Identifying and addressing barriers to contraception uptake among adolescent girls in urban Burkina Faso: Evidence from a qualitative study.

Several barriers drive low uptake of contseraception among adolescents. This study investigates the effectiveness of (re)solve, a school-based program in Burka Faso, to overcome barriers to contraception uptake and facilitate the development of intention to use it. This paper presents qualitative endline findings from a mixed-methods longitudinal study conducted between 2019 and 2020 in two urban sites using in-depth interviews with girl participants and implementers, and key informant interviews with local stakeholders. We found that adolescent girls in the target group are likely to soon become sexually active but may be underestimating this risk. We also identified three key barriers to access to contraception in the study sites: misinformation and fear of side effects of contraception, stigma and negative attitudes, and a lack of youth-friendly sexual and reproductive health services. We conclude that the school-based (re)solve program was able to address barriers and spark contraceptive interest among participant girls.

Adolescents' narratives of coping with unintended pregnancy in Nairobi's informal settlements.

AIM: This study explored adolescent experiences and coping strategies for unintended pregnancy in two informal settlements-Viwandani and Korogocho-in Nairobi, Kenya. METHODS: Forty-nine in-depth-interviews and eight focus group discussions were conducted with male and female adolescents aged 15-19 years from households in two informal settlements. Participants were purposively selected to include adolescents of varying socio-demographic characteristics, including the married and unmarried, and adolescents who had never/ever been pregnant. Data were transcribed, translated verbatim and analyzed thematically. RESULTS: Adolescents attributed unintended pregnancy to poverty, sexual violence and inconsistent contraceptive use. Lack of parental support and guidance, as well as household conflicts also exposed girls to early sexual debut and risky sexual behavior. Decisions about pregnancy management centered on carrying the pregnancy to term or terminating it. Deciding to terminate a pregnancy was not always straightforward and was motivated by concerns about stigma or shame, and school disruption. Participants reiterated that carrying an unintended pregnancy to term disrupts adolescents' schooling, with few girls returning to school after childbirth. Upon deciding to carry a pregnancy to term, adolescents used several coping strategies such as relocating from usual residence, hiding until delivery and planning to put up the child for adoption upon delivery. CONCLUSIONS: Early interventions to provide adolescents with comprehensive pregnancy prevention information and to address sexual violence and poverty can prevent unintended pregnancy in adolescents. Efforts to support adolescents to positively cope with unintended pregnancy and facilitate re-entry to school are also warranted.

Correlates of intimate partner violence among urban women in sub-Saharan Africa.

INTRODUCTION: The dynamics of intimate partner violence (IPV)-one of the world's leading public health problems-in urban Africa remain poorly understood. Yet, urban areas are key to the future of women's health in Africa. STUDY OBJECTIVES: We explored survivor-, partner-, and household-level correlates of prevalence rates for types of IPV in urban SSA women. METHOD: The study uses DHS data from 42,143 urban women aged 15-49 in 27 SSA countries. Associations at the bivariate level were examined using the Pearson Chi-square test. The modified Poisson regression test estimated the relative prevalence of IPV subtypes in the study population at the multivariate level. RESULTS: Approximately 36% of women in urban SSA experienced at least one form of IPV; 12.8% experienced two types; and 4.6% experienced all three types. SSA urban women who had only primary-level education, had 3 or more living children, were informally employed, were in polygynous unions, or who approved of wife-beating similarly displayed higher adjusted prevalence rates for all three forms of IPV compared respectively to their counterparts without formal education, without a living child, were unemployed, in monogamous unions, or who do not approve of wife-beating. On the other hand, the region's urban women who began cohabiting between ages 25 and 35 years or who lived in higher wealth households showed consistently lower adjusted prevalence rates for all three forms of IPV relative to their counterparts who began cohabiting before 18 years or who lived in lower wealth households. Compared to their counterparts without formal education, without a living child, or whose partners did not have formal education, women with secondary and higher education, with 1-2 living children, or whose partners had only primary level schooling displayed higher adjusted prevalence rates for both IPEV and IPPV, but not for IPSV. However, relative to their counterparts whose partners were aged 25 years or below, living with a partner aged 40 years and above was associated with statistically significant reduced prevalence rates for IPPV and IPSV, but not for IPEV. Only for IPPV did women with partners educated at secondary and above levels display statistically significant higher adjusted prevalence rates relative to their counterparts with uneducated partners. Also, solely for IPPV did women who began cohabiting between ages 18 and 24 years or whose partners were employed (whether formally or informally) show decreased adjusted prevalence rates relative to their counterparts who started cohabiting before 18 years or whose partners were unemployed. In addition, only for IPSV did women aged 40 years and above or living in middle wealth households show statistically significant reduced adjusted prevalence rates relative to their counterparts aged less than 25 years or living in lower wealth households. DISCUSSION AND CONCLUSION: By 2030, the majority of SSA women will be urban dwellers. Complexities surround IPV in urban SSA, highlighting the unique dynamics of the problem in this setting. While affirming the link between IPV and marital power inequities and dynamics, findings suggest that the specific correlates of prevalence rates for different IPV sub-types in urban SSA women can, at once, be both similar and unique. The contextual drivers of the differences and similarities in the correlates of the prevalence rates of IPV sub-types among the region's urban women need further interrogation.

