A Longitudinal Multilevel Analysis of the Effects of Contraceptive Failures on Unintended Pregnancies among Women in Urban Nigeria.

Unintended pregnancy is a global public health concern. However, the effect of contraceptive failure on unintended pregnancy remains unclear in Nigeria. We undertook a longitudinal analysis to examine the effect of contraceptive failure on unintended pregnancy among urban women in Nigeria. We used panel data from the Nigerian Urban Reproductive Health Initiative. The Measurement, Learning and Evaluation program conducted the surveys among a cohort of women aged 15-49 who were first interviewed at baseline in 2010/2011 and followed up at endline in 2014/2015. Analytic sample was 4140 women aged 15-49 who ever used contraceptives. We fitted three-level multilevel binary logistic regression models estimated with GLLAMM. The study established evidence that there is a significant effect of contraceptive failure on unintended pregnancy among urban women in Nigeria. The positive effect of between-person contraceptive failure indicates that respondents who experienced more contraceptive failure than the average in the sample had 5.26 times higher odds of unintended pregnancy (OR = 5.26; p-value < 0.001). Results also established a significant effect of within-person contraceptive failures among the respondents. Findings suggest there is evidence of a significant longitudinal effect of contraceptive failure on unintended pregnancy in urban Nigeria. Efforts to reduce unintended pregnancy must include interventions to address the problem of contraceptive failure among urban women in Nigeria.

Comparing the reasons for contraceptive discontinuation between parenting adolescents and young women in sub-Saharan Africa: a multilevel analysis.

BACKGROUND: Adolescent sexual and reproductive health remains a major public health and development issue of global importance. Given that adolescents and young people are heterogenous groups in terms of many characteristics, this study expands the literature by comparing the reasons for contraceptive discontinuation between parenting adolescents (aged 15-19) and parenting young women (aged 20-24) in sub-Saharan Africa (SSA). METHODS: Data for the study came from Demographic and Health Surveys of 22 SSA countries. The outcome variable was reasons for discontinuation. We performed multilevel binary logistic regression on analytic samples comprising 1485 parenting adolescents and 10,287 parenting young women across the selected SSA countries. RESULTS: Findings show that the proportion of respondents who used modern contraceptives was lower among parenting adolescents (35%) relative to their 20-24-year-old counterparts (43%). Higher percentages of parenting adolescents than young women discontinued contraceptives because of reasons such as pregnancy or method failure (i.e., 9.9% and 8.17% accordingly), husband disapproval, access or availability issues, wanting more effective methods, and inconvenience in using methods. The multilevel analysis further highlighted disparities between parenting adolescents and parenting young women who discontinued contraceptives. For instance, parenting young women had 30% lower odds of discontinuing contraceptives due to pregnancy or method failure than parenting adolescents. CONCLUSION: The study established disparities in the reasons for contraceptive discontinuation between parenting adolescents and parenting young women, with adolescents demonstrating greater vulnerabilities and higher risks. Considerable attention must be given to parenting adolescents in the efforts to achieve equity goals such as the Sustainable Development Goals and universal health coverage in SSA.

Understanding context in the implementation of emergency obstetric and neonatal care in health facilities in Osun State, Nigeria- a mixed-methods study.

