Family planning service disruptions in the first two years of the COVID-19 pandemic: Evidence from health facilities in seven low- and middle-income countries.

Many speculated that COVID-19 would severely restrict the delivery of essential health services, including family planning (FP), but evidence of this impact is limited, partly due to data limitations. We use cross-sectional data collected from regional and national samples of health facilities (n = 2,610) offering FP across seven low- and middle-income countries (LMICs) between 2019 and 2021, with longitudinal data from four geographies, to examine reported disruptions to the FP service environment during COVID-19, assess how these disruptions varied according to health system characteristics, and evaluate how disruptions evolved throughout the first two years of the pandemic, relative to a pre-pandemic period. Findings show significant variation in the impact of COVID-19 on facility-based FP services across LMICs, with the largest disruptions to services occurring in Rajasthan, India, where COVID-19 cases were highest among geographies sampled, while in most sub-Saharan African settings there were limited disruptions impacting FP service availability, method provision, and contraceptive supplies. Facility-reported disruptions to care were not reflected in observed changes to the number of FP clients or types of stockouts experienced in the first two years of the pandemic. Public and higher-level facilities were generally less likely to experience COVID-19-related disruptions to FP services, suggesting policy mitigation measures-particularly those implemented among government-operated health facilities-may have been critical to ensuring sustained delivery of reproductive healthcare during the pandemic.

Risk for Severe Intimate Partner Violence in Nairobi's Informal Settlements: Tailoring the Danger Assessment to Kenya.

INTRODUCTION: Understanding the risk for severe intimate partner violence (IPV) can help women and providers assess danger. The validated, widely used Danger Assessment (DA) developed for this purpose has not been tested in a low- and middle-income country (LMIC). We tailored the DA to Nairobi, Kenya, and prospectively evaluated baseline danger against severe IPV at 3-month follow-up. METHODS: We used data from the myPlan Kenya trial conducted in 3 informal settlements in Nairobi, Kenya, from 2017 to 2018. DA items were refined through formative and pilot phases, yielding minor wording modifications. Quantitative analyses prospectively evaluated baseline DA against severe IPV at 3-month follow-up to understand the predictive effect of the (1) original 20-item DA, (2) 16-item Kenya-DA (highest relative risk ratios [RRR] with severe IPV), and (3) 16-item Kenya-DA weighted (weighting based on strength of RRRs). Diagnostic criteria, including C-statistics, sensitivity, specificity, receiver operating characteristic curve, and area under the curve, were examined; logistic regressions quantified the odds of each metric predicting severe IPV at follow-up. RESULTS: The original 20-item DA produced the highest specificity (75.41%) and lowest sensitivity (57.14%), resulting in the overall lowest C-statistic. Compared to the 16-item Kenya-DA, the Kenya-DA weighted produced slightly higher sensitivity (66.67% vs. 64.29%) and specificity (77.05% vs. 72.13%), resulting in the highest C-statistic (0.78 vs. 0.75). All versions successfully predicted severe IPV at 3-month follow-up (original DA: odds ratio [OR]=1.26, 95% confidence interval [CI]=1.12, 1.41, P<.001; Kenya-DA: OR=1.33, 95% CI=1.16, 1.53, P<.001; Kenya-DA weighted: OR=1.19, 95% CI=1.10, 1.28, P<.001). Several factors identified as homicide risk factors in other settings were not prospectively associated with severe IPV. CONCLUSION: Within a high-danger LMIC context, all 3 DA configurations performed well diagnostically. We recommend the 16-item Kenya-DA given the value for simplicity and field implementation, whereas the Kenya-DA weighted can add accuracy for research purposes.

Differential discontinuation by covert use status in Kenya.

