Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study.

BACKGROUND: Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria. METHODS: Data were collected in 2010/2011 from 16,118 women aged 15-49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples' family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women's age, education, marital status, religion, parity, household wealth, and city of residence. RESULTS: The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples' family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women's demographic characteristics accounted for 55-61% of the variation between neighborhoods in the change in modern contraceptive use during the study period. CONCLUSION: Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.

Trends in reproductive health indicators in Nigeria using demographic and health surveys (1990-2013).

There is an urgent need to improve reproductive health (RH) in Nigeria - the most populous country in Africa. In 2015, Nigeria had the highest number of maternal deaths in the world. This study assessed the trends in select RH indicators in Nigeria over two decades. Data used were from Nigeria Demographic and Health Surveys (NDHS) conducted between 1990 and 2013. The NDHS uses a two-stage cluster sampling design to select nationally representative samples of reproductive-age women. The study sample ranged from 7620 to 38,948 women aged 15-49 across the five surveys. Trends in modern contraceptive prevalence rate, skilled antenatal care, skilled birth attendance, and adolescent birth were assessed. The results show increasing trends in modern contraceptive prevalence rate from 4% in 1990 to 11% in 2013 (p < .001); in skilled antenatal care from 57% in 1990 to 61% in 2013 (p < .001); and in skilled birth attendance from 31% in 1990 to 40% in 2013 (p < .001). The trend in adolescent birth decreased from 24% in 1990 to 17% in 2013 (p < .001). Marked disparities exist as rural, poor, and less educated women bear the greatest burden. Interventions should target the at-risk populations to improve their access and use of RH services.

Influence of parental factors on adolescents' transition to first sexual intercourse in Nairobi, Kenya: a longitudinal study.

BACKGROUND: Several studies have demonstrated a link between young people's sexual behavior and levels of parental monitoring, parent-child communication, and parental discipline in Western countries. However, little is known about this association in African settings, especially among young people living in high poverty settings such as urban slums. The objective of the study was to assess the influence of parental factors (monitoring, communication, and discipline) on the transition to first sexual intercourse among unmarried adolescents living in urban slums in Kenya. METHODS: Longitudinal data collected from young people living in two slums in Nairobi, Kenya were used. The sample was restricted to unmarried adolescents aged 12-19 years at Wave 1 (weighted n = 1927). Parental factors at Wave 1 were used to predict adolescents' transition to first sexual intercourse by Wave 2. Relevant covariates including the adolescents' age, sex, residence, school enrollment, religiosity, delinquency, and peer models for risk behavior were controlled for. Multivariate logistic regression models were used to assess the associations of interest. All analyses were conducted using Stata version 13. RESULTS: Approximately 6% of our sample transitioned to first sexual intercourse within the one-year study period; there was no sex difference in the transition rate. In the multivariate analyses, male adolescents who reported communication with their mothers were less likely to transition to first sexual intercourse compared to those who did not (p < 0.05). This association persisted even after controlling for relevant covariates (OR: ≤0.33; p < 0.05). However, parental monitoring, discipline, and communication with their fathers did not predict transition to first sexual intercourse for male adolescents. For female adolescents, parental monitoring, discipline, and communication with fathers predicted transition to first sexual intercourse; however, only communication with fathers remained statistically significant after controlling for relevant covariates (OR: 0.30; 95% C.I.: 0.13-0.68). CONCLUSION: This study provides evidence that cross-gender communication with parents is associated with a delay in the onset of sexual intercourse among slum-dwelling adolescents. Targeted adolescent sexual and reproductive health programmatic interventions that include parents may have significant impacts on delaying sexual debut, and possibly reducing sexual risk behaviors, among young people in high-risk settings such as slums.

Exposure to family planning messages and modern contraceptive use among men in urban Kenya, Nigeria, and Senegal: a cross-sectional study.

