Spatial and Socioeconomic Inequalities in Cesarean Section Deliveries in Urban Settings in Dakar, Senegal.

As part of an initiative aimed at reducing maternal and child mortality, Senegal implemented a policy of free Cesarean section (C-section) since 2005. Despite the implementation, C-section rates have remained low and significant large disparities in access, particularly in major cities such as Dakar. This paper aims to assess C-section rates and examines socioeconomic inequalities in C-section use in the Dakar region between 2005 and 2019. This study incorporates data from various sources, including the health routine data within District Health Information Software 2 (DHIS2) platform, government statistics on slum areas, and data from Demographic and Health Surveys (DHS). A geospatial analysis was conducted to identify locations of Comprehensive emergency obstetric and Newborn Care (CEmONC) services using the Direction des Travaux Géographiques et Cartographiques (DTGC) databases and satellite imagery from the Google Earth platform. The analytical approach encompassed univariate, bivariate, and multivariate analyses. The C-section rate fluctuated over the years, increasing from 11.1% in 2005 to 16.4% in 2011, declined to 9.8% in 2014, and then raised to 13.3% in 2019. The wealth tertile demonstrated a positive correlation with C-sections in urban areas of the Dakar region. Geospatial analyses revealed that women residing in slum areas were less likely to undergo C-section deliveries. These findings underscore the importance of public health policies extending beyond merely providing free C-section delivery services. Strategies that improve equitable access to C-section delivery services for women across all socioeconomic strata are needed, particularly targeting the poor women and those in urban slums.

Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa.

The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities and other urban and rural areas. We analyzed mortality data from 163 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020 and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality rates and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence, slower trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.

Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa.

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

Adolescents' accessibility and use of sexual and reproductive health services in Kaolack and Gossas, Senegal.

In Senegal, the needs for care related to sexual and reproductive health and rights (SRHR) among adolescents are significant. This study evaluates the accessibility and use of gender-related SRHR services by adolescents in the municipalities of Kaolack and Gossas. It is based on quantitative and qualitative data from 2,263 adolescents in the 2 sites, 84 in-depth individual interviews, 12 focus groups with adolescents and sexual reproductive Health actors, and 4 interviews with key informants. Quantitative analysis consisted of the interpretation of univariate statistics and bivariate analyses, while qualitative analysis relied on the coding and thematic analysis of verbatim statements. The results show low use of health structures (3% and 0.4% in Gossas and Kaolack respectively). This was attributed to the perceptions that services are not suitable to the needs of adolescents, and also because of socio-cultural constraints in the two sites. Additionally, the distribution of access to reproductive health services by sex shows gaps between boys and girls. We conclude that efforts should be made to tailor the sexual and reproductive health services offered to adolescents to their needs and social circumstances.

Au Sénégal, les besoins en soins de Santé Sexuelle et Reproductive des Adolescent(e)s (SSRA) sont importants. Cette étude évalue l'accessibilité et l'utilisation des services de SSRA, en rapport avec le genre dans les communes de Kaolack et de Gossas. Elle est basée sur les données quantitatives et qualitatives provenant de 2263 adolescents, de 84 entretiens individuels approfondis, de 12 focus groupes avec des adolescents/tes et des acteurs de la SSRA et de 4 entretiens avec les informateurs clés. L'analyse quantitative concerne les statistiques univariées et bivariées, alors que l'analyse qualitative s'appuie sur le codage et l'extraction des verbatim. L'étude révèle une faible utilisation des structures de santé, liée à leur inadaptation aux besoins des adolescent(e)s et aux contraintes socio-culturelles. Le recours des adolescent(e)s aux services de SSRA (3% et 0,4% à Gossas et Kaolack respectivement) est très faible et on note des écarts entre les garçons et les filles.

Child marriages in Senegal: Qualitative study on the perceptions of adolescents in Kaolack and Gossas.