Objectives: Qualitative research suggests that covert users may be more likely to discontinue contraception due to the logistics of discretion and fear of disclosure. This study sought to quantify whether covert users are more likely to discontinue contraception than overt users. Study design: We used a national longitudinal survey from Kenya conducted from November 2019/February 2020 to November 2020/April 2021 to test whether the time to discontinuation between covert and overt users still in need of contraception differed using survival analyses over a period of 5 years since method initiation. Results: Multivariate Cox regression results showed there was an interaction with time and covert use on the risk of discontinuation; for every additional month of use, there was an increased risk of discontinuation of covert users compared to overt users (3% increased hazard, p = 0.02). At 1 and 2 years, there were no differences in the hazard of discontinuation (adjusted hazard ratio [aHR]1 year 0.95, 95% CI 0.54-1.65 and aHR2 years 1.37, 95% CI 0.85-2.21), yet at 3, 4, and 5 years, the hazard of discontinuation was higher for covert compared to overt users (aHR3 years 1.99, 95% 1.11-3.56; aHR4 years 2.89, 95% CI 2.0-6.40; aHR5 years 4.18, 95% CI 1.45-12.0). Conclusions: These results suggest efforts are needed to support covert users in managing their contraceptive use and for improving contraceptive counseling surrounding covert use. Our findings shed light on the increasing challenge covert users face after approximately the first 2 years of use; covert users require additional follow-up in both research and care provision. Implications: Covert users are at a higher risk of discontinuation of contraception while still trying to avoid pregnancy, particularly after the first 2 years of use. Family planning providers and programs must protect access to and maintain the privacy of reproductive services to this population, focusing on follow-up care provision and counseling.

Fertility and contraceptive dynamics amidst COVID-19: who is at greatest risk for unintended pregnancy among a cohort of adolescents and young adults in Nairobi, Kenya?

OBJECTIVES: Among youth in Nairobi, we (1) characterised fertility and contraceptive use dynamics by gender; (2) estimated pregnancy prevalence over the pandemic; and (3) assessed factors associated with unintended pandemic pregnancy for young women. DESIGN: Longitudinal analyses use cohort data collected at three timepoints prior to and during the COVID-19 pandemic: June to August 2019 (pre-pandemic), August to October 2020 (12-month follow-up) and April to May 2021 (18-month follow-up). SETTING: Nairobi, Kenya. PARTICIPANTS: At initial cohort recruitment, eligible youth were aged 15-24 years, unmarried and residing in Nairobi for at least 1 year. Within-timepoint analyses were restricted to participants with survey data per round; trend and prospective analyses were restricted to those with complete data at all three timepoints (n=586 young men, n=589 young women). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes comprised fertility and contraceptive use for both genders, and pregnancy for young women. Unintended pandemic pregnancy (assessed at 18-month follow-up) was defined as a current or past 6-month pregnancy with intent to delay pregnancy for more than 1 year at 2020 survey. RESULTS: While fertility intentions remained stable, contraceptive dynamics varied by gender-young men both adopted and discontinued coital-dependent methods, whereas young women adopted coital-dependent or short-acting methods at 12-month follow-up (2020). Current pregnancy was highest at 2020 (4.8%), and approximately 2% at 2019 and 2021. Unintended pandemic pregnancy prevalence was 6.1%, with increased odds for young women recently married (adjusted OR (aOR)=3.79; 95% confidence interval (CI) 1.83-7.86); recent contraceptive use was protective against unintended pandemic pregnancy (aOR=0.23; 95% CI 0.11-0.47). CONCLUSIONS: Current pregnancy in Nairobi was highest at the height of the COVID-19 pandemic (2020), and subsided to pre-pandemic levels by 2021 data collection; however, requires further monitoring. New marriages posed considerable risk for unintended pandemic pregnancy. Contraceptive use remains a crucial preventive strategy to averting unintended pregnancy, particularly for married young women.

Intersection of reproductive coercion and intimate partner violence: cross-sectional influences on women's contraceptive use in Burkina Faso, Côte d'Ivoire and Kenya.

