age in 29 African countries: a multilevel analysis.

BACKGROUND: Knowledge of the ovulatory cycle (KOC) can help reduce the chances of unwanted pregnancies and may improve a woman's reproductive health. However, little is known about the factors associated with knowledge of the ovulatory cycle across Africa. Therefore, we aimed to investigate the individual/household and community level determinants of KOC among women of childbearing age in 29 African countries. METHODS: We used data from the Demographic and Health Surveys of 29 African countries conducted between 2010 and 2020. Bivariate and multivariate multilevel logistic regressions were used to examine the association between women's correct knowledge of the ovulatory cycle and individual/household and community-level factors. The results were reported using adjusted odds ratios (AOR) with a 95% confidence interval (CI). RESULTS: The pooled results showed that correct KOC among women was 15.5% (95% CI 14.2-17.0%), varying from 11.5% in Liberia to 57.1% in the Democratic Republic of Congo. Regarding regional distribution, the highest prevalence of KOC was observed in West Africa (38.8%) followed by East Africa (21.3%) and was lowest in Southern Africa (15.6%) and Central Africa (15.5%). After adjusting for potential confounders, at the individual level, we found the odds of KOC to be higher among older women (40-44 years-aOR 3.57, 95% CI 1.90-6.67, 45-49 years-aOR 2.49, 95% CI 1.29-4.82), and women with higher educational level (aOR 2.58, 95% CI 1.40-4.75); at the community level, higher KOC was among women exposed to media (aOR 2.24, 95% CI 1.32-3.81). CONCLUSIONS: Knowledge of ovulatory cycle among women of reproductive age was found to be low in the region and varied by country. Women's age and educational level were the individual-level factors associated with increased knowledge of ovulatory cycle while community-level media exposure was found to be associated with increased knowledge of ovulatory cycle in this study. This finding highlights the need for appropriate strategies (possibly use of mass media) to increase knowledge of ovulatory cycle among women of reproductive age, especially among adolescents in Africa.

Women's decision-making power and knowledge of prevention of mother to child transmission of HIV in sub-Saharan Africa.

BACKGROUND: Sub-Saharan Africa (SSA) bears the highest burden of Human Immunodeficiency Virus (HIV) in the world. Even though the prevention of mother to child transmission (PMTCT) programmme is one of the strategies to control the HIV pandemic, the uptake in SSA countries is low. Women's decision-making power has a positive influence on health seeking behavior and uptake of several maternal health services. However, its relationship with knowledge of PMTCT services is understudied in SSA. Therefore, this study aimed to examine the association between women's decision-making power and knowledge of PMTCT in 24 countries in SSA. METHODS: Analysis of this study included data on 158,812 married women from the Demographic and Health Surveys of 24 sub-Saharan African countries conducted between 2010 and 2020. Using Stata version-14 software, bivariate and multivariable logistic regression analyses were conducted. The results were presented using adjusted odd ratios (aOR) with the corresponding 95% confidence intervals (CI). RESULTS: In the pooled results, 69.5% (95% CI; 66.7-72.1%) of married women in the studied countries had knowledge of PMTCT, ranging from 13.9% (95% CI; 11.9-16.2%) in Comoros to 75.4% (95% CI; 73.7-76.9%) in Zimbabwe. Higher odds of PMTCT knowledge were seen among married women who had decision-making power compared to married women who had no decision-making power. Moreover, we found higher odds of PMTCT knowledge among married women with manual occupation, those in the richest households and those with 1-2 children compared to married women who were not working, from the poorest households, and those with no children, respectively. CONCLUSION: Women's decision-making power had positive influence on PMTCT knowledge. To increase the coverage of PMTCT knowledge, policy makers and other stakeholders need to target ways to empower women through increasing women's decision-making power. Moreover, creating employment opportunities and economic empowerment for women need to be considered, especially in countries with very low coverage of PMTCT knowledge.

Understanding the factors associated with married women's attitudes towards wife-beating in sub-Saharan Africa.