Timing of abortion among adolescent and young women presenting for post-abortion care in Kenya: a cross-sectional analysis of nationally-representative data.

BACKGROUND: Complications of unsafe abortion are a leading cause of maternal mortality in sub-Saharan Africa. Adolescents and young women are disproportionately represented among those at risk of these complications. Currently, we know little about the factors associated with young women's timing of abortion. This study examined the timing of abortion as well as factors influencing it among adolescents and young women aged 12-24 years who sought post-abortion care (PAC) in health facilities in Kenya. METHODS: We draw on data from a cross-sectional study on the magnitude and incidence of induced abortion in Kenya conducted in 2012. The study surveyed women presenting with a diagnosis of incomplete, inevitable, missed, complete, or septic abortion over a one-month data collection period in 328 health facilities (levels 2-6). Survey data, specifically, from adolescents and young women were analyzed to examine their characteristics, the timing of abortion, and the factors associated with the timing of abortion. RESULTS: One thousand one hundred forty-five adolescents and young women presented for PAC during the data collection period. Eight percent of the women reported a previous induced abortion and 78% were not using a modern method of contraception about the time of conception. Thirty-nine percent of the index abortions occurred after 12 weeks of gestation. A greater proportion of women presenting with late abortions (more than 12 weeks gestational age) (46%) than those presenting with early abortions (33%) presented with severe complications. Controlling for socio-demographic and reproductive history, timing of abortion was significantly associated with place of residence (marginal), education, parity, clinical stage of abortion and level of severity. CONCLUSIONS: Late-term abortions were substantial, and may have contributed substantially to the high proportion of women with post-abortion complications. Efforts to reduce the severity of abortion-related morbidities and mortality must target young women, particularly those living in rural and other remote areas. Interventions to reduce unintended pregnancies in this population are also urgently needed to improve early pregnancy detection and timely care seeking.

WOMEN'S EDUCATION AND UTILIZATION OF MATERNAL HEALTH SERVICES IN AFRICA: A MULTI-COUNTRY AND SOCIOECONOMIC STATUS ANALYSIS.

There is an abundant literature on the relationship between women's education and maternal and child outcomes, including antenatal and postnatal care, onset of antenatal care and skilled birth attendance. However, few studies have adopted the 'equity' lens, despite increasing evidence that inequities between rich and poor are increasing although maternal and child mortality is declining. This study examined the differential effects of women's education within different socioeconomic strata in Africa. The most recent Demographic and Health Surveys (DHS) conducted in the Democratic Republic of the Congo, Egypt, Ghana, Nigeria and Zimbabwe were used. In each country, the original sample was stratified into three socioeconomic groups: poor, middle and rich. For each maternal health service utilization variable, the gross and net effects of women's education, controlling for age, parity, religion, marital status, health insurance, access to health facilities, partner's education and current place of residence, were estimated using logistic regression, taking into account the complex sampling design of the DHS. The findings revealed country-specific variations in maternal health service utilization, and for most indicators there was a clear gradient among socioeconomic strata: women living in better-off households exhibited greater access to, and utilization of, maternal health services. Multivariate analyses revealed that women's education had a positive association with type of antenatal care provider, timing and frequency of antenatal care visits, place of delivery and presence of a skilled birth attendant at delivery. Many other factors were found to be significantly associated with maternal health service utilization. For instance, parity had a negative and significant association with timing of first antenatal care visit. Likewise, partner's education was positively and statistically associated with timing of first antenatal care visit. It is argued that an over-generalization of the association between women's education and maternal health service utilization can be misleading. Efforts to improve maternal health service utilization in Africa must adopt an 'equity' approach, taking into account the specific needs of sub-populations.