BACKGROUND: Successful implementation of Emergency Obstetric and Neonatal Care (EmONC) is likely to improve pregnancy outcomes and is essential for quality maternity care. Context in implementation is described as factors that enabled or disabled implementation of interventions. While the context of implementation is important for the effectiveness of evidence-based interventions, the context of EmONC implementation has not been widely studied in Nigeria. METHODS: The research design was cross-sectional descriptive. A mixed-methods approach was used to assess and explore the context of implementing EmONC in referral centres in Osun state. A purposive sampling technique was used to select the three tertiary health facilities in Osun State and six secondary health facilities from the six administrative zones in the State. A total of 186 healthcare providers in these referral centres participated in the quantitative part of the study, and eighteen in-depth interviews were conducted for its qualitative aspect. An adapted questionnaire from Context Assessment Index and an interview guide were used to collect data. Quantitative data were analysed using descriptive and inferential statistics at 0.05 significance level, while qualitative data were analysed using the thematic approach. RESULTS: The percentage mean score of context strength in EmONC implementation was 63% ± 10.46 in secondary and 68% ± 10.47 in tertiary health facilities. There was a significant difference in the leadership (F (1, 184) = 8.35, p < 0.01), evaluation (F (1, 184) = 5.35, p = 0.02) and overall context (F (1, 184) = 6.46, p = 0.01) of EmONC implementation in secondary and tertiary health facilities. Emerging themes in EmONC context were: Resources for EmONC implementation; Demand for EmONC; Efficiency of funding; Institutional leadership; and Performance evaluation. CONCLUSIONS: The context of EmONC implementation in the referral health facilities was generally weak. The secondary health facilities' weaknesses were worse compared to the tertiary health facilities. The five key contextual factors could inform strategies for improving EmONC implementation in health facilities to ensure improved access to care that will reduce deaths from obstetric complications in Nigeria.

Exploring barriers and facilitators to integrated policy formulation and implementation of family planning and urban development programmes in Nigeria.

BACKGROUND: As more people now live in urban areas than in rural communities in Nigeria, urban development (UD) requires urgent policy and programmatic attention. Although the population factor has been identified as important to achieving national development goals, and evidence suggests that meeting the family planning (FP) and reproductive health (RH) needs of the vulnerable urban population can serve as an important recipe for achieving population growth rates consistent with building sustainable, habitable and prosperous urban settings, FP remains a neglected subject in UD initiatives in Nigeria. This study explored barriers and facilitators in achieving integrated policy formulation and implementation of FP and UD programmes in Nigeria. METHODS: We conducted key informant interviews (n = 37) with relevant FP/RH and UD stakeholders in Ibadan and Kaduna-two megacities that have undergone several UD and FP intervention programmes in the south and north of Nigeria. The sample size was determined by data saturation. Data were organized using ATLAS.ti and NVivo 12 software, and analysis was conducted using a thematic approach. RESULTS: We found that relevant government agencies largely work in silos. Other identified barriers to integrated policy formulation/implementation of FP and UD programmes in Nigeria include lack of knowledge about the FP-UD nexus between professionals, ineffective implementation and monitoring of existing guidelines, lack of policy documentation that clearly links FP and UD, and frequent transfer of government stakeholders. Notwithstanding the identified barriers, the study established ways of achieving synergy between FP and UD sectors, including stakeholder engagement, intersectoral collaborations, sensitization and publicity, roundtable discussion, interdisciplinary research, conferences and other interactive and knowledge-sharing fora. CONCLUSIONS: We conclude that addressing barriers to the intersectoral linkage between FP and UD is fundamental to achieving sustainable urbanization in Nigeria.

Influence of child marriage on institutional delivery and high-risk births among young women in 31 sub-Saharan African countries.

While child marriage persists in sub-Saharan Africa (SSA), little is known about its influence on institutional delivery/high-risk births (IDHRB). We analyzed pooled data on young women aged 15-24 (N = 113,588) from the most recent Demographic and Health Surveys of 31 SSA countries to examine the influence of child marriage on IDHRB. Binary logistic regression analysis was done to explore statistically significant relationships. Findings showed that unskilled delivery was significantly higher among women who married before age 15 (67.2%) and at ages 16-17 (48.2%) compared to those who married at age 18+ (30.2%). The prevalence of high-risk birth was higher among women who married before age 15 (97.2%) and at ages 16-17 (80.8%) compared to those who married at 18+ (48.4%). Inferential analysis showed that respondents who married before age 15 and at ages 16-17, respectively, had five-fold and two-fold higher odds of experiencing unskilled delivery compared to those who married at age 18 +. Odds of having high-risk births were significantly higher among child-brides compared to those who had first marriage as adults. This study concludes that policies/programs that would successfully delay first marriage among women must be pursued to reduce high-risk births and unskilled delivery in SSA.