BACKGROUND: Intimate partner violence remains a major public health problem, especially in countries in sub-Saharan Africa. We examined the factors associated with married women's attitudes towards wife-beating in sub-Saharan Africa. METHODS: We used Demographic and Health Survey data of 28 sub-Saharan African countries that had surveys conducted between 2010 and 2019. A sample of 253,782 married women was considered for the analysis. Bivariate and multivariate logistic regression analyses were carried out, and the results were presented using crude odds ratio (cOR) and adjusted odds ratio (aOR) at 95% confidence interval. RESULTS: The pooled result showed about 71.4% of married women in the 28 countries in this study did not justify wife-beating. However, the prevalence of non-justification of wife-beating varied from 83.4% in Malawi to 17.7% in Mali. Women's age (40-44 years-aOR = 1.61, 95% CI 1.16-2.24), women's educational level (secondary school-aOR = 1.47, 95% CI 1.13-1.91), husband's educational level (higher-aOR = 0.55, 95% CI 0.31-0.95), women's occupation type (professional, technical or managerial-aOR = 1.66, 95% CI 1.06-2.62), wealth index (richest-aOR = 5.52, 95% CI 3.46-8.80) and women's decision-making power (yes-aOR = 1.39, 95% CI 1.19-1.62) were significantly associated with attitude towards wife-beating. CONCLUSION: Overall, less than three-fourth of married women in the 28 sub-Saharan African countries disagreed with wife-beating but marked differences were observed across socio-economic, decision making and women empowerment factors. Enhancing women's socioeconomic status, decision making power, and creating employment opportunities for women should be considered to increase women's intolerance of wife-beating  practices, especially among countries with low prevalence rates such as Mali.

Inequalities in childhood stunting: evidence from Sudan multiple indicator cluster surveys (2010-2014).

BACKGROUND: Leaving no one behind has been an important marker of the Sustainable Development Goals. Closing the gap in malnutrition between children of different backgrounds aligns well with the tenet of this international agenda. To this end, high-quality evidence of the magnitude and trends of socioeconomic and geographic related existing inequalities in the childhood stunting among Sudanese children emanate from this study help for policy maker and planners to design and implement effective interventions to narrow down inequality. METHODS: We used the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) for our analysis of stunting inequality. Following standard equity analysis methods recommended by the WHO, we performed the disaggregated analysis of stunting across five equity stratifiers: Wealth, education, residence, sex, and sub-national regions. Then, we summarized stunting inequality through four measures of inequality: Difference, Ratio, Slope Index of Inequality (SII), and Relative Index of Inequality (RII). The point estimates of stunting were accompanied by 95% confidence intervals to measure the statistical significance of the findings. RESULTS: In this study, the national average childhood stunting prevalence was increased by 4% from 2010 to 2014. The findings revealed stark inequalities in stunting in all the studied dimensions of inequality. Huge inequality has existed along the wealth quintiles. Simple difference measure for education was increased by four points and simple relative measure decreased by one point for economic status. CONCLUSIONS: Sex, residence and, geographically related inequalities remain unchanged over time, while economic status and educational inequality had seen a change by some inequality measures over the same time period.

Health insurance coverage and timely antenatal care attendance in sub-Saharan Africa.

INTRODUCTION: Out-of-pocket payments for healthcare remain a significant health financing challenge in sub-Saharan Africa (SSA), preventing women from using maternal health services. There is a paucity of empirical literature on the influence of health insurance coverage on the timeliness of antenatal care (ANC) attendance in low- and middle-income countries. In this study, we examined the association between health insurance coverage and timely ANC attendance among pregnant women in SSA. METHODS: Secondary data from Demographic and Health Surveys conducted between 2015 and 2020 in sixteen (16) sub-Saharan African countries with 113,918 women aged 15-49 years were included in the analysis. The outcome variable was the timing of antenatal care (ANC). A multilevel binary logistic regression analysis was carried out to determine the association between health insurance coverage and timely ANC. RESULTS: The overall coverage of health insurance and timely antenatal attendance among pregnant women in SSA were 4.4% and 39.0% respectively. At the country level, the highest coverage of health insurance was found in Burundi (24.3%) and the lowest was in Benin (0.9%). For timely ANC attendance, the highest prevalence was in Liberia (72.4%) and the lowest was in Nigeria (24.2%). The results in the model showed that women who were covered by health insurance were more likely to have timely ANC attendance compared to those who were not covered by health insurance (aOR = 1.21, 95% CI = 1.11-1.31). CONCLUSION: Our findings show that that being covered under health insurance is associated with higher likelihood of seeking timely ANC attendance. To accelerate progress towards achievement of the Sustainable Development Goal targets by the year 2030, we recommend that governments and health insurance authorities across the sub-Saharan African countries actively implement health insurance policies as well as roll out health educational programmes that facilitate and ensure increased coverage of health insurance.