OBJECTIVES: Among nationally representative cross-sections of women in need of contraception from Burkina Faso, Côte d'Ivoire and Kenya, we aimed to: (1) examine the intersection of past-year physical/sexual intimate partner violence (IPV), emotional IPV and reproductive coercion (RC) and (2) assess the impact of physical/sexual IPV, emotional IPV and RC on women's contraceptive use outcomes, including current contraceptive use, method type and covert use. DESIGN: The present analysis uses cross-sectional female data collected in Burkina Faso (December 2020-March 2021), Côte d'Ivoire (October-November 2021) and Kenya (November-December 2020). SETTINGS: Burkina Faso, Côte d'Ivoire and Kenya PARTICIPANTS: Analytical samples were restricted to partnered women with contraceptive need who completed a violence module (Burkina Faso n=1863; Côte d'Ivoire n=1105; Kenya n=3390). PRIMARY AND SECONDARY OUTCOME MEASURES: The exposures of interest-past-year emotional IPV, physical/sexual IPV and RC-were assessed using abridged versions of the Revised Conflict and Tactics Scale-2 and Reproductive Coercion Scale, respectively. Outcomes of interest included current contraceptive use, contraceptive method type (female controlled vs male compliant), and covert contraceptive use, and used standard assessments. RESULTS: Across sites, 6.4% (Côte d'Ivoire) to 7.8% (Kenya) of women in need of contraception experienced RC; approximately one-third to one-half of women experiencing RC reported no other violence forms (31.7% in Burkina Faso to 45.8% in Côte d'Ivoire), whereas physical/sexual IPV largely occurred with emotional IPV. In multivariable models, RC was consistently associated with covert use (Burkina Faso: aOR 2.84 (95% CI 1.21 to 6.64); Côte d'Ivoire: aOR 4.45 (95% CI 1.76 to 11.25); Kenya: aOR 5.77 (95% CI 3.51 to 9.46)). Some IPV in some settings was also associated with covert use (emotional IPV, Burkina Faso: aOR 2.99 (95% CI 1.56 to 5.74); physical/sexual, Kenya: aOR 2.35 (95% CI 1.33 to 4.17)). CONCLUSIONS: Across settings, covert use is a critical strategy for women experiencing RC. Country policies must recognise RC as a unique form of violence with profound implications for women's reproductive health.

Needs and unmet needs for support services for recently pregnant intimate partner violence survivors in Ethiopia during the COVID-19 pandemic.

BACKGROUND: Globally, 2-14% of women experience intimate partner violence (IPV) during pregnancy. Timely response to IPV is critical to mitigate related adverse health outcomes. Barriers to accessing limited IPV support services are pervasive in low- and middle-income countries (LMICs), such as Ethiopia; key barriers include mistrust, stigmatization, and self-blame, and discourage women from disclosing their experiences. Infection control measures for COVID-19 have the potential to further disrupt access to IPV services. METHODS: In-depth qualitative interviews were undertaken from October-November 2020 with 24 women who experienced IPV during recent pregnancy to understand the needs and unmet needs of IPV survivors in Ethiopia amid the COVID-19 pandemic. Trained qualitative interviewers used a structured note-taking tool to allow probing of experiences, while permitting rapid analysis for timely results. Inductive thematic analysis identified emergent themes, which were organized into matrices for synthesis. RESULTS: Qualitative themes center around knowledge of IPV services; experiences of women in seeking services; challenges in accessing services; the impact of COVID-19 on resource access; and persistent unmet needs of IPV survivors. Notably, few women discussed the violence they experienced as unique to pregnancy, with most referring to IPV over an extended period, both prior to and during COVID-19 restrictions. The majority of IPV survivors in our study heavily relied on their informal network of family and friends for protection and assistance in resolving the violence. Though formal IPV services remained open throughout the pandemic, restrictions resulted in the perception that services were not available, and this perception discouraged survivors from seeking help. Survivors further identified lack of integrated and tailored services as enduring unmet needs. CONCLUSIONS: Results reveal a persistent low awareness and utilization of formal IPV support and urge future policy efforts to address unmet needs through expansion of services by reducing socio-cultural barriers. COVID-19 impacted access to both formal and informal support systems, highlighting needs for adaptable, remote service delivery and upstream violence prevention. Public health interventions must strengthen linkages between formal and informal resources to fill the unmet needs of IPV survivors in receiving medical, psychosocial, and legal support in their home communities.