An estimated 650 million girls worldwide are married before their 18th birthday. The phenomenon is recurrent in sub-Saharan Africa with a prevalence of 18% and particularly in Senegal where one in three girls is married before the age of 18, i.e. a prevalence of 31%. Despite the legislative and legal arsenals, the laws on the legal age of marriage are not respected. The general objective of this study is to document the way in which gender norms define and influence the perceptions of adolescents in Gossas and Kaolack on child marriages and to collect possible solutions proposed to prevent/ reduce the practice. We used qualitative data collected in the two study sites. These were individual interviews with adolescents aged 10-19 (n=30) and focus groups (n=8) with the same target. The interviews were conducted in Wolof and transcribed into French then coded using Dedoose software. The results are presented for each age group and each gender then triangulated in order to highlight similarities and divergences according to the different perspectives. The results show that child marriages are rooted in patriarchal social and cultural norms, while reflecting gender inequalities. Thus, adolescents' arguments regarding the causes of child marriage align with those described in the literature on gender norms. Most adolescents cited poverty, tradition, fear of early pregnancy, and concern to preserve the girl's honor as the main factors contributing to the persistence of child marriages.

On estime à 650 millions le nombre de filles mariées dans le monde avant leur 18e anniversaire. Le phénomène est récurrent en Afrique subsaharienne avec une prévalence de 18% et particulièrement au Sénégal où, une fille sur trois est mariée avant l'âge de 18 ans, soit une prévalence de 31%. Malgré l'arsenal juridique législatif, les lois sur l'âge légal du mariage ne sont pas respectées. L'objectif général de cette étude est de documenter la manière dont les normes de genre définissent et influencent les perceptions des adolescent(e)s de Gossas et de Kaolack sur les mariages d'enfants et de recueillir les pistes de solutions proposées pour prévenir/réduire la pratique. Nous avons utilisé les données qualitatives collectées dans les deux sites de l'étude. Il s'agit d'entretiens individuels avec des adolescent(e)s de 10-19 ans (n=30) et de groupes de discussion (n=8) avec la même cible. Les entretiens ont été conduits en wolof et transcrits en Français puis codés à l'aide du logiciel Dedoose. Les résultats sont présentés pour chaque groupe d'âge et chaque sexe puis triangulés afin de ressortir les similarités et divergences selon les différentes perspectives. Les résultats montrent que les mariages d'enfants sont ancrés dans des normes sociales et culturelles patriarcales, tout en reflétant les inégalités de genre. Ainsi, les arguments des adolescent(e)s par rapport aux causes des mariages d'enfants s'alignent avec celles décrites dans la littérature sur les normes de genre. La plupart des adolescent(e)s ont évoqué la pauvreté, la tradition, la peur d'une grossesse précoce, le souci de préserver l'honneur de la fille comme étant les principaux facteurs contribuant à la persistance des mariages d'enfants.

Coverage, Trends, and Inequalities of Maternal, Newborn, and Child Health Indicators among the Poor and Non-Poor in the Most Populous Cities from 38 Sub-Saharan African Countries.

Rapid urbanization is likely to be associated with suboptimal access to essential health services. This is especially true in cities from sub-Saharan Africa (SSA), where urbanization is outpacing improvements in infrastructure. We assessed the current situation in regard to several markers of maternal, newborn, and child health, including indicators of coverage of health interventions (demand for family planning satisfied with modern methods, at least four antenatal care visits (ANC4+), institutional birth, and three doses of DPT vaccine[diphtheria, pertussis and tetanus]) and health status (stunting in children under 5 years, neonatal and under-5 mortality rates) among the poor and non-poor in the most populous cities from 38 SSA countries. We analyzed 136 population-based surveys (year range 2000-2019), contrasting the poorest 40% of households (referred to as poor) with the richest 60% (non-poor). Coverage in the most recent survey was higher for the city non-poor compared to the poor for all interventions in virtually all cities, with the largest median gap observed for ANC4+ (13.5 percentage points higher for the non-poor). Stunting, neonatal, and under-5 mortality rates were higher among the poor (7.6 percentage points, 21.2 and 10.3 deaths per 1000 live births, respectively). The gaps in coverage between the two groups were reducing, except for ANC4, with similar median average annual rate of change in both groups. Similar rates of change were also observed for stunting and the mortality indicators. Continuation of these positive trends is needed to eliminate inequalities in essential health services and child survival in SSA cities.