Women's household decision-making power and contraceptive use in Mali.

BACKGROUND: Utilization of contraceptives remains low in several countries in sub-Saharan Africa despite evidence of its benefits. Several factors are associated with contraceptive use. However, little is known about the association between women's decision-making capacity and the utilization of contraceptives in Mali. This study sought to determine the effect of women's household decision-making power on contraceptive use in Mali. METHODS: This study involved a cross-sectional analysis of data from the 2018 Mali Demographic and Health Survey. A total of 7893 married women were included in the final analysis. A binary logistic regression analysis was conducted with statistical significance set at p < 0.05. RESULTS: Contraceptive use among married women in Mali was 17.1%. The odds of using contraceptives were higher among women with joint decision-making with their husbands on how to spend respondent's earnings [aOR = 1.79; 95% CI = 1.12, 2.85], joint decision-making with their husbands on what to do with their husband's earnings [aOR = 1.43; 95% CI = 1.12, 1.83], and joint decision-making with husband on large household purchases [aOR = 1.32; 95% CI = 1.10, 1.59]. Deciding alone on a visit to family or relatives was associated with lower odds of contraceptive use [AOR = 0.72; 95% CI = 0.58, 0.89]. CONCLUSION: The study has revealed that joint household decision-making is positively associated with contraceptive use. Therefore, to achieve Sustainable Development Goal 3, the ministry for the advancement of women, children and families and related stakeholders must unearth strategies to empower women in joint decision-making and encourage men's involvement in contraceptive decision-making.

Pregnant women's decision-making capacity and adherence to iron supplementation in sub-Saharan Africa: a multi-country analysis of 25 countries.

BACKGROUND: Anaemia and related complications during pregnancy is a global problem but more prevalent in sub-Sahara Africa (SSA). Women's decision-making power has significantly been linked with maternal health service utilization but there is inadequate evidence about adherence to iron supplementation. This study therefore assessed the association between household decision-making power and iron supplementation adherence among pregnant married women in 25 sub-Saharan African countries. METHODS: We used data from the Demographic and Health Surveys (DHS) of 25 sub-Saharan African countries conducted between 2010 and 2019. Women's decision-making power was measured by three parameters; own health care, making large household purchases and visits to her family or relatives. The association between women's decision-making power and iron supplementation adherence was assessed using logistic regressions, adjusting for confounders. The results were presented as adjusted odds ratio (AOR) with 95% confidence intervals (CIs). RESULTS: Approximately 65.4% of pregnant married women had made decisions either alone or with husband in all three decisions making parameters (i.e., own health care, making large household purchases, visits to her family or relatives). The rate of adherence to iron medication during pregnancy was 51.7% (95% CI; 48.5-54.9%). Adherence to iron supplementation was found to be higher among pregnant married women who had decision-making power (AOR = 1.46, 95% CI; 1.16-1.83), secondary education (AOR = 1.45, 95% CI; 1.05-2.00) and antenatal care visit (AOR = 2.77, 95% CI; 2.19-3.51). Wealth quintiles and religion were significantly associated with adherence to iron supplementation. CONCLUSIONS: Adherence to iron supplementation is high among pregnant women in SSA. Decision making power, educational status and antenatal care visit were found to be significantly associated with adherence to these supplements. These findings highlight that there is a need to design interventions that enhance women's decision-making capacities, and empowering them through education to improve the coverage of antenatal iron supplementation.

Factors affecting the utilization of antenatal care services among women in Guinea: a population-based study.