Community perspectives and caregivers' healthcare practices and responses to the four major childhood killer diseases in Nigeria.

Two-thirds of Nigeria's childhood deaths is attributable to four preventable/curable diseases-diarrhoea, malaria, meningitis and pneumonia (DMMP). Community perspectives and caregivers' practices about these child-killer diseases are poorly documented. Drawing on individual and group interviews (n=259), we explored community members' perspectives, and caregivers' practices/responses regarding DMMP among children across Nigeria's three major ethnic groups. Using deductive reasoning and data analysis in Atlas.ti, results from the narratives formed four thematic issues-respondents' perception and knowledge about the causes of the diseases; perception and knowledge about prevention; perception and knowledge of symptoms and fatality of the diseases; and caregivers' practices regarding the prevention and management of the diseases. Results demonstrate significant misconception about the aetiology of pneumonia and meningitis. We found ostensible disconnection between knowledge and practice. Interventions including health education programmes/sensitizations on the causes, prevention/management of DMMP are necessary to achieve reduction in the burden of childhood mortality in Nigeria.

Ethnicity, religious affiliation and girl-child marriage: a cross-sectional study of nationally representative sample of female adolescents in Nigeria.

BACKGROUND: The persistently high prevalence of girl-child marriage remains a public health and developmental concern in Nigeria. Despite global campaign against the practice and policy efforts by Nigerian government, the prevalence remains unabated. This study investigates the prevalence and the influence of ethnicity and religious affiliation on the girl-child marriage among female adolescents in Nigeria. METHODS: Data of 7804 girls aged 15-19 years extracted from the 2013 Nigeria Demographic and Health Survey were used. Ethnic groups were classified into five: major Northern ethnic group (Hausa/Fulani); Northern ethnic minorities; two major Southern ethnic groups (Yoruba and Igbo), and Southern ethnic minorities. The prevalence of girl-child marriage was determined for the five ethnic groups and individually for each ethnic minority group. Relationships between ethnicity and religious affiliation on girl-child marriage were explored using Cox proportional hazard regression models, adjusting for residence, education and wealth quintile. RESULTS: Child marriage was higher for the Northern majority ethnic group of Hausa/Fulani (54.8%) compared to the two major Southern ethnic groups (3.0-3.6%) and aggregated Northern ethnic minorities (25.7%) and Southern minorities (5.9%). However, overall, the less known Northern ethnic minority groups of Kambari (74.9%) and Fulfude (73.8%) recorded the highest prevalence. Compared to the major Southern ethnic group of Yoruba, the adjusted hazard ratio (AHR) of child marriage was significantly higher for Northern ethnic minorities (AHR = 2.50; 95% C.I. = 1.59-3.95) and Northern major ethnicity (AHR = 3.67, 95% C.I. = 2.33-5.77). No significant difference was recorded among Southern ethnic groups. Girls affiliated to other religions (Muslim and traditionalist) had higher child-marriage risks compared to Christians (AHR = 2.10; 95% C.I. = 1.54-2.86). CONCLUSION: Ethnicity and religion have independent associations with girl-child marriage in Nigeria; interventions must address culturally-laden social norms that vary by ethnic groups as well as religious-related beliefs.

Regional variations in the use of postnatal care in Nigeria: a spatial analysis.

Maternal health outcomes vary considerably in Nigeria, with maternal mortality ratio ranging from 165 per 100,000 live births in the South-west to 1549 per 100,000 live births in the North-east. One important maternal health indicator is an adequate use of postnatal care (PNC); however, the evidence is sparse on its spatial distribution across regions in Nigeria. This paper thus examined the spatial distribution of uptake of postnatal care in Nigeria using data from the 2013 Nigeria Demographic and Health Survey, with a sample of 12,127 women aged 15-49 years. The Bayesian-structured additive regression of the logit model was used to examine the spatial relationships. The results revealed a north-south divide in the use of postnatal care, with higher PNC uptake established in the latter. Interestingly, results showed significant intra-region residual spatial variations with higher PNC use in Yobe and Bauchi in North-east Nigeria compared to other states within the region. The findings indicate the need for policymakers to develop state- and region-specific health policy and intervention programs to address the inequity in postnatal care coverage and usage across regions in Nigeria.