Hot-spots of HIV infection in Cameroon: a spatial analysis based on Demographic and Health Surveys data.

BACKGROUND: The Human Immunodeficiency Virus(HIV) infection prevalence in Cameroon has decreased from [Formula: see text] in 2004 to [Formula: see text] in 2018. However, this decrease in prevalence does not show disparities especially in terms of spatial or geographical pattern. Efficient control and fight against HIV infection may require targeting hotspot areas. This study aims at presenting a cartography of HIV infection situation in Cameroon using the 2004, 2011 and 2018 Demographic and Health Survey data, and investigating whether there exist spatial patterns of the disease, may help to detect hot-spots. METHODS: HIV biomarkers data and Global Positioning System (GPS) location data were obtained from the Cameroon 2004, 2011, and 2018 Demographic and Health Survey (DHS) after an approved request from the MEASURES Demographic and Health Survey Program. HIV prevalence was estimated for each sampled area. The Moran's I (MI) test was used to assess spatial autocorrelation. Spatial interpolation was further performed to estimate the prevalence in all surface points. Hot-spots were identified based on Getis-Ord (Gi*) spatial statistics. Data analyses were done in the R software(version 4.1.2), while Arcgis Pro software tools' were used for all spatial analyses. RESULTS: Generally, spatial autocorrelation of HIV infection in Cameroon was observed across the three time periods of 2004 ([Formula: see text], [Formula: see text]), 2011 ([Formula: see text], [Formula: see text]) and 2018 ([Formula: see text], [Formula: see text]). Subdivisions in which one could find persistent hot-spots for at least two periods including the last period 2018 included: Mbéré, Lom et Djerem, Kadey, Boumba et Ngoko, Haute Sanaga, Nyong et Mfoumou, Nyong et So'o Haut Nyong, Dja et Lobo, Mvila, Vallée du Ntem, Océan, Nyong et Kellé, Sanaga Maritime, Menchum, Dounga Mantung, Boyo, Mezam and Momo. However, Faro et Déo emerged only in 2018 as a subdivision with HIV infection hot-spots. CONCLUSION: Despite the decrease in HIV epidemiology in Cameroon, this study has shown that there are spatial patterns for HIV infection in Cameroon and possible hot-spots have been identified. In its effort to eliminate HIV infection by 2030 in Cameroon, the public health policies may consider these detected HIV hot-spots, while maintaining effective control in other parts of the country.

Birth registration coverage according to the sex of the head of household: an analysis of national surveys from 93 low- and middle-income countries.

BACKGROUND: Within-country inequalities in birth registration coverage (BRC) have been documented according to wealth, place of residence and other household characteristics. We investigated whether sex of the head of household was associated with BRC. METHODS: Using data from nationally-representative surveys (Demographic and Health Survey or Multiple Indicator Cluster Survey) from 93 low and middle-income countries (LMICs) carried out in 2010 or later, we developed a typology including three main types of households: male-headed (MHH) and female-led with or without an adult male resident. Using Poisson regression, we compared BRC for children aged less than 12 months living the three types of households within each country, and then pooled results for all countries. Analyses were also adjusted for household wealth quintiles, maternal education and urban-rural residence. RESULTS: BRC ranged from 2.2% Ethiopia to 100% in Thailand (median 79%) while the proportion of MHH ranged from 52.1% in Ukraine to 98.3% in Afghanistan (median 72.9%). In most countries the proportion of poor families was highest in FHH (no male) and lowest in FHH (any male), with MHH occupying an intermediate position. Of the 93 countries, in the adjusted analyses, FHH (no male) had significantly higher BRC than MHH in 13 countries, while in eight countries the opposite trend was observed. The pooled analyses showed t BRC ratios of 1.01 (95% CI: 1.00; 1.01) for FHH (any male) relative to MHH, and also 1.01 (95% CI: 1.00; 1.01) for FHH (no male) relative to MHH. These analyses also showed a high degree of heterogeneity among countries. CONCLUSION: Sex of the head of household was not consistently associated with BRC in the pooled analyses but noteworthy differences in different directions were found in specific countries. Formal and informal benefits to FHH (no male), as well as women's ability to allocate household resources to their children in FHH, may explain why this vulnerable group has managed to offset a potential disadvantage to their children.