What does quality maternity care mean in a context of medical pluralism? Perspectives of women in Nigeria.

User priorities regarding quality care in contexts of medical pluralism are poorly documented. Drawing on group and individual interviews with women, we interrogate ideas of quality maternity care in the context of Nigeria's medical pluralism. We found complex utilization patterns for conventional, complementary and alternative maternity care services as well as ideas of quality maternity care that stress effective coordination and integration of different typologies of maternity health services; socially sensitive and truthful providers; and socioeconomic, physical and parochial forms of safety. Informal providers were the commonly reported source of maternal health services in the study. Maternal health services in the country were also generally viewed as poor quality, characterized by pervasive abuse, quackery and lack of commitment to the needs and sensitivities of women. Convenience, availability and affordability of maternal health services, as well as sociocultural factors were major influences on women's use of services. Results demonstrate the embeddedness of women's quality of care notions in the vast socioeconomic inequities that typify Nigeria's particular form of poorly regulated medical pluralism, raising need for strategies to strengthen the delivery, coordination and supervision of maternal health services in the country.

"It takes more than a fellowship program": reflections on capacity strengthening for health systems research in sub-Saharan Africa.

Sub-Saharan Africa (SSA) experiences an acute dearth of well-trained and skilled researchers. This dearth constrains the region's capacity to identify and address the root causes of its poor social, health, development, and other outcomes. Building sustainable research capacity in SSA requires, among other things, locally led and run initiatives that draw on existing regional capacities as well as mutually beneficial global collaborations. This paper describes a regional research capacity strengthening initiative-the African Doctoral Dissertation Research Fellowship (ADDRF) program. This Africa-based and African-led initiative has emerged as a practical and tested platform for producing and nurturing research leaders, strengthening university-wide systems for quality research training and productivity, and building a critical mass of highly-trained African scholars and researchers. The program deploys different interventions to ensure the success of fellows. These interventions include research methods and scientific writing workshops, research and reentry support grants, post-doctoral research support and placements, as well as grants for networking and scholarly conferences attendance. Across the region, ADDRF graduates are emerging as research leaders, showing signs of becoming the next generation of world-class researchers, and supporting the transformations of their home-institutions. While the contributions of the ADDRF program to research capacity strengthening in the region are significant, the sustainability of the initiative and other research and training fellowship programs on the continent requires significant investments from local sources and, especially, governments and the private sector in Africa. The ADDRF experience demonstrates that research capacity building in Africa is possible through innovative, multifaceted interventions that support graduate students to develop different critical capacities and transferable skills and build, expand, and maintain networks that can sustain them as scholars and researchers.

Providers, Unmarried Young Women, and Post-Abortion Care in Kenya.

Young women and girls in Kenya face challenges in access to abortion care services. Using in-depth and focus group interviews, we explored providers' constructions of these challenges. In general, providers considered abortion to be commonplace in Kenya; reported being regularly approached to offer abortion-related care and services; and articulated the structural, contextual, and personal challenges they faced in serving young post-abortion care (PAC) patients. They also considered induced abortion among young unmarried girls to be especially objectionable; stressed premarital fertility and out-of-union sexual activity among unmarried young girls as transgressive of respectable femininity and proper adolescence; blamed young women and girls for the challenges they reported in obtaining PAC services; and linked these challenges to young women's efforts to conceal their failures related to gender and adolescence, exemplified by pre-marital pregnancy and abortion. This study shows how providers' distinctive emphasis that young abortion care-seekers are to blame for their own difficulties in accessing PAC may add to the ongoing crisis of post-abortion care for young women and adolescent girls in Kenya.

A cross-sectional analysis of Kenyan postabortion care services using a nationally representative sample.