Health and Demographic Surveillance Systems Within the Child Health and Mortality Prevention Surveillance Network.

Health and demographic surveillance systems (HDSSs) provide a foundation for characterizing and defining priorities and strategies for improving population health. The Child Health and Mortality Prevention Surveillance (CHAMPS) project aims to inform policy to prevent child deaths through generating causes of death from surveillance data combined with innovative diagnostic and laboratory methods. Six of the 7 sites that constitute the CHAMPS network have active HDSSs: Mozambique, Mali, Ethiopia, Kenya, Bangladesh, and South Africa; the seventh, in Sierra Leone, is in the early planning stages. This article describes the network of CHAMPS HDSSs and their role in the CHAMPS project. To generate actionable health and demographic data to prevent child deaths, the network depends on reliable demographic surveillance, and the HDSSs play this crucial role.

Mortality Surveillance Methods to Identify and Characterize Deaths in Child Health and Mortality Prevention Surveillance Network Sites.

Despite reductions over the past 2 decades, childhood mortality remains high in low- and middle-income countries in sub-Saharan Africa and South Asia. In these settings, children often die at home, without contact with the health system, and are neither accounted for, nor attributed with a cause of death. In addition, when cause of death determinations occur, they often use nonspecific methods. Consequently, findings from models currently utilized to build national and global estimates of causes of death are associated with substantial uncertainty. Higher-quality data would enable stakeholders to effectively target interventions for the leading causes of childhood mortality, a critical component to achieving the Sustainable Development Goals by eliminating preventable perinatal and childhood deaths. The Child Health and Mortality Prevention Surveillance (CHAMPS) Network tracks the causes of under-5 mortality and stillbirths at sites in sub-Saharan Africa and South Asia through comprehensive mortality surveillance, utilizing minimally invasive tissue sampling (MITS), postmortem laboratory and pathology testing, verbal autopsy, and clinical and demographic data. CHAMPS sites have established facility- and community-based mortality notification systems, which aim to report potentially eligible deaths, defined as under-5 deaths and stillbirths within a defined catchment area, within 24-36 hours so that MITS can be conducted quickly after death. Where MITS has been conducted, a final cause of death is determined by an expert review panel. Data on cause of death will be provided to local, national, and global stakeholders to inform strategies to reduce perinatal and childhood mortality in sub-Saharan Africa and South Asia.

Child's Risk Attributes at Birth and Infant Mortality Disparities in Nigeria.

Births in avoidable high-risk contexts defined by the interplay of sub-optimal childbearing age, short spacing, and first and high birth order incur elevated risks of childhood death. However, the extent of disparities in risks of dying in infancy vis-à-vis the continuum of non-high-risk and (un)avoidable high-risk attributes at birth as determined by mother's age at childbirth, child spacing, and birth order characteristics is yet to be adequately explored in Nigeria as elsewhere. To fill this gap, chi-square association test and Cox's proportional hazards regression were used to analyze data of 31,260 nationally representative children aged 0-59 months drawn from 2013 Nigeria Demographic and Health Survey. Disparities in infant mortality risks were mainly examined across the spectrum of birth-related risk attributes at birth broadly categorized as no extra high-risk, unavoidable first- order risk and combined avoidable high-risk. The risks of dying in infancy differed significantly by risk attributes to the extent dictated by other confounders. Also, infant mortality risks varied significantly by all moderating factors excluding religion, water source, toilet type and place of delivery. Interventions targeted at reducing avoidable high-risk fertility rate and strengthening health system to provide life-saving care to most-at-risk children would engender rapid improvement in infant survival.

THE ROLE OF COMMUNITY STRUCTURE IN SHAPING AFRICAN FERTILITY PATTERN: EVIDENCE FROM DEMOGRAPHIC AND HEALTH SURVEYS.