BACKGROUND: Family planning (FP) researchers and policy makers have often overlooked the importance of involving men in couples' fertility choices and contraception, despite the fact that male involvement is a vital factor in sexual and reproductive health programming. This study aimed to assess whether men's exposure to FP demand-generation activities is associated with their reported use of modern contraceptive methods. METHODS: We used evaluation data from the Measurement, Learning & Evaluation project for the Urban Reproductive Health Initiative (URHI) in select cities of three African countries (Kenya, Nigeria, and Senegal) collected in 2012/2013. A two-stage cluster sampling design was used to select a representative sample of men in the study sites. The sample for this study includes men aged 15-59 years who had no missing data on any of the key variables: 696 men in Kenya, 2311 in Nigeria, and 1613 in Senegal. We conducted descriptive analyses and multivariate logistic regression analyses to assess the associations of interest. All analyses were weighted to account for the study design and non-response rates using Stata version 13. RESULTS: The proportion of men who reported use of modern contraceptive methods was 58 % in Kenya, 43 % in Nigeria, and 27 % in Senegal. About 80 % were exposed to at least one URHI demand-generation activity in each country. Certain URHI demand-generation activities were significantly associated with men's reported use of modern contraception. In Kenya, those who participated in URHI-led community events had four times higher odds of reporting use of modern methods (aOR: 3.70; p < 0.05) while in Senegal, exposure to URHI-television programs (aOR: 1.40; p < 0.05) and having heard a religious leader speak favorably about FP (aOR: 1.72; p < 0.05) were associated with modern contraceptive method use. No such associations were observed in Nigeria. CONCLUSION: Study findings are important for informing future FP program activities that seek to engage men. Program activities should be tailored by geographic context as results from this study indicate city and country-level variations. These types of gender-comprehensive and context-specific programs are likely to be the most successful at reducing unmet need for FP.

Skilled Birth Attendance in Nigeria: A Function of Frequency and Content of Antenatal Care.

The utilization rate of maternal services remains low in sub-Saharan Africa and may be contributing to the region's high maternal mortality rate. This study examines the influence of antenatal care (ANC) on skilled birth attendance (SBA) in Nigeria. The data used were collected from a nationally representative sample of women (aged 15-49) in 2011. The sample is restricted to women who were within two years postpartum (weighted n = 9879). Multivariate logistic regression was used to assess the association between ANC (number of visits attended and services received during last pregnancy) and SBA. Despite 70% of the women receiving any ANC, only 49% had SBA during their last childbirth. The number of ANC services received, rather than the number of ANC visits attended, was positively associated with having SBA during last childbirth after controlling for relevant covariates (p < 0.05). The focus, therefore, should be on increasing the number of services received during ANC.

Determinants of Sexual Activity and Pregnancy among Unmarried Young Women in Urban Kenya: A Cross-Sectional Study.

OBJECTIVES: With age of marriage rising in Kenya, the period between onset of puberty and first marriage has increased, resulting in higher rates of premarital sexual activity and pregnancy. We assessed the determinants of sexual activity and pregnancy among young unmarried women in urban Kenya. METHODS: Baseline data from five urban areas in Kenya (Nairobi, Mombasa, Kisumu, Machakos, and Kakamega) collected in 2010 by the Measurement, Learning & Evaluation project were used. Women aged 15-24 years, who had never been married, and were not living with a male partner at the time of survey (weighted n = 2020) were included. Using weighted, multivariate Cox proportional hazard regression and logistic regression analyses, we assessed factors associated with three outcome measures: time to first sex, time to first pregnancy, and teenage pregnancy. RESULTS: One-half of our sample had ever had sex; the mean age at first sex among the sexually-experienced was 17.7 (± 2.6) years. About 15% had ever been pregnant; mean age at first pregnancy was 18.3 (± 2.2) years. Approximately 11% had a teenage pregnancy. Three-quarters (76%) of those who had ever been pregnant (weighted n = 306) reported the pregnancy was unwanted at the time. Having secondary education was associated with a later time to first sex and first pregnancy. In addition, religion, religiosity, and employment status were associated with time to first sex while city of residence, household size, characteristics of household head, family planning knowledge and misconceptions, and early sexual debut were significantly associated with time to first pregnancy. Education, city of residence, household wealth, early sexual debut, and contraceptive use at sexual debut were associated with teenage pregnancy for those 20-24 years. CONCLUSION: Understanding risk and protective factors of youth sexual and reproductive health can inform programs to improve young people's long-term potential by avoiding early and unintended pregnancies.