INTRODUCTION: Evidence suggests that a better understanding of determinants of antenatal care (ANC) utilization is crucial to reducing maternal and child deaths. Little is known about the utilization of ANC services in Guinea. OBJECTIVE: The aim of this study was to explore factors determining utilization of skilled ANC in Guinea. METHODS: This study focused on a sample of 7812 ever married women. Using multivariate logistic regression, factors associated with the utilization of ANC were identified. The output of the multivariate logistic regression was presented using adjusted odds ratio and the corresponding 95% confidence interval (CI). RESULTS: Several factors had significant association with utilization of skilled ANC service in Guinea: having decision-making power (2.21, 95% CI: 1.63, 3.00), employment status (1.86, 95% CI: 1.39, 2.48), media exposure (1.60, 95% CI: 1.26, 2.02), maternal education (2.68, 95% CI: 1.36, 5.28), husband/partner education status (1.66, 95% CI: 1.08, 2.55), household economic status (2.19, 95% CI: 1.40, 3.44), place of residence (0.29, 95% CI: 0.16, 0.50) and ethnicity (0.40, 95% CI: 0.23, 0.69). CONCLUSIONS: These findings suggest a variety of socio-demographic and economic factors as well as media exposure are associated with women's use of ANC. Policymakers should implement appropriate measures to address the existing variations and gaps in ANC services utilization among different subgroups of women in Guinea.

Trends in inequalities in childhood stunting in Ethiopia from 2000 to 2016: a cross sectional study.

BACKGROUND: The decrease in the magnitude of stunting over the past 20 years has been slow in Ethiopia. To date, in Ethiopia, the trends in and extent of inequality in stunting have not been investigated using methods suitably developed for disparity studies. This paper investigated both the extent and overtime dynamics of stunting inequality in Ethiopia over the last 17 years. METHODS: Using the World Health Organization's Health Equity Assessment Toolkit software, data from the Ethiopia Demographic and Health surveys (EDHS) were analyzed between 2000 and 2016. The inequality analysis consisted of disaggregated rates of stunting using five equity stratifiers (economic status, education, residence, region and sex) and four summary measures (Difference, Population Attributable risk, Ratio and Absolute Concentration Index). A 95% uncertainty interval was constructed around point estimates to measure statistical significance. RESULTS: The study showed that both absolute and relative inequalities in stunting exist in all the studied years in Ethiopia. The inequality disfavors children of mothers who are poor, uneducated and living in rural areas and specific regions such as Amhara. The pro-rich (R = 1.2; 1.1, 1.3 in 2000 to R = 1.7; 1.4, 2 in 2016) and pro-educated (R = 1.6; 95%UI = 1.3, 1.9 in 2000 and R = 2.3; 95%UI = 1.5, 3 in 2011) inequalities slightly increased with time. Male children bear a disproportionately higher burden of stunting, and the disparity increased between the first and the last time points (PAR = -1.5 95%UI = -2.5, -0.6 in 2000 and PAR = -2.9 95%UI = -3.9, -1.9) based on complex measures but remained constant with simple measures (R = 1; 95%UI = 0.9, 1.1 in 2000 and R = 1.1 95%UI = 1, 1.2 in 2016). Similarly, both the sub-national regional and residence-related stunting disparities generally widened over time according to some of the inequality measures. CONCLUSIONS: Stunting appeared to be highly prevalent among certain sub-groups (i.e. poor, uneducated and living in rural regions). The subpopulations experiencing excessively high stunting prevalence should be the focus of policy makers' attention as they work to achieve the WHO 40% reduction in stunting target by 2025 and the UN Agenda 2030 for Sustainable Development Goals.

Time trends in socio-economic, urban-rural and regional disparities in prevalence of obesity among non-pregnant women in Lesotho: evidence from Lesotho demographic and health surveys (2004-2014).

BACKGROUND: The growing rates of obesity in developing countries are alarming. There is a paucity of evidence about disparities of obesity in Lesotho. This study examined socioeconomic and area-based inequalities in obesity among non-pregnant women in Lesotho. METHODS: Data were extracted from the 2004, 2009 and 2014 Lesotho Demographic and Health Surveys (LDHS) and analyzed through the recently updated Health Equity Assessment Toolkit (HEAT) of the World Health Organization. Obesity prevalence was disaggregated by four equity stratifiers, namely education, wealth, residence and sub-national region. For each equity stratifier, simple and complex as well as relative and absolute summary measures were calculated. A 95% confidence interval was used to measure statistical significance of findings. RESULTS: We noticed substantial wealth-driven (D = -21.10, 95% CI; - 25.94, - 16.26), subnational region (PAR = -11.82, 95%CI; - 16.09, - 7.55) and urban-rural (- 9.82, 95% CI; - 13.65, - 5.99) inequalities in obesity prevalence without the inequalities improved over time in all the studied years. However, we did not identify educational inequality in obesity. CONCLUSIONS: Wealth-driven and geographical inequalities was identified in Lesotho in all the studied time periods while education related inequalities did not appear during the same time period. All population groups in the country need to be reached with interventions to reduce the burden of obesity in the country.

