Trends in and predictors of pregnancy termination among 15-24 year-old women in Nigeria: a multi-level analysis of demographic and health surveys 2003-2018.

BACKGROUND: Three-quarters of pregnancy terminations in Africa are carried out in unsafe conditions. Unsafe abortion is the leading cause of maternal mortality among 15-24 year-old women in Sub-Saharan Africa. Greater understanding of the wider determinants of pregnancy termination in 15-24 year-olds could inform the design and development of interventions to mitigate the harm. Previous research has described the trends in and factors associated with termination of pregnancy for women of reproductive age in Nigeria. However, the wider determinants of pregnancy termination have not been ascertained, and data for all women have been aggregated which may obscure differences by age groups. Therefore, we examined the trends in and individual and contextual-level predictors of pregnancy termination among 15-24 year-old women in Nigeria. METHODS: We analysed data from the 2003, 2008, 2013 and 2018 Nigerian Demographic and Health Surveys (NDHS) comprising 45,793 women aged 15-24 years. Trends in pregnancy termination across the four survey datasets were examined using bivariate analysis. Individual and contextual predictors of pregnancy termination were analysed using a three-level binary logistic regression analysis and are reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Trends in pregnancy termination declined from 5.8% in 2003 to 4.2% in 2013 then reversed to 4.9% in 2018. The declining trend was greater for 15-24 year-old women with higher socioeconomic status. Around 17% of the total variation in pregnancy termination was attributable to community factors, and 7% to state-level factors. Of all contextual variables considered, only contraceptive prevalence (proxy for reproductive health service access by young women) at community level was significant. Living in communities with higher contraceptive prevalence increased odds of termination compared with communities with lower contraceptive prevalence (aOR = 4.2; 95% CI 2.7-6.6). At the individual-level, sexual activity before age 15 increased odds of termination (aOR = 2.3; 95% CI 1.9-2.8) compared with women who initiated sexual activity at age 18 years or older, and married women had increased odds compared with never married women (aOR = 3.0; 95% CI 2.5-3.7). CONCLUSION: Our findings highlight the importance of disaggregating data for women across the reproductive lifecourse, and indicates where tailored interventions could be targeted to address factors associated with pregnancy termination among young women in Nigeria.

Is polygyny a risk factor in the transmission of HIV in sub- Saharan Africa? A systematic review.

Using a systematic literature review approach, this paper focused on the role of polygyny in the spread of HIV/AIDS in sub-Saharan Africa (SSA) countries. The widespread practice of polygyny is one feature of many SSA contexts that may be relevant to understanding patterns of HIV prevalence. Building on the conflicting studies on the importance of polygyny, this study investigated whether or not polygyny is a conduit for elevating HIV transmission in SSA countries. Findings showed that polygyny as an institution is perhaps less of a concern; rather the implication that men and women who are in polygamous relationships are also more likely to engage in extra-marital sex - raises secondary questions about their patterns of sexual networking and concurrent sexual partnerships. The findings however show that polygyny amplifies risky sexual behaviours such as sexual networking and concurrent sexual partnerships, all of which were found to be significantly associated with the risk of HIV transmission. This demonstrates that targeting risky sexual behaviours in a broader marital context may be more important for HIV risk reduction than targeting polygyny as an institution.

Views of Service Providers and Adolescents on Use of Sexual and Reproductive Health Services by Adolescents: A Systematic Review.

This review examines the literature on adolescents' and providers' views on access and use of Sexual and Reproductive Health (SRH) information and services. The SRH services referred to in this study were predominantly family planning services, STI treatment including HIV testing and counselling services. The study design was a systematic review of empirical studies. Twenty-five databases were searched using a well-defined search strategy and Boolean operators. A total of 45 studies were included in the review, and the findings were reported thematically under four emerging themes. The review showed that adolescents and sexual health service providers had differing views on barriers and enablers to adolescent access to SRH services and often had contradictory views on key markers of youth-friendly services, service preferences, barriers and enablers of service use. While service providers perceived physical and financial barriers as fundamental, adolescents identified barriers emanating from providers' attitude as the key hindrance to their access and use of services. The review also revealed that the unprofessional attitudes of some service providers limit adolescents' access to SRH services. These findings serve as evidence to policy actors at all levels to consider attitudinal qualities of service providers when planning and designing sexual health services for adolescents.

Socioeconomic Status and Vulnerability to HIV Infection in Uganda: Evidence from Multilevel Modelling of AIDS Indicator Survey Data.