Disruptions to youth contraceptive use during COVID-19: Mixed-methods results from Nairobi, Kenya.

Ensuring access to sexual and reproductive health (SRH) services for adolescents is a global priority, given the detrimental health and economic impact of unintended pregnancies. To examine whether and how COVID-19 affected access to SRH services, we use mixed-methods data from young men and women in Nairobi, Kenya to identify those at greatest risk of contraceptive disruptions during COVID-19 restrictions. Analyses utilize cross-sectional data collected from August to October 2020 from an existing cohort of youth aged 16-26. Unadjusted and adjusted logistic regression examined sociodemographic, contraceptive, and COVID-19-related correlates of contraceptive disruption among users of contraception. Qualitative data were collected concurrently via focus group discussions (n = 64, 8 groups) and in-depth interviews (n = 20), with matrices synthesizing emergent challenges to obtaining contraception by gender. Among those using contraception, both young men (40.4%) and young women (34.6%) faced difficulties obtaining contraception during COVID-19. Among young men, difficulty was observed particularly for those unable to meet their basic needs (aOR = 1.60; p = 0.05). Among young women, risk centered around those with multiple partners (aOR = 1.91; p = 0.01), or who procured their method from a hospital (aOR = 1.71; p = 0.04) or clinic (aOR = 2.14; p = 0.03). Qualitative data highlight economic barriers to obtaining contraceptives, namely job loss and limited supply of free methods previously available. Universal access to a variety of contraceptive methods during global health emergencies, including long-acting reversible methods, is an essential priority to help youth avert unintended pregnancies and withstand periods of disruptions to services. Non-judgmental, youth-friendly services must remain accessible throughout the pandemic into the post-COVID-19 period.

Prevalence and correlates of reproductive coercion across ten sites: commonalities and divergence.

BACKGROUND: Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. Recent research emphasizes that RC experiences may differ within and across low- and middle-income countries (LMICs), as compared to higher income contexts, given social pressures surrounding childbearing. To date, nationally representative surveys have lacked comprehensive measures for RC, leading to gaps in understanding its prevalence and risk factors. Across eight LMICs (10 sites), we aimed to (1) validate the RC Scale; (2) calculate prevalence of RC and specific behaviors; and (3) assess correlates of RC. METHODS: This analysis leverages cross-sectional Performance Monitoring for Action (PMA) data collected from November 2020 to May 2022. Analyses were limited to women in need of contraception (Burkina Faso n = 2767; Côte d'Ivoire n = 1561; Kongo Central, Democratic Republic of Congo (DRC) n = 830; Kinshasa, DRC n = 846; Kenya n = 4588; Kano, Nigeria n = 535; Lagos, Nigeria n = 612; Niger n = 1525; Rajasthan, India n = 3017; Uganda n = 2020). Past-year RC was assessed via five items adapted from the original RC Scale and previously tested in LMICs. Confirmatory factor analysis examined fit statistics by site. Per-item and overall prevalence were calculated. Site-specific bivariate and multivariable logistic regression examined RC correlates across the socioecological framework. RESULTS: Confirmatory factor analysis confirmed goodness of fit across all sites, with moderate internal consistency (alpha range: 0.66 Cote d'Ivoire-0.89 Kinshasa, DRC/Lagos, Nigeria). Past-year reported prevalence of RC was highest in Kongo Central, DRC (20.3%) and lowest in Niger (3.1%). Prevalence of individual items varied substantially by geography. Polygyny was the most common RC risk factor across six sites (adjusted odds ratio (aOR) range: 1.59-10.76). Increased partner education levels were protective in Kenya and Kano, Nigeria (aOR range: 0.23-0.67). Other assessed correlates differed by site. CONCLUSIONS: Understanding RC prevalence and behaviors is central to providing woman-centered reproductive care. RC was most strongly correlated with factors at the partner dyad level; future research is needed to unpack the relative contributions of relationship power dynamics versus cultural norms surrounding childbearing. Family planning services must recognize and respond to women's immediate needs to ensure RC does not alter reproductive trajectories, including vulnerability to unintended pregnancy.

Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. While RC was conceptualized in the United States, recent research highlights that it may be prominent in other geographies, including sub-Saharan Africa. Existing national surveillance programs, including the Demographic and Health Surveys, have included a single item on RC beginning in 2018. Given the phased approach to Demographic and Health Survey roll-out, no studies have examined this single item across diverse contexts. Further, this single item may miss the range of abusive experiences women face when seeking to manage their fertility. Using annual national cross-sections in 10 diverse contexts (eight countries), we sought to: (1) validate a comprehensive RC measure; (2) calculate prevalence of RC and specific behaviors; (3) understand risk factors for RC across contexts. We found that the comprehensive RC measure performed well across sites. Prevalence of past-year RC was highest in the Kongo Central region of the Democratic Republic of Congo (20.3%) and lowest in Niger (3.1%). Polygynous marriage was associated with increased risk of RC across six sites, whereas increased partner education levels were protective against RC in two sites. Understanding the prevalence of RC within a given context and range of specific abusive behaviors, as well as risk profiles, can help alert local service providers to women's needs. A thorough understanding of commonalities and divergence of RC experiences and drivers across sites can help inform prevention and response programming to address RC and its health effects.

Understanding the Link Between Reproductive Coercion and Covert Use of Contraception as a Safety Strategy for Women Experiencing Violence in Nairobi's Urban Informal Settlements.

This mixed-methods study examined the relationship between reproductive coercion (RC) and covert contraceptive use among intimate partner violence survivors in Nairobi, Kenya. Quantitative analyses utilize baseline data from the myPlan Kenya trial (n = 321). Purposive in-depth interviews (IDIs) (n = 30) explored women's reproductive safety strategies. Multinomial analyses indicated increased covert use and decreased overt use compared to nonuse, for women experiencing RC; logistic models similarly report increased odds of covert use with RC experience. Qualitative data contextualize women's reasons for use and challenges faced. Integration of reproductive safety strategies into family planning and violence services can improve the safe use of contraception.

Impact of COVID-19 on the mental health of adolescents and youth in Nairobi, Kenya.

Objective: To report on the mental health status of adolescents and youth in relation to the COVID-19 pandemic in Nairobi County, Kenya. Methodology: This was a mixed-methods study with cross-sectional quantitative and qualitative components conducted in Nairobi County, Kenya from August to September 2020. The quantitative survey involved phone interviews of n = 1,217 adolescents and youth. Qualitative components included virtual focus group discussions (FGDs) with adolescents and youth (n = 64 unmarried youths aged 16-25 years, across 8 FGDs) and youth-serving stakeholders (n = 34, across 4 FGDs), key informant interviews (n = 12 higher-level stakeholders from Ministries of Health, Gender, and Education), and in-depth interviews with youth (n = 20) so as to examine the COVID-19 impact on mental health. Results: Among the participants, 26.6% of young men and 30.0% of young women reported probable depressive symptoms, of whom 37.7% of young men and 38.9% of young women reported little interest or pleasure in doing various activities. Hopelessness and feeling down nearly every day was additionally reported by 10.7% of young women and 6.3% of young men. Further, about 8.8% of young men and 7.6% of young women reported they could not get the emotional help and support they may need from people in their life. Multivariable regression results showed an association between depressive symptoms and reduced working hours due to COVID-19 and increased intimate partner violence. Additionally, the results show that respondents with higher emotional help and support were less likely to report depressive symptoms. Qualitative results confirm the quantitative findings and exemplify the negative behavior arising from the impact of adherence to COVID-19 prevention measures. Conclusion: Mental health issues were common among adolescents and youth and may have been augmented by isolation and economic hardships brought about by COVID-19 restrictions. There is a need for concerted efforts to support adolescents and young people to meet their mental health needs, while considering the unique variations by gender. There is need to urgently strengthen the mental health system in Kenya, including via integrating psychosocial support services in communities, schools, and healthcare services, to ensure adolescents and young persons are not left behind.

Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria and Côte d'Ivoire.

BACKGROUND: Unsafe abortions contribute to maternal mortality and morbidity worldwide, with disproportionate impacts in lower-income countries. Identifying factors associated with an elevated risk of experiencing an abortion under the most unsafe conditions is an important component of addressing this burden. The partner's role in obtaining a safe or unsafe abortion is not well understood. This study provides a quantitative assessment of the relationship between partner involvement and subsequent abortion safety. METHODS: The data are drawn from the PMA2020 female surveys and abortion follow-up surveys, fielded in Nigeria and Côte d'Ivoire between 2018 and 2020. The sample includes 1144 women in Nigeria and 347 women in Côte d'Ivoire who reported having ever experienced an abortion. We assess partner involvement in discussing the abortion decision and/or in selecting the method or source and evaluate the relationship between partner involvement and most unsafe abortion (using non-recommended methods from a non-clinical source) versus safe or less safe abortion, adjusting for sociodemographic characteristics. RESULTS: We find a strong association between experiencing any partner involvement and decreased odds of experiencing a most unsafe abortion (Nigeria: aOR = 0.34, 95% CI 0.26-0.45; Côte d'Ivoire: aOR = 0.27, 95% CI 0.16-0.47). Analyzing the two types of partner involvement separately, we find that partner involvement in the decision is associated with lower odds of most unsafe abortion in both countries (Nigeria: aOR = 0.48, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.34, 95% CI 0.19-0.60); partner involvement in selecting the method and/or source was only significantly associated with lower odds of most unsafe abortion in Nigeria (Nigeria: aOR = 0.53, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.65, 95% CI 0.32-1.32). CONCLUSION: In Nigeria and in Côte d'Ivoire, respondents whose partners were involved in their abortion trajectory experienced safer abortions than those whose partners were not involved. These findings suggest the potential importance of including men in education on safe abortion care and persistent need to make safe abortion accessible to all, regardless of partner support.

Pregnancy coercion, correlates, and associated modern contraceptive use within a nationally representative sample of Ethiopian women.

Partner-perpetrated pregnancy coercion inhibits women's reproductive autonomy. However, few studies have quantified pregnancy coercion and its effects on women's health within low- and middle-income countries. Among a national sample of Ethiopian women, this study aimed to: (1) assess the prevalence of past-year pregnancy coercion and explore regional differences; (2) identify correlates; (3) examine the relationship between pregnancy coercion and modern contraceptive use. Analyses utilise cross-sectional data from Performance Monitoring for Action (PMA)-Ethiopia, a nationally representative sample of females aged 15-49 conducted from October to November 2019. Past-year pregnancy coercion was assessed via five items and analysed dichotomously and categorically for severity. Among women in need of contraception, bivariate and multivariable logistic regression examined associations between variables of interest, per aim, accounting for sampling weights and clustering by enumeration area. Approximately 20% of Ethiopian women reported past-year pregnancy coercion (11.4% less severe; 8.6% more severe), ranging from 16% in Benishangul-Gumuz to 35% in Dire Dawa. Increasing parity was associated with decreased odds of pregnancy coercion. Among women in need of contraception, experience of pregnancy coercion was associated with a 32% decrease in odds of modern contraceptive use (aOR = 0.68; 95% CI: 0.53-0.89); when disaggregated by severity, odds decreased for most severe pregnancy coercion (aOR = 0.59; 95% CI = 0.41-0.83). Results indicate that partner-perpetrated pregnancy coercion is prevalent across diverse regions of Ethiopia, and most severe forms could interrupt recent gains in contraceptive coverage and progress to sexual and reproductive health and rights. Providers must be aware of potential contraceptive interference and address coercive influences during contraceptive counselling.