OBJECTIVE: To assess quality of postabortion care (PAC) offered by Kenyan healthcare facilities. METHODS: A cross-sectional survey was conducted using data from the Incidence and Magnitude of Unsafe Abortions study, conducted among 326 PAC-providing healthcare facilities throughout Kenya from March 13 to June 30, 2012. Descriptive results with weighted proportions and an ordered probit model were used. RESULTS: Overall, 408 (41.8%) first-trimester PAC cases were treated using appropriate technology versus 826 (82.6%) second-trimester cases. Private healthcare facilities lagged behind public healthcare facilities on the use of appropriate technology: 264 (47.5%) public and 144 (33.1%) private facilities used such technology for first-trimester abortion, and 664 (89.6%) public versus 162 (68.8%) private for second-trimester abortions). Most healthcare facilities (251, 70.7%) had at least one provider trained in PAC. A total of 273 (80.7%) healthcare facilities reported offering contraception to all PAC patients, mainly short-acting methods. Delivery of PAC services depended on the availability of separate evacuation room (public level 2-3: odds ratio [OR] 22.93; public level 4-6: OR 77.14), and the number of family planning methods offered within the facility (public level 2-3: OR 1.38; public level 4-6 OR 1.57; private level 2-3: OR 2.27; private level 4-5: 4.89). CONCLUSION: Effective monitoring of PAC services, particularly among private healthcare facilities, might improve overall quality of services.

Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review.

BACKGROUND: Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA. METHODS: African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability). RESULTS: Seventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess. CONCLUSIONS: Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015023750.

Previous induced abortion among young women seeking abortion-related care in Kenya: a cross-sectional analysis.

BACKGROUND: Unsafe abortion is a leading cause of death among young women aged 10-24 years in sub-Saharan Africa. Although having multiple induced abortions may exacerbate the risk for poor health outcomes, there has been minimal research on young women in this region who have multiple induced abortions. The objective of this study was therefore to assess the prevalence and correlates of reporting a previous induced abortion among young females aged 12-24 years seeking abortion-related care in Kenya. METHODS: We used data on 1,378 young women aged 12-24 years who presented for abortion-related care in 246 health facilities in a nationwide survey conducted in 2012. Socio-demographic characteristics, reproductive and clinical histories, and physical examination assessment data were collected from women during a one-month data collection period using an abortion case capture form. RESULTS: Nine percent (n = 98) of young women reported a previous induced abortion prior to the index pregnancy for which they were receiving care. Statistically significant differences by previous history of induced abortion were observed for area of residence, religion and occupation at bivariate level. Urban dwellers and unemployed/other young women were more likely to report a previous induced abortion. A greater proportion of young women reporting a previous induced abortion stated that they were using a contraceptive method at the time of the index pregnancy (47 %) compared with those reporting no previous induced abortion (23 %). Not surprisingly, a greater proportion of young women reporting a previous induced abortion (82 %) reported their index pregnancy as unintended (not wanted at all or mistimed) compared with women reporting no previous induced abortion (64 %). CONCLUSIONS: Our study results show that about one in every ten young women seeking abortion-related care in Kenya reports a previous induced abortion. Comprehensive post-abortion care services targeting young women are needed. In particular, post-abortion care service providers must ensure that young clients receive contraceptive counseling and effective pregnancy prevention methods before discharge from the health care facility to prevent unintended pregnancies that may result in subsequent induced abortions.

Factors associated with delays in seeking post abortion care among women in Kenya.

BACKGROUND: Delays in seeking quality post abortion care services remain a major contributor to high levels of mortality and morbidity among women who experience unsafe abortion. However, little is known about the causes of and factors associated with delays in seeking care among women who suffer complications of unsafe abortion. This study looks at factors that are associated with delays in seeking post-abortion care among women in Kenya. METHODS: Data for this study were from a nationally representative sample of 350 healthcare facilities that participated in the 2012 Incidence and Magnitude of Unsafe Abortion study in Kenya. Data included socio-demographic characteristics, reproductive health and clinical histories from all women treated with PAC during a one-month data collection period. RESULTS: Delay in seeking care was associated with women's age, education level, contraceptive history, fertility intentions and referral status. CONCLUSIONS: There is need to improve women's access to quality sexual and reproductive health information and services, contraception and abortion care. Improving current PAC services at lower level facilities will also minimize delays resulting from long referral processes.