BACKGROUND: There is controversy on the association between socioeconomic status (SES) and HIV infection. Some evidence claims higher SES is negatively associated with HIV infection while others report the reverse. OBJECTIVES: To examine the association between SES and HIV infection in Uganda and to examine whether the SES-HIV relationship varies by gender, rural-urban place of residence, and time (2004-2005 and 2011) in Uganda. METHODS: Multilevel analysis was applied to 39,766 individual cases obtained in 887 clusters of Uganda HIV/AIDS Indicators Survey conducted in 2004-2005 and 2011. RESULTS: Household wealth is associated with increased vulnerability in the general population and in rural areas. Compared with no educational attainment, secondary or higher education is associated with reduced vulnerability to the risk of HIV infection by 37% in the general population. However, this effect was stronger in urban than rural areas. Besides individual-level factors, unobserved community factors too play an important role and account for 9% of unexplained variance after individual-level factors are considered. CONCLUSION: Household wealth increases vulnerability but education reduces it. The social environment influences vulnerability to HIV infection independent of individual-level factors. HIV/AIDS awareness targeting sexual practices of wealthy individuals and those with primary-level educational attainment together with improving educational attainment and addressing contextual factors influencing vulnerability to HIV infection are necessary strategies to reduce HIV infections in Uganda.

Multilevel determinants of teenage childbearing in sub-Saharan Africa in the context of HIV/AIDS.

This paper examined national variations and multilevel determinants of teenage childbearing in sub-Saharan Africa (SSA) in the context of HIV/AIDS using data from recent Demographic and Health Surveys conducted in 29 countries of SSA. Results showed significant community and national variations in teenage childbearing, partly explained by socio-economic and HIV/AIDS context. At community level, lower HIV/AIDS stigma, higher wealth and female education were associated with lower teenage childbearing. However, national socio-economic status had an intricate relationship with teenage childbearing. Higher national GDP per-capita was generally associated with higher teenage childbearing, and this relationship was stronger in lower HIV prevalence countries.

Understanding the urban-rural disparity in HIV and poverty nexus: the case of Kenya.

Background: The relationship between HIV and poverty is complex and recent studies reveal an urban-rural divide that is not well understood. This paper examines the urban-rural disparity in the relationship between poverty and HIV infection in Kenya, with particular reference to possible explanations relating to social cohesion/capital and other moderating factors. Methods: Multilevel logistic regression models are applied to nationally-representative samples of 13 094 men and women of reproductive age from recent Kenya Demographic and Health Surveys. Results: The results confirm a disproportionate higher risk of HIV infection among the urban poor, despite a general negative association between poverty and HIV infection among rural residents. Estimates of intra-community correlations suggest lower social cohesion in urban than rural communities. This, combined with marked socio-economic inequalities in urban areas is likely to result in the urban poor being particularly vulnerable. The results further reveal interesting cultural variations and trends. In particular, recent declines in HIV prevalence among urban residents in Kenya have been predominantly confined to those of higher socio-economic status. Conclusion: With current rapid urbanization patterns and increasing urban poverty, these trends have important implications for the future of the HIV epidemic in Kenya and similar settings across the sub-Saharan Africa region.

HIV/AIDS and contraceptive use: factors associated with contraceptive use among sexually active HIV-positive women in Kenya.

OBJECTIVES: With increased availability of antiretroviral therapy and improved survival for people living with HIV, more HIV-positive women are leading full reproductive lives. However, HIV-positive women have special contraceptive needs/concerns. This paper examines the individual and community-level HIV/AIDS factors associated with contraceptive use and compares predictors of contraceptive uptake between HIV-positive and HIV-negative women in Kenya. STUDY DESIGN: The study is based on secondary analysis of cross-sectional data of a sample of 9132 sexually active women of reproductive age from the Kenya Demographic and Health Surveys collected in 2003 and 2008. Multilevel logistic regression models are used to examine individual and contextual community-level factors associated with current contraceptive use. RESULTS: The study provides evidence of lower contraceptive uptake among women living in high HIV-prevalence communities. It further reveals striking differences in factors associated with contraceptive uptake between HIV-positive and HIV-negative women. Education and the desire to stop childbearing are strongly associated with contraceptive uptake among uninfected women, but both factors are not significant among HIV-positive women for whom wealth is the most important factor. While HIV-negative women in the richest wealth quintile are about twice as likely to use contraceptives as their counterparts of similar characteristics in the poorest quintile, this gap is about sevenfold among HIV-positive women. CONCLUSION: These findings suggest that having the desire and relevant knowledge to use contraceptives does not necessarily translate into expected contraceptive behavior for HIV-positive women in Kenya and that poor HIV-positive women may be particularly in need of increased access to contraceptive services. IMPLICATIONS: • Study provides evidence of lower contraceptive uptake among women living in high HIV-prevalence communities in Kenya. • Results reveal striking differences in factors associated with contraceptive use between HIV-positive and HIV-negative women. • Poverty may be an impediment to contraceptive uptake among HIV-positive women in Kenya.