Provider barriers to family planning access in urban Kenya.

OBJECTIVE: A better understanding of the prevalence of service provider-imposed barriers to family planning can inform programs intended to increase contraceptive use. This study, based on data from urban Kenya, describes the frequency of provider self-reported restrictions related to clients' age, parity, marital status, and third-party consent, and considers the impact of facility type and training on restrictive practices. STUDY DESIGN: Trained data collectors interviewed 676 service providers at 273 health care facilities in five Kenyan cities. Service providers were asked questions about their background and training and were also asked about age, marital, parity, or consent requirements for providing family planning services. RESULTS: More than half of providers (58%) reported imposing minimum age restrictions on one or more methods. These restrictions were commonly imposed on clients seeking injectables, a popular method in urban Kenya, with large numbers refusing to offer injectables to women younger than 20 years. Forty-one percent of providers reported that they would not offer one or more methods to nulliparous women and more than one in four providers reported that they would not offer the injectable to women without at least one child. Providers at private facilities were significantly more likely to impose barriers, across all method types, and those without in-service training on family planning provision had a significantly higher prevalence of imposing parity, marital, and consent barriers across most methods. CONCLUSION: Programs need to address provider-imposed barriers that reduce access to contraceptive methods particularly among young, lower parity, and single women. Promising strategies include targeting private facility providers and increasing the prevalence of in-service training.

Media Influence on Sexual Activity and Contraceptive Use: A Cross Sectional Survey among Young Women in Urban Nigeria.

This study assessed the relationship between recent exposure to family planning (FP) messages in the media (newspaper, radio, television, and mobile phones) and use of modern contraceptive methods among women aged 15-24 years living in six cities in Nigeria. Logistic regression models were used to predict recent media exposure to FP messages and its association with sexual experience and modern contraceptive method use. About 45% of our sample had ever had sex with only a quarter of them using a modern contraceptive method at the time of survey. Approximately 71% of our sample was exposed to FP messages in the media within the three months preceding the survey. The main sources of media exposure were mobile phones (48%), radio (37%), and television (29%). Controlling for relevant factors, recent media exposure to FP messages predicted both sexual experience and use of modern contraceptive methods, although there were city-level differences.

Belief in Family Planning Myths at the Individual and Community Levels and Modern Contraceptive Use in Urban Africa.

CONTEXT: Negative myths and misconceptions about family planning are a barrier to modern contraceptive use. Most research on the subject has focused on individual beliefs about contraception; however, given that myths spread easily within communities, it is also important to examine how the prevalence of negative myths in a community affects the aggregate level of method use. METHODS: Baseline data collected in 2010-2011 by the Measurement, Learning & Evaluation project on women aged 15-49 living in selected cities in Kenya, Nigeria and Senegal were used. Multivariate analyses examined associations between modern contraceptive use and belief in negative myths for individuals and communities. RESULTS: In each country, the family planning myths most prevalent at the individual and community levels were that "people who use contraceptives end up with health problems," "contraceptives are dangerous to women's health" and "contraceptives can harm your womb." On average, women in Nigeria and Kenya believed 2.7 and 4.6 out of eight selected myths, respectively, and women in Senegal believed 2.6 out of seven. Women's individual-level belief in myths was negatively associated with their modern contraceptive use in all three countries (odds ratios, 0.2-0.7). In Nigeria, the women's community-level myth variable was positively associated with modern contraceptive use (1.6), whereas the men's community-level myth variable was negatively associated with use (0.6); neither community-level variable was associated with modern contraceptive use in Kenya or Senegal. CONCLUSION: Education programs are needed to dispel common myths and misconceptions about modern contraceptives. In Nigeria, programs that encourage community-level discussions may be effective at reducing myths and increasing modern contraceptive use.

Risk factors for transactional sex among young females in post-conflict Liberia.