Measuring coverage of maternal and child health services using routine health facility data: a Sierra Leone case study.

BACKGROUND: There are limited existing approaches to generate estimates from Routine Health Information Systems (RHIS) data, despite the growing interest to these data. We calculated and assessed the consistency of maternal and child health service coverage estimates from RHIS data, using census-based and health service-based denominators in Sierra Leone. METHODS: We used Sierra Leone 2016 RHIS data to calculate coverage of first antenatal care contact (ANC1), institutional delivery and diphtheria-pertussis-tetanus 3 (DPT3) immunization service provision. For each indicator, national and district level coverages were calculated using denominators derived from two census-based and three health service-based methods. We compared the coverage estimates from RHIS data to estimates from MICS 2017. We considered the agreement adequate when estimates from RHIS fell within the 95% confidence interval of the survey estimate. RESULTS: We found an overall poor consistency of the coverage estimates calculated from the census-based methods. ANC1 and institutional delivery coverage estimates from these methods were greater than 100% in about half of the fourteen districts, and only 3 of the 14 districts had estimates consistent with the survey data. Health service-based methods generated better estimates. For institutional delivery coverage, five districts met the agreement criteria using BCG service-based method. We found better agreement for DPT3 coverage estimates using DPT1 service-based method as national coverage was close to survey data, and estimates were consistent for 8 out of 14 districts. DPT3 estimates were consistent in almost half of the districts (6/14) using ANC1 service-based method. CONCLUSION: The study highlighted the challenge in determining an appropriate denominator for RHIS-based coverage estimates. Systematic and transparent data quality check and correction, as well as rigorous approaches to determining denominators are key considerations to generate accurate coverage statistics using RHIS data.

Examining the recent trends in adolescent sexual and reproductive health in five countries of sub-Saharan Africa based on PMA and DHS household surveys.

BACKGROUND: The annual collection of fertility, marriage, sexual behaviour, and contraceptive use data in the nationally representative rounds of Performance Monitoring and Accountability (PMA) surveys in sub-Saharan Africa may contribute to the periodic monitoring of adolescent sexual and reproductive health (ASRH). However, we need to understand the reliability of these data in monitoring the ASRH indicators. We assessed the internal and external consistencies in ASRH indicators in five countries. METHODS: We included countries with at least three nationally representative rounds of PMA surveys and two recent DHS: Ethiopia, Ghana, Kenya, Nigeria, and Uganda. Our analysis focused on four current status indicators of ASRH among girls 15-19 years: ever had sex, currently married, has given birth or currently pregnant, and currently using modern contraceptives among sexually active unmarried girls. We compared the PMA survey and DHS data and tested for statistical significance and assessed trends over time using Jonckheere-Terpstra test statistic. RESULTS: PMA and DHS survey methodologies were similar and, where there were differences, these were shown to have minimal impact on the indicator values. The comparison of the data points from PMA and DHS for the same years showed statistically significant differences in 12 of the 20 comparisons, which was most common for sexual behaviour (4/5) and least for contraceptive use (2/5). This is partly due to larger confidence intervals in both surveys. The time trends were consistent between the annual PMA surveys in most instances in Ethiopia, Kenya, and Nigeria but less so for Ghana and Uganda. However, both surveys highlight slow progress in adolescent and reproductive health indicators with major disparities between the countries. CONCLUSIONS: Despite the differences between PMA 2020 surveys and DHS surveys conducted in the same year, and inconsistencies of the PMA survey time series for several indicators in some countries, we found no systematic issues with PMA surveys and consider PMA surveys a valuable data source for the assessment of levels and trends of ASRH beyond contraceptive use and family planning for indicators of fertility, marriage, and sex among adolescent girls in sub-Saharan Africa.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa.