ONSET OF SEXUAL ACTIVITY AMONG ADOLESCENTS IN HIV/AIDS-AFFECTED HOUSEHOLDS IN SUB-SAHARAN AFRICA.

This paper examines the effect of orphanhood and HIV status of adults in a household on onset of sexual activity among adolescent girls and boys aged 15-17 years in sub-Saharan Africa. Multilevel logistic regression models were applied to pooled Demographic and Health Surveys data from nineteen countries of sub-Saharan Africa where HIV test data were collected during 2003-2008 from nationally representative samples of men and women of reproductive age. The results highlight increased vulnerability among adolescent boys and girls living in households where an adult is infected with HIV, and adolescent boys who are paternal orphans. On average, adolescent boys and girls living in households where at least one adult is HIV-positive have about 25% higher odds of having initiated sexual activity compared with their counterparts of similar characteristics in households where no adult is HIV-positive. Furthermore, adolescent boys who are paternal orphans have about 25% higher odds of having initiated sexual activity than their non-orphan counterparts of similar individual characteristics. Further analysis reveals that household circumstances relating to living arrangements and poverty are important pathways through which household HIV/AIDS status is linked to adolescent sexual debut. The findings underscore the importance of international efforts in the sub-Saharan Africa region to address the plight of other children in HIV/AIDS-affected households, beyond orphans.

The disproportionate high risk of HIV infection among the urban poor in sub-Saharan Africa.

The link between HIV infection and poverty in sub-Saharan Africa (SSA) is rather complex and findings from previous studies remain inconsistent. While some argue that poverty increases vulnerability, existing empirical evidence largely support the view that wealthier men and women have higher prevalence of HIV. In this paper, we examine the association between HIV infection and urban poverty in SSA, paying particular attention to differences in risk factors of HIV infection between the urban poor and non-poor. The study is based on secondary analysis of data from the Demographic and Health Surveys from 20 countries in SSA, conducted during 2003-2008. We apply multilevel logistic regression models, allowing the urban poverty risk factor to vary across countries to establish the extent to which the observed patterns are generalizable across countries in the SSA region. The results reveal that the urban poor in SSA have significantly higher odds of HIV infection than their urban non-poor counterparts, despite poverty being associated with a significantly lower risk among rural residents. Furthermore, the gender disparity in HIV infection (i.e. the disproportionate higher risk among women) is amplified among the urban poor. The paper confirms that the public health consequence of urban poverty that has been well documented in previous studies with respect to maternal and child health outcomes does apply to the risk of HIV infection. The positive association between household wealth and HIV prevalence observed in previous studies largely reflects the situation in the rural areas where the majority of the SSA populations reside.

Household and community HIV/AIDS status and child malnutrition in sub-Saharan Africa: evidence from the demographic and health surveys.

This paper examines the extent to which under five children in households or communities adversely affected by HIV/AIDS are disadvantaged, in comparison with other children in less affected households/communities. The study is based on secondary analysis of the Demographic and Health Survey (DHS) data collected during 2003-2008 from 18 countries in sub-Saharan Africa, where the DHS has included HIV test data for adults of reproductive age. We apply multilevel logistic regression models that take into account the effect of contextual community/country level HIV/AIDS factors on child malnutrition. The outcome variable of interest is child undernutrition: stunting, wasting and underweight. The results suggest that across countries in sub-Saharan Africa, children whose mothers are infected with HIV are significantly more likely to be stunted, wasted or underweight compared to their counterparts of similar demographic and socio-economic background whose mothers are not infected. However, the nutritional status of children who are paternal orphans or in households where other adults are HIV positive are not significantly different from non-orphaned children or those in households where no adult is infected with HIV. Other adult household members being HIV positive is, however, associated with higher malnutrition among younger children below the age of one. Further analysis reveals that the effect of mothers' HIV status on child nutritional status (underweight) varies significantly across communities within countries, the effect being lower in communities with generally higher levels of malnutrition. Overall, the findings have important implications for policy and programme efforts towards improved integration of HIV/AIDS and child nutrition services in affected communities and other sub-groups of the population made vulnerable by HIV/AIDS. In particular, children whose mothers are infected with HIV deserve special attention.