Anthropological explanations of demographic outcomes have emphasized the need to understand how community structures contribute to those outcomes. However, studies on fertility dynamics in Africa have largely focused on micro-level factors, thus ignoring the influence of community contexts. Using the most recent Demographic and Health Survey data from Egypt (Northern Africa), Cameroon (Middle Africa), Kenya (Eastern Africa), Nigeria (Western Africa) and Zimbabwe (Southern Africa), the study employed multilevel Poisson regression models to examine the influence of community factors on African fertility levels and patterns. The number of sampled women (aged 15-44) ranged from 7774 in Kenya (2008-09) to 30,480 in Nigeria (2008). The findings demonstrate some significant community effects on African fertility patterns, even after controlling for a number of individual-level factors. For instance, residence in socioeconomically disadvantaged regions, rural settings, poor neighbourhood and communities with high family size norm were found to be associated with higher fertility levels in the selected countries. The emerging African fertility patterns require the need to go beyond addressing individual-level characteristics in the efforts to reduce fertility levels in Africa.

The relation of female circumcision to sexual behavior in Kenya and Nigeria.

One of the reasons for the perpetuation of female circumcision is that it controls female sexuality. In this study, the authors examined the relationship between female circumcision and the sexual behavior of women in Kenya and Nigeria. Data on women who were aware of circumcision and were circumcised were extracted from the Kenya Demographic and Health Survey of 2008-09 as well as the Nigeria Demographic and Health Survey of 2008. The sample size was 7,344 for Kenya and 16,294 for Nigeria. The outcome variables were age at first intercourse and total lifetime number of sexual partners. The study hypothesis was that women who were circumcised were less likely to have initiated sex early and to have only one sex partner. Cox proportional hazards regression and Poisson regression were used to examine the relations of female circumcision and other selected variables to sexual behavior. No association was observed between female circumcision and the outcomes for sexual behavior of women in Kenya and Nigeria. The argument of sexual chastity is insufficient to sustain the perpetuation of female circumcision.

Ecological correlates of multiple sexual partnerships among adolescents and young adults in urban Cape Town: a cumulative risk factor approach.

Studies in South Africa have reported unsafe levels of risky sexual behvaiours among adolescents and young adults, with the country reporting the highest burden of HIV/AIDS globally, as well as a high rate of teenage pregnancy. While determinants of risky sexual behaviours have been investigated for factors occurring at the individual and household levels, not fully explored in the literature is the effect of community level factors. Furthermore, it is unclear whether risk factors occurring within the ecology of adolescents and young adults act cumulatively to influence their sexual practices. This article aims to address this knowledge gap using a case study of the Cape Area Panel Study of adolescents and young adults in urban Cape Town, South Africa. The ecological framework was adopted to guide the selection of risk factors at the individual, household, and community levels. Multivariate linear discriminant function analyses were used to select significant risk factors for multiple sexual partnerships and used to produce risk indices for the respondents. The cumulative risk approach was applied to test whether significant risk factors acted cumulatively. Findings point to the importance of ecological factors in influencing outcomes of multiple sexual partnerships among respondents and further demonstrate that ecological risk factors may act cumulatively. These findings are important for South Africa that is grappling with teenage pregnancy and disproportionate HIV epidemic among the youth.

Independent and combined effects of maternal smoking and solid fuel on infant and child mortality in sub-Saharan Africa.

OBJECTIVE: To estimate the independent and combined risks of infant and child mortality associated with maternal smoking and use of solid fuel in sub-Saharan Africa. METHODS: Pooled weighted data on 143 602 under-five children in the most recent demographic and health surveys for 15 sub-Saharan African countries were analysed. The synthetic cohort life table technique and Cox proportional hazard models were employed to investigate the effect of maternal smoking and solid cooking fuel on infant (age 0-11 months) and child (age 12-59 months) mortality. Socio-economic and other confounding variables were included as controls. RESULTS: The distribution of the main explanatory variable in households was as follows: smoking + solid fuel - 4.6%; smoking + non-solid fuel - 0.22%; no smoking + solid fuel - 86.9%; and no smoking + non-solid fuel - 8.2%. The highest infant mortality rate was recorded among children exposed to maternal smoking + solid fuel (72 per 1000 live births); the child mortality rate was estimated to be 54 per 1000 for this group. In full multivariate models, the risk of infant death was 71% higher among those exposed to maternal smoking + solid fuel (HR = 1.71, CI: 1.29-2.28). For ages 12 to 59 months, the risk of death was 99% higher (HR = 1.99, CI: 1.28-3.08). CONCLUSIONS: Combined exposures to cigarette smoke and solid fuel increase the risks of infant and child mortality. Mothers of under-five children need to be educated about the danger of smoking while innovative approaches are needed to reduce the mortality risks associated with solid cooking fuel.