'High profile health facilities can add to your trouble': Women, stigma and un/safe abortion in Kenya.

Public health discourses on safe abortion assume the term to be unambiguous. However, qualitative evidence elicited from Kenyan women treated for complications of unsafe abortion contrasted sharply with public health views of abortion safety. For these women, safe abortion implied pregnancy termination procedures and services that concealed their abortions, shielded them from the law, were cheap and identified through dependable social networks. Participants contested the notion that poor quality abortion procedures and providers are inherently dangerous, asserting them as key to women's preservation of a good self, management of stigma, and protection of their reputation, respect, social relationships, and livelihoods. Greater public health attention to the social dimensions of abortion safety is urgent.

Constructions of masculinity and femininity and sexual risk negotiation practices among women in urban Ghana.

Using qualitative data gathered through in-depth interviews with women in Accra, Ghana, this paper explores narratives of masculinity and femininity and sexual risk negotiation practices among women. While women framed 'proper' masculinity in terms of stereotypical reproductive norms, they also acknowledged the fluidity and multiplicity of masculinities. Femininity was more uniformly characterised in terms of physical attractiveness and beauty, responsibility and reproduction. These features, especially those related to adherence to morally and socially appropriate sexual norms (e.g., menstrual and bodily hygiene, unplanned pregnancy etc.), influenced women's approach to sexual negotiation. Work aiming to support women to negotiate sex safely needs to pay attention to their notions of gender and practices of sexual negotiation.

The health and wellbeing of young people in sub-Saharan Africa: an under-researched area?

A third of sub-Saharan Africa's (SSA) population comprises persons aged 10-24 years. These youth are growing up in a context marked by pervasive poverty, limited educational opportunities, high HIV/AIDS prevalence, widespread conflict, and weak social controls. Published research on the broad issues that affect youth health and wellbeing in SSA is limited and centers heavily on sexual and reproductive health. In this commentary, we provide a broad overview of sub-Saharan African youth, highlight research gaps with respect to youth health and wellbeing, and describe potential avenues to develop the region's research capacity on youth health and wellbeing.

Client retention and health among sex workers in Nairobi, Kenya.

It is still a small body of research that directly addresses female sex workers' relationships with their regular commercial male partners. I used ethnographic data from Nairobi, Kenya to interrogate motivations and strategies for recruiting and retaining regular male clients among female sex workers (FSWs). Regular commercial male partners, popularly called customer care, wera or wesh by Nairobi's FSWs, played diverse roles in their lives. Client retention enabled sex workers to manage the risk of reduced marriage prospects, guaranteed them steady work, livelihoods, and incomes, and prevented their victimization and harassment. To retain clients, sex workers obliged them a great deal, pretended they had quit prostitution, and sometimes resorted to magical practices. However, these strategies were also accompanied by risks that reinforced the vulnerability of sex workers. Lack of critical attention to sex workers' practices for managing perceived risks in their particular type of work may hamper current programmatic efforts to make their job safer.

Gender scripts and unwanted pregnancy among urban Kenyan women.

Women's lived experiences and lay accounts of unwanted pregnancy remain poorly interrogated. We investigated portrayals of unwanted pregnancy using narrative data gathered from 80 women in Nairobi, Kenya. Unwanted pregnancy had a diversity of significance for the women. Pregnancies were not simply unwanted because they occurred when women became pregnant without wanting to. Rather, pregnancies were considered unwanted largely because they had occurred in contexts that did not reinforce socially-sanctioned notions of motherhood and 'proper' procreation and/or revealed women's use of their sexuality in ways deemed culturally-inappropriate. Kenyan women's invocation of femininity scripts to explain unwanted pregnancy; the centrality of gender in everyday life in contemporary Kenya; women's and girls' poor access to effective family planning services; growing female poverty; and Kenya's restrictive abortion policy imply that unwanted pregnancy and its consequences will persist in the country. Addressing unwanted pregnancy and its consequences requires making accessible quality contraceptive and abortion services as well as sexuality information. It also calls for providers who understand the socio-cultural norms that circumscribe fertility and reproductive behaviours.