Cross-national analysis of the risk factors of child malnutrition among children made vulnerable by HIV/AIDS in sub-Saharan Africa: evidence from the DHS.

OBJECTIVE: To examine the risk factors of malnutrition among children whose mothers are infected with HIV in sub-Saharan Africa (SSA). METHODS: Multilevel logistic regression models applied to Demographic and Health Survey (DHS) data collected during 2003-2008 from 18 countries in SSA, where the DHS included HIV test data for adults of reproductive age. RESULTS: Across countries in SSA, the risk of malnutrition among children whose mothers are infected with HIV is particularly high among children aged one, boys, multiple/twin births, those who were smaller than average at birth, or whose mothers had no education, or in poorest or single parent households. Although these risk factors generally apply to all children from the same communities, the higher risk of child malnutrition among those in the poorest households is amplified among children whose mothers are infected with HIV. Also, while in general children who are breastfed for up to 6 months are significantly less likely to be malnourished than those who were never breastfed; the benefit of breastfeeding is not evident among children whose mothers are infected with HIV. CONCLUSION: Contextual community/country HIV prevalences show interesting patterns: the risk of malnutrition among children whose mothers are infected with HIV is lower in countries with higher HIV prevalence. These findings have important implications for interventions to address malnutrition among children made vulnerable by HIV/AIDS in the SSA region.

Determinants of transitions to first sexual intercourse, marriage and pregnancy among female adolescents: evidence from South Nyanza, Kenya.

The timing of transitions to sexual activity, marriage and childbearing in sub-Saharan Africa is undergoing profound changes. This study investigates the determinants of adolescent transitions in South Nyanza, a socioeconomically deprived setting in Kenya where adolescent reproductive health is a particular concern. The analysis is based on Cox regression of timing of first sexual intercourse, first marriage and first pregnancy, using data from a survey of 1247 females aged 12-19 years. The results show that higher household socioeconomic status and educational attainment are associated with delayed onset of all three transition events. Furthermore, mother's higher educational attainment is protective for initiation of sexual intercourse while rural residence is protective for pregnancy experience. Other protective factors include communication with parents or with fellow girlfriends. However, discussing sexual matters with boyfriends, high internal locus of control, and gender bias are associated with early onset of the three transition events.

Parental presence and adolescent reproductive health among the Nairobi urban poor.

PURPOSE: To investigate whether the presence of parents constitute a protective factor against adverse reproductive health outcomes for adolescents living in slums of Nairobi, Kenya. METHODS: The data come from a cross-sectional survey that canvassed a random sample of 4564 households representative of all Nairobi slums in February-June 2000. Structured questionnaires on household census, reproduction and adolescent health were verbally administered to household heads, women of reproductive ages, and adolescents, respectively. We restrict the analysis to a sub-sample of 788 never-married adolescent girls aged 12-19 years. We compare reproductive health outcomes of adolescents who live with neither parent, father only, mother only, and both parents. Data were analyzed using simple descriptive analysis and logistic regression models of three outcome variables: ever sexually active, ever experienced an unplanned pregnancy, and sexually active within the past 4 weeks. For each of the outcome variables, two models, one with and one without a proxy for adolescents' disorderly behavior are presented to establish whether parental presence affects adolescents' reproductive health. RESULTS: When the father is present in the household (i.e., father only or both parents present), adolescent girls are 42% less likely to have ever had sex (p<.05), 45% less likely to have been sexually active in the most recent 4-week period (p<0.1), and 59% less likely to have ever experienced an unwanted pregnancy (p<.05) than when neither parent, or only the mother, is present in the household. CONCLUSIONS: In the slums of Nairobi, father's presence, unlike that of the mother, is associated with stronger resilience among adolescents. When programming for adolescents in these resource-constrained settings, it is important, therefore, to involve parents.

Trends and determinants of contraceptive method choice in Kenya.

This study uses data from the 1989, 1993, and 1998 Kenya Demographic and Health Surveys to examine trends and determinants of contraceptive method choice in Kenya. The analysis, based on two-level multinomial regression models, shows that, over time, the use of modern contraceptive methods, especially long-term methods, is higher in urban than in rural areas, whereas the pattern is reversed for traditional methods. Use of barrier methods among unmarried women is steadily rising, but the levels remain disappointingly low, particularly in view of the HIV/AIDS epidemic in Kenya. One striking result from this analysis is the dramatic rise in the use of injectables. Of particular program relevance is the notably higher levels of use of injectables among rural women, women whose partners disapprove of family planning, uneducated women, and those less frequently exposed to family planning media messages, compared with their counterparts who have better access to services and greater exposure to family planning information.