BACKGROUND: The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys. METHODS: We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status. RESULTS: Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = - 1.7%, p < 0.001) and unmarried (AARC = - 4.7%, p < 0.001) AGYW from poorest households in Mozambique. CONCLUSION: Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. RESULTS: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). CONCLUSION: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators. METHODS: We analyzed national household surveys from 37 countries in SSA, conducted during 1990-2018, to examine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15-24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban-rural residence and educational status (primary or less versus secondary or higher education). RESULTS: In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000-2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10-14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban-rural and wealth-related inequalities remained stagnant or widened during 2000-2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories. CONCLUSION: Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress.

Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region.

OBJECTIVE: To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. METHODS: We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. FINDINGS: We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. CONCLUSION: Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.

Analysing child linear growth trajectories among under-5 children in two Nairobi informal settlements.

OBJECTIVE: We sought to identify factors associated with linear growth among under-5 children in two urban informal settlements in Nairobi. DESIGN: We used longitudinal data for the period 2007-2012 from under-5 children recruited in the two sites between birth and 23 months and followed up until they reached 5 years of age. We fitted a generalized linear model on height-for-age Z-scores using the generalized estimating equations method to model linear growth trajectories among under-5 children. Known for its flexibility, the model provides strong parameter estimates and accounts for correlated observations on the same child. SETTING: Two urban informal settlements in Nairobi, Kenya.ParticipantsUnder-5 children (n 1917) and their mothers (n 1679). RESULTS: The findings show that child weight at birth, exclusive breast-feeding and immunization status were key determinants of linear growth among under-5 children. Additionally, maternal characteristics (mother's age, marital status) and household-level factors (socio-economic status, size of household) were significantly associated with child linear growth. There were biological differences in linear growth, as female children were more likely to grow faster than males. Finally, the model captured significant household-level effects to investigate further. CONCLUSIONS: Findings from the study point to the need to improve the targeting of child health programmes directed at the urban poor population in Nairobi. Specific modifiable determinants of child linear growth, particularly child weight at birth, exclusive breast-feeding, immunization status and mother's background characteristics, should be considered when designing interventions aiming at addressing child health inequities in these settings.

Family influences on child nutritional outcomes in Nairobi's informal settlements.

BACKGROUND: Improving child nutritional status is an important step towards achieving the Sustainable Development Goals 2 and 3 in developing countries. Most child nutrition interventions in these countries remain variably effective because the strategies often target the child's mother/caregiver and give limited attention to other household members. Quantitative studies have identified individual level factors, such as mother and child attributes, influencing child nutritional outcomes. METHODS: We used a qualitative approach to explore the influence of household members on child feeding, in particular, the roles of grandmothers and fathers, in two Nairobi informal settlements. Using in-depth interviews, we collected data from mothers of under-five children, grandmothers, and fathers from the same households. RESULTS: Our findings illustrate that poverty is a root cause of poor nutrition. We found that mothers are not the sole decision makers within the household regarding the feeding of their children, as grandmothers appear to play key roles. Even in urban informal settlements, three-generation households exist and must be taken into account. Fathers, however, are described as providers of food and are rarely involved in decision making around child feeding. Lastly, we illustrate that promotion of exclusive breastfeeding for 6 months, as recommended by the World Health Organization, is hard to achieve in this community. CONCLUSIONS: These findings call for a more holistic and inclusive approach for tackling suboptimal feeding in these communities by addressing poverty, targeting both mothers and grandmothers in child nutrition strategies, and promoting environments that support improved feeding practices such as home-based support for breastfeeding and other baby-friendly initiatives.

Trends and correlates of single motherhood in Kenya: Results from the Demographic and Health Survey.