The impact of partner autonomy constraints on women's health-seeking across the maternal and newborn continuum of care.

Background: Gendered health inequities impede women's reproductive autonomy over the life course. Pregnancy is a critical time point for assessing inequities and partners are integral actors in the achievement or impediment of women's and children's health during this time. Methods: Among a nationally representative cohort of Ethiopian women 5-9 weeks postpartum with data collected from October 2019-September 2020, this study aimed to 1) understand the prevalence and interplay of partner-related autonomy constraints (intimate partner violence (IPV), reproductive coercion (RC), lack of encouragement from seeking antenatal care (ANC), and lack of encouragement from seeking postnatal care (PNC), and 2) examine the impact of autonomy constraints on the maternal and newborn health (MNH) continuum of care. Findings: Sixty percent of women experienced a partner-related autonomy constraint prior to or during pregnancy. Approximately 20% of women were not encouraged to seek antenatal care and postpartum care, respectively, whereas fewer women experienced IPV during pregnancy (12.3%) and RC (11.0%). Less than one in five women completed the MNH continuum of care. Lack of encouragement of ANC and PNC were associated with decreased care-seeking at every point across the MNH continuum of care. Lack of encouragement of ANC (aOR = 0.45; p = 0.05) and of PNC (aOR = 0.16; p < 0.001) were associated with reductions in completing the continuum. Interpretation: Partner engagement, interventions, and messaging are critical to enhance MNH care-seeking behaviors. Funding: This work was supported, in whole, by the Bill & Melinda Gates Foundation [INV 009466]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.

Sexual harassment before and during the COVID-19 pandemic among adolescent girls and young women (AGYW) in Nairobi, Kenya: a cross-sectional study.

OBJECTIVES: Sexual harassment among adolescent girls and young women (AGYW) is a prevalent and understudied form of gender-based violence (GBV) with negative impacts on health and well-being. The COVID-19 pandemic raised global concern about GBV within homes; less is known about how it affected GBV in public spaces. METHODS: Present analyses use cross-sectional data from a cohort of adolescents and young adults residing in Nairobi, Kenya, restricted to female participants. Data were collected August-October 2020 via phone after implementation of COVID-19 restrictions. Prevalence of past-year sexual harassment and harassment relative to COVID-19 restrictions were calculated for overall sample, and by individual, household, and pandemic-related factors. Multivariate negative binomial regression models examine correlates of (1) past-year sexual harassment and (2) increases in sexual harassment relative to COVID-19 restrictions. RESULTS: Overall, 18.1% of AGYW experienced past-year sexual harassment at the 2020 survey. Among this group, 14.6% experienced sexual harassment pre-COVID-19 only, 18.8% after only and 66.6% at both time points. Among the latter group, 34.9% reported more occurrences following COVID-19 restrictions, 20.5% reported less occurrences and 44.7% reported no change in occurrence. Overall, 42.0% of AGYW experienced an increase in sexual harassment while 58.0% experienced no increase since COVID-19. In adjusted models, past-year sexual harassment was associated with higher educational attainment (adjusted risk ratio, aRR 2.11; 95% CI 1.27 to 3.52) and inability to meet basic financial needs (aRR 1.67; 95% CI 1.05 to 2.66). Increased sexual harassment since COVID-19 was associated with having full control to leave the home (aRR 1.69; 95% CI 1.00 to 2.90). CONCLUSIONS: Sexual harassment among AGYW in Nairobi, Kenya was prevalent before and during COVID-19 restrictions. Safety in public spaces remains a highly gendered issue that impacts women's safety and ability to participate in public life. Prevention and support services to address sexual harassment remain an important element in ensuring safe, sustainable public spaces.