This study aimed to examine the risk factors for engaging in transactional sex among young females in Montserrado County, Liberia. Data from an HIV behavioral survey conducted among young people aged 14 - 25 years were used. The analytical sample included 493 sexually-experienced females. Bivariate and multivariate analyses were conducted. We found that 72% of our sample had ever engaged in transactional sex. Engagement in transactional sex was associated with education (OR: 0.5); reporting no earned income (OR: 1.9); longer duration of sexual activity (OR: 3.5); early sexual debut (OR: 2.5); history of sexual violence (OR: 2.1) and multiple sexual partnerships (OR: 4.0). Respondents' age, residence, and drug/alcohol use were not associated with engagement in transactional sex. HIV interventions should incorporate educational strategies to reduce the prevalence of transactional sex among young people. These strategies should include economic opportunities to offset financial need as well as efforts to eradicate sexual violence.

Factors associated with unmet need for modern contraception in post-conflict Liberia.

We examined the association between intimate partner violence and unmet need for modern contraception in post-conflict Liberia. This is a secondary analysis of data collected using the Priorities for Local AIDS Control Efforts (PLACE) method. Data from 499 sexually experienced young women (aged 14-25) in Montserrado County, Liberia were examined. Intimate partner violence (55.7%), unintended pregnancy (83.2%), and abortion (45.3%) were pervasive in the study population. An estimated 35.9% of respondents had an unmet need for modern contraception. However, multivariate logistic regression results did not reveal an association between intimate partner violence and unmet need (OR 1.11; 95% CI 0.70-1.75). Among covariates examined, only contraceptive use at sexual debut (26.1%) was significantly associated with unmet need (OR 0.27; 95% CI 0.14-0.52). Liberian youth need information about and access to modern contraceptive methods besides condoms. Interventions to identify and treat victims of violence are also needed.

Unmet need for contraception among clients of FP/HIV integrated services in Nigeria: the role of partner opposition.

While women are aware of family planning (FP) methods in Nigeria, the unmet need for modern contraception remains high. We assessed the association between male partner opposition to FP and unmet need for modern contraception among women seeking anti-retroviral therapy (ART), HIV counseling and testing (HCT) and prevention-of-mother-to-child-transmission of HIV (PMTCT) services in Cross-River State, Nigeria. This secondary analysis used data from a facility-based FP/HIV integration study. Logistic regression was used to model the association of interest. Unmet need for modern contraception was high among all clients--ART (49%), HCT (75%), and PMTCT (32%). Perceived partner opposition to FP was widespread (> or = 70%); however, multivariate analysis showed no significant association with unmet need for modern contraception. Significant covariates were woman's age, marital status, parity, and previous use of modern contraception. Efforts to improve modern contraceptive use among women at risk of HIV infection in Nigeria should contemplate involving their male partners.

Informing HIV prevention efforts targeting Liberian youth: a study using the PLACE method in Liberia.

BACKGROUND: Preventing HIV infection among young people is a priority for the Liberian government. Data on the young people in Liberia are scarce but needed to guide HIV programming efforts. METHODS: We used the Priorities for Local AIDS Control Efforts (PLACE) method to gather information on risk behaviors that young people (ages 14 to 24) engage in or are exposed to that increase their vulnerability for HIV infection. Community informants identified 240 unique venues of which 150 were visited and verified by research staff. 89 of the 150 venues comprised our sampling frame and 571 females and 548 males were interviewed in 50 venues using a behavioral survey. RESULTS: Ninety-one percent of females and 86% of males reported being sexually active. 56% of females and 47% of males reported they initiated sexual activity before the age of 15. Among the sexually active females, 71% reported they had received money or a gift for sex and 56% of males reported they had given money or goods for sex. 20% of females and 6% males reported that their first sexual encounter was forced and 15% of females and 6% of males reported they had been forced to have sex in the past year. Multiple partnerships were common among both sexes with 81% females and 76% males reporting one or more sex partners in the past four weeks. Less than 1% reported having experiences with injecting drugs and only 1% of males reporting have sex with men. While knowledge of HIV/AIDS was high, prevention behaviors including HIV testing and condom use were low. CONCLUSION: Youth-focused HIV efforts in Liberia need to address transactional sex and multiple and concurrent partnerships. HIV prevention interventions should include efforts to meet the economic needs of youth.