Single motherhood exposes women to poorer socioeconomic and health outcomes, which may also negatively impact child outcomes. The Demographic and Health Surveys of 1989, 1993, 1998, 2003, and 2009 were used to investigate trends over time and factors associated with single motherhood in Kenya. Urban residence, older age, and poorer economic status were associated with single motherhood over time. Women with more than one child, and those with children under 15 years living at home were less likely to be single mothers. As women become single mothers at different stages, targeted and supportive strategies are required to mitigate associated risks.

Influence of integrated services on postpartum family planning use: a cross-sectional survey from urban Senegal.

BACKGROUND: Although the majority of postpartum women indicate a desire to delay a next birth, family planning (FP) methods are often not offered to, or taken up by, women in the first year postpartum. This study uses data from urban Senegal to examine exposure to FP information and services at the time of delivery and at child immunization appointments and to determine if these points of integration are associated with greater use of postpartum FP. METHODS: A representative, household sample of women, ages 15-49, was surveyed from six cities in Senegal in 2011. This study focuses on women who were within two years postpartum (n = 1879). We also include women who were surveyed through exit interviews after a visit to a high volume health facility in the same six cities; clients included were visiting the health facility for delivery, post-abortion care, postnatal care, and child immunization services (n = 794). Descriptive analyses are presented to examine exposure to FP services among postpartum women and women visiting the health facility. Logistic regression models are used to estimate the effect of integrated services on postpartum FP use in the household sample of women. Analyses were conducted using Stata version 12. RESULTS: Among exit interview clients, knowledge of integrated services is high but only a few reported receiving FP services. A majority of the women who did not receive FP services indicated an interest in receiving such information and services.Among the household sample of women up to two-years postpartum, those who received FP information at the time of delivery are more likely to be using modern FP postpartum than their counterparts who also delivered in a facility but did not receive such information. Exposure to FP services at an immunization visit was not significantly related to postpartum FP use. Another key finding is that women with greater self-efficacy are more likely to use a modern FP method. CONCLUSION: This study's findings lend strong support for the need to improve integration of FP services into maternal, newborn, and child health services with the goal of increasing postpartum women's use of FP methods in urban Senegal.

Unintended pregnancy: magnitude and correlates in six urban sites in Senegal.

BACKGROUND: In Senegal, unintended pregnancy has become a growing concern in public health circles. It has often been described through the press as a sensational subject with emphasis on the multiple infanticide cases as a main consequence, especially among young unmarried girls. Less scientific evidence is known on this topic, as fertility issues are rarely discussed within couples. In a context where urbanization is strong, economic insecurity is persistent and the population is globalizing, it is important to assess the magnitude of unintended pregnancy among urban women and to identify its main determinants. METHODS: Data were collected in 2011 from a representative sample of 9614 women aged 15-49 years in six urban sites in Senegal. For this analysis, we include 5769 women who have ever been pregnant or were pregnant at the time of the survey. These women were asked if their last pregnancy in the last two years was 'wanted 'then', 'wanted later' or 'not wanted'. Pregnancy was considered as unintended if the woman responded 'wanted later' or 'not wanted'. Descriptive analyses were performed to measure the magnitude of unintended pregnancies, while multinomial logistic regression models were used to identify factors associated with the occurrence of unintended pregnancy. The analyses were performed using Stata version 12. All results were weighted. RESULTS: The results show that 14.3% of ever pregnant women reported having a recent unintended pregnancy. The study demonstrates important distinctions between women whose last pregnancy was intended and those whose last pregnancy was unintended. Indeed, this last group is more likely to be poor, from a young age (< 25 years) and multiparous. In addition, it appears that low participation of married women in decision-making within the couple (management of financial resources) and the lack of discussion on family planning issues are associated with greater experience of unintended pregnancy. CONCLUSION: This study suggests a need to implement more targeted programs that guarantee access to family planning for all women in need. In urban areas that are characterized by economic insecurity, as in Senegal, it is important to consider strategies for promoting communication within couples on fertility issues.