Ethnic differentials in under-five mortality in Nigeria.

OBJECTIVE: There are huge regional disparities in under-five mortality in Nigeria. While a region within the country has as high as 222 under-five deaths per 1000 live births, the rate is as low as 89 per 1000 live births in another region. Nigeria is culturally diverse as there are more than 250 identifiable ethnic groups in the country; and various ethnic groups have different sociocultural values and practices which could influence child health outcome. Thus, the main objective of this study was to examine the ethnic differentials in under-five mortality in Nigeria. DESIGN: The study utilized 2008 Nigeria Demographic and Health Survey (NDHS) data. We analyzed data from a nationally representative sample drawn from 33,385 women aged 15-49 that had a total of 104,808 live births within 1993-2008. In order to examine ethnic differentials in under-five mortality over a sufficiently long period of time, our analysis considered live births within 15 years preceding the 2008 NDHS. The risks of death in children below age five were estimated using Cox proportional regression analysis. Results were presented as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: The study found substantial differentials in under-five mortality by ethnic affiliations. For instance, risks of death were significantly lower for children of the Yoruba tribes (HR: 0.39, CI: 0.37-0.42, p < 0.001), children of Igbo tribes (HR: 0.58, CI: 0.55-0.61, p < 0.001) and children of the minority ethnic groups (HR: 0.66, CI: 0.64-0.68, p < 0.001), compared to children of the Hausa/Fulani/Kanuri tribes. Besides, practices such as plural marriage, having higher-order births and too close births showed statistical significance for increased risks of under-five mortality (p < 0.05). CONCLUSION: The findings of this study stress the need to address the ethnic norms and practices that negatively impact on child health and survival among some ethnic groups in Nigeria.

Unmet need for family planning: implication for under-five mortality in Nigeria.

There are gaps in evidence on whether unmet need for family planning has any implication for under-five mortality in Nigeria. This study utilized 2008 Nigeria Demographic and Health Survey data to examine the effect of unmet need on under-five mortality. Cox regression analysis was performed on 28,647 children born by a nationally-representative sample of 18,028 women within the five years preceding the survey. Findings indicated elevated risks of under-five death for children whose mothers had unmet need for spacing [Hazard ratio (HR): 1.60, confidence interval (CI) 1.37-1.86, p<0.001] and children whose mothers had unmet need for limiting (HR: 1.78, CI 1.48-2.15, p<0.001) compared to children whose mothers had met need. These findings were consistent after adjusting for the effects of factors that could confound the association. Findings of this study underscore the need to address the present level of unmet need for family planning in Nigeria, if the country would achieve meaningful reduction in under-five mortality.

REGIONAL VARIATIONS IN INFANT AND CHILD MORTALITY IN NIGERIA: A MULTILEVEL ANALYSIS.