Summary measures of socioeconomic and area-based inequalities in fertility rates among adolescents: evidence from Ethiopian demographic and health surveys 2000-2016.

BACKGROUND: One of the highest rates of adolescent pregnancies in the world is in sub-Saharan Africa. Most adolescent pregnancies in the region are unintended or unwanted, due to poor access to information and services on sexual and reproductive health for adolescents. Ethiopia has high adolescent fertility rates (AFR) with disparities across socioeconomic subgroups and regions. This study assessed the magnitude and trends of socioeconomic and area-based AFR inequalities in Ethiopia. METHODS: The 2000 and 2016 Ethiopia Demographic and Health surveys (EDHS) was analyzed using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software. Adolescent fertility rates were disaggregated using three equity stratifiers (economic status, education and residence) and analyzed through four summary measures (Difference (D), Population Attributable Risk (PAR), Ratio (R) and Population Attributable Fraction (PAF)) to assess inequality. To measure statistical significance, point estimates were constructed using a 95% Uncertainty Interval (UI). RESULTS: Large socio-economic and urban-rural inequalities were observed within the 16-year period. Adolescents in less well-off socio-economic groups (PAF: -62.9 [95% UI; - 64.3, - 61.4], D: 96.4 [95% UI; 47.7, 145.1]), uneducated (R: 8.5 [95% UI; 4.8, 12.2], PAR: -76.4 [95% UI;-77.7, - 75.0]) and those from rural areas (D: 81.2 [95% UI; 67.9, 94.6], PAF: -74.2 [95% UI, - 75.7, - 72.7]) had a higher chance of pregnancy and more births than their counterparts. CONCLUSIONS: Socioeconomic (education and economic status) and place of residence determine adolescents' pregnancy and childbearing. Policies and programs should be directed at preventing child marriage and early fertility so that adolescents continue to access education, sexual and reproductive health care as well as access employment opportunities. More emphasis should be placed on subpopulations with disproportionately higher adolescent pregnancy and childbirth.

Trends of inequalities in care seeking behavior for under-five children with suspected pneumonia in Ethiopia: evidence from Ethiopia demographic and health surveys (2005-2016).

BACKGROUND: Pneumonia is a leading public health problem in under-five children worldwide and particularly in Africa. Unfortunately, progress in reducing pneumonia related mortality has been slow. The number of children with symptoms of pneumonia taken to health facilities for treatment is low in Ethiopia, and disparities among sub-groups regarding health seeking behavior for pneumonia have not been well explored in the region. This study assessed the trends of inequalities in care seeking behavior for children under five years of age with suspected pneumonia in Ethiopia. METHODS: Using cross-sectional data from the 2005, 2011 and 2016 Ethiopia Demographic and Health Surveys (DHS) and the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT), this study investigated the inequalities in health seeking behavior for children with suspected pneumonia. Four measures of inequality were calculated: Difference, Ratio, Slope Index of Inequality and Relative Index of Inequality. Results were disaggregated by wealth, education, residence, and sex with computed 95% Uncertainty Intervals for each point estimate to determine significance. RESULTS: The percentage of under-five children with symptoms of pneumonia who were taken to a health facility was significantly lower for children in the poorest families, 15.48% (95% UI; 9.77, 23.64) as compared to children in the richest families, 61.72% (95% UI; 45.06, 76.02) in 2011. Substantial absolute (SII = 35.61; 95% UI: 25.31, 45.92) and relative (RII = 4.04%; 95% UI: 2.25, 5.84) economic inequalities were also observed. Both educational and geographic inequalities were observed; (RII = 2.07; 95% UI: 1.08, 3.06) and (D = 28.26; 95% UI: 7.14, 49.37), respectively. Economic inequality decreased from 2011 to 2016. There was no statistically significant difference between male and female under-five children with pneumonia symptoms taken to health facility, in all the studied years. CONCLUSIONS: Health care seeking behavior for children with pneumonia was lower among the poorest and non-educated families as well as children in rural regions. Policies and strategies need to target subpopulations lagging behind in seeking care for pneumonia treatment as it impedes achievement of key UN sustainable development goals (SDGs).