Violence against women from partners and other household members during COVID-19 in Burkina Faso and Kenya.

BACKGROUND: Global evidence indicates increases in gender-based violence (GBV) during the COVID-19 pandemic following mitigation measures, such as stay at home orders. Indirect effects of the pandemic, including income loss, strained social support, and closed or inaccessible violence response services, may further exacerbate GBV and undermine help-seeking. In Kenya and Burkina Faso, as in many settings, GBV was prevalent prior to the COVID-19 pandemic. Studies specific to COVID-impact on GBV in Kenya indicate mixed results and there remains a lack of evidence from Burkina Faso. Our study takes a comprehensive lens by addressing both intimate partner violence (IPV) and non-partner household abuse through the COVID-19 pandemic in two priority settings. METHODS: Annual, national cross-sections of women ages 15-49 completed survey data collection in November-December 2020 and December 2020-March 2021; the GBV module was limited to one woman per household [Kenya n = 6715; Burkina n = 4065]. Descriptive statistics, Venn diagrams, and logistic and multinomial regression characterized prevalence of IPV and other household abuse, frequency relative to the COVID-19 pandemic, help-seeking behaviors, and predictors of IPV and household abuse across the socioecological framework. RESULTS: In both settings, past-year IPV prevalence exceeded non-partner household abuse (Kenya: 23.5%IPV, 11.0%household; Burkina Faso: 25.7%IPV, 16.2%household). Over half of those affected in each setting did not seek help; those that did turned first to family. Among those with past-year experiences, increased frequency since COVID-19 was noted for IPV (16.0%Burkina Faso; 33.6%Kenya) and household violence (14.3%Burkina Faso; 26.2%Kenya). Both context-specific (i.e., financial autonomy in Burkina Faso) and universal (i.e., COVID-related income loss) risk factors emerged. CONCLUSION: Past-year IPV and household violence against women in Kenya and Burkina Faso were prevalent, and in some cases, intensified during the COVID-19 pandemic. Across settings, help-seeking from formal services was notably low, likely reflecting shame, blame, and stigmatization identified as barriers in pre-COVID literature. Both primary prevention and survivor-centered support services, including those related to economic empowerment, should be integrated within COVID-recovery efforts, and extended into the post-pandemic period to fully meet women's safety needs.

Pregnancy coercion and partner knowledge of contraceptive use among Ethiopian women.

Objective: To examine the relationship between pregnancy coercion and partner knowledge of contraceptive use. Study design: Cross-sectional Performance Monitoring for Action-Ethiopia data were collected in October-November 2019 from a nationally representative sample of women ages 15 to 49. The analytical sample (n = 2,469) included partnered women using contraception in the past year. We used multinomial logistic regression to examine associations between past-year pregnancy coercion (none, less severe, more severe) and partner knowledge/couple discussion of contraceptive use (overt use with couple discussion before method initiation (reference group), overt use with discussion after method initiation, and covert use of contraception). Results: Most women reported their partner knew they were using contraception and had discussed use prior to method initiation (1,837/2,469, 75%); 16% used overtly and discussed use after method initiation, and 7% used contraception covertly. The proportion of covert users increased with pregnancy coercion severity (4%none, 14%less severe, 31%more severe), as did the proportion of overt users who delayed couple contraceptive discussions, (14%none, 23%less severe, 26% more severe); however, overt use with couple discussion before method initiation decreased with pregnancy coercion severity (79%none, 60%less severe, 40%more severe). The risk of covert use among women experiencing less severe pregnancy coercion was four times greater than women who experienced no pregnancy coercion (adjusted relative risk ratio, (aRRR) = 3.95, 95% confidence interval (