There are substantial regional disparities in under-five mortality in Nigeria, and evidence suggests that both individual- and community-level characteristics have an influence on health outcomes. Using 2008 Nigeria Demographic and Health Survey data, this study (1) examines the effects of individual- and community-level characteristics on infant/child mortality in Nigeria and (2) determines the extent to which characteristics at these levels influence regional variations in infant/child mortality in the country. Multilevel Cox proportional hazard analysis was performed on a nationally representative sample of 28,647 children nested within 18,028 mothers of reproductive age, who were also nested within 886 communities. The results indicate that community-level variables (such as region, place of residence, community infrastructure, community hospital delivery and community poverty level) and individual-level factors (including child's sex, birth order, birth interval, maternal education, maternal age and wealth index) are important determinants of infant/child mortality in Nigeria. For instance, the results show a lower risk of death in infancy for children of mothers residing in communities with a high proportion of hospital delivery (HR: 0.70, p < 0.05) and for children whose mothers had secondary or higher education (HR: 0.84, p < 0.05). Although community factors appear to influence the association between individual-level factors and death during infancy and childhood, the findings consistently indicate that community-level characteristics are more important in explaining regional variations in child mortality, while individual-level factors are more important for regional variations in infant mortality. The results of this study underscore the need to look beyond the influence of individual-level factors in addressing regional variations in infant and child mortality in Nigeria.

Differential effect of wealth quintile on modern contraceptive use and fertility: evidence from Malawian women.

BACKGROUND: High fertility and wide inequality in wealth distribution are phenomenal problems in sub-Saharan Africa. Modern Contraceptives (MC) are useful for limiting fertility, but are not always easily accessible in Malawi. This study examines the gap in MC use and fertility between women in the richest and poorest Wealth Quintile (WQ). METHODS: The study was cross-sectional in design and utilized Malawi DHS dataset, 2010. It focused on women of reproductive age. The dependent variables are ever and current use of MC. Chi-square and multinomial logistic regression were used for the analysis. RESULTS: Mean children ever born by women in the poorest and richest WQs were 3.94 ± 2.7 and 2.82 ± 2.3 respectively (p < 0.001). The adjusted total fertility rate (Adj.TFR) was higher among women in the poorest (Adj.TFR = 7.60) WQ than the richest (Adj.TFR = 4.45). The prevalence of ever use of MC was higher among women in the richest WQ (82.4%) than the poorest (66.8%) (p < 0.001). Similar pattern exists for current use of MC; 58.5% and 45.9% for women in the richest and poorest WQs respectively (p < 0.001). Women in the richest WQ were more likely to ever use (OR = 2.36; C.I = 2.07-2.69, p < 0.001) and currently using (OR = 1.66; C.I = 1.40-1.97, p < 0.001) MC than their counterparts in the poorest WQ. Slight reduction in odd-ratio of MC use among women in richest WQ resulted when socio-demographic variables were used as control. CONCLUSION: Fertility was higher and the use of MC was lower among women in the poorest than their counterparts in the richest WQ. Ensuring availability of MC at little or no cost may bridge the gap in contraceptive use between women in the poorest and richest WQ in Malawi.

Does it really matter where women live? A multilevel analysis of the determinants of postnatal care in Nigeria.

Although postnatal care is one of the major interventions recommended for the reduction of maternal and newborn deaths worldwide, almost two-third (56 %) of women in Nigeria do not receive postnatal care. Attempts to explain this situation have focused on individual and household level factors, but the role of community characteristics has received less attention.This study examines community factors associated with the receipt of postnatal care in Nigeria and the moderating effects of community factors on the association between individual factors and postnatal care. Data was drawn from the 2008 Nigeria Demographic and Health Survey, and a sample of 17,846 women aged 15-49 years was selected. We employed a multilevel logistic regression analysis to identify community factors associated with postnatal care. Our findings showed that significant variations in receiving postnatal care exist across communities. Specifically, Nigerian women's likelihood of receiving postnatal care is a function of where they reside. Living in communities with a high proportion of educated women (OR = 2.04; 95 % CI = 1.32-3.16; p < 0.001) and a high proportion of those who have had a health facility delivery (OR = 17.86; 95 % CI = 8.34-38.24; p < 0.001) was significantly associated with an increased likelihood of receiving postnatal care. Community women's education moderated the association between ethnic origin and postnatal care. Community variance in postnatal care was significant (τ = 10.352, p = 0.001). Community interventions aimed at improving postnatal care should take into account the community context in which women live. To close the gap in community variations in postnatal care, secondary and higher education for women, and health facility delivery should be increased in disadvantaged communities.