Modern contraceptive utilization and its associated factors among married women in Senegal: a multilevel analysis.

BACKGROUND: Utilization of modern contraceptives is still low in low-and middle-income countries, although fertility and population growth rates are high. In Senegal, modern contraceptive utilization is low, with few studies focusing on its associated factors. This study examined modern contraceptive use and its associated factors among married women in Senegal. METHODS: Data from the 2017 Continuous Demographic and Health Survey (C-DHS) on 11,394 married women was analysed. We examined the associations between the demographic and socioeconomic characteristics of women and their partners and modern contraceptive use using multilevel logistic regression models. Adjusted odds ratios with 95% confidence intervals (CI) were estimated. RESULTS: The utilization of modern contraceptives among married women was 26.3%. Individual level factors associated with modern contraceptive use were women's age (45-49 years-aOR = 0.44, 0.30-0.63), women's educational level (higher-aOR = 1.88, 1.28-2.76) husband's educational level (higher-aOR = 1.43, 1.10-1.85)), number of living children (5 or more children-aOR = 33.14, 19.20-57.22), ideal number of children (2 children-aOR = 1.95, 1.13-3.35), desire to have more children (wants no more-aOR = 2.46, 2.06-2.94), ethnicity (Diola-aOR = 0.70, 0.50-0.99), media exposure (yes-aOR = 1.44, 1.16-1.79)), wealth index (richer-aOR = 1.31, 1.03-1.67) and decision making power of women (decision making two-aOR = 1.20, 1.02-1.41). Whereas, region (Matam-aOR = 0.35, 0.23-0.53), place of residence (rural-aOR = 0.76, 0.63-0.93), community literacy level (high-aOR = 1.31, 1.01-1.71) and community knowledge level of modern contraceptives (high-aOR = 1.37, 1.13-1.67) were found as significant community level factors. CONCLUSIONS: The findings indicate that both individual and community level factors are significantly associated with modern contraceptive use among married women in Senegal. Interventions should focus on enhancing literacy levels of women, their husbands and communities. Furthermore, strengthening awareness and attitude towards family planning should be given priority, especially in rural areas and regions with low resources.

Sub-regional disparities in the use of antenatal care service in Mauritania: findings from nationally representative demographic and health surveys (2011-2015).

BACKGROUND: Skilled antenatal care (ANC) has been identified as a proven intervention to reducing maternal deaths. Despite improvements in maternal health outcomes globally, some countries are signaling increased disparities in ANC services among disadvantaged sub-groups. Mauritania is one of sub-Saharan countries in Africa with a high maternal mortality ratio. Little is known about the inequalities in the country's antenatal care services. This study examined both the magnitude and change from 2011 to 2015 in socioeconomic and geographic-related disparities in the utilization of at least four antenatal care visits in Mauritania. METHODS: Using the World Health Organization's Health Equity Assessment Toolkit (HEAT) software, data from the 2011 and 2015 Mauritania Multiple Indicator Cluster Surveys (MICS) were analyzed. The inequality analysis consisted of disaggregated rates of antenatal care utilization using four equity stratifiers (economic status, education, residence, and region) and four summary measures (Difference, Population attributable risk, Ratio and Population attributable fraction). A 95% Uncertainty Interval was constructed around point estimates to measure statistical significance. RESULTS: Substantial absolute and relative socioeconomic and geographic related disparities in attending four or more ANC visits (ANC4+ utilization) were observed favoring women who were richest/rich (PAR = 19.5, 95% UI; 16.53, 22.43), educated (PAF = 7.3 95% UI; 3.34, 11.26), urban residents (D = 19, 95% UI; 14.50, 23.51) and those living in regions such as Nouakchott (R = 2.1, 95% UI; 1.59, 2.56). While education-related disparities decreased, wealth-driven and regional disparities remained constant over the 4 years of the study period. Urban-rural inequalities were constant except with the PAR measure, which showed an increasing pattern. CONCLUSION: A disproportionately lower ANC4+ utilization was observed among women who were poor, uneducated, living in rural areas and regions such as Guidimagha. As a result, policymakers need to design interventions that will enable disadvantaged subpopulations to benefit from ANC4+ utilization to meet the Sustainable Development Goal (SDG) of reducing the maternal mortality ratio (MMR) to 140/100, 000 live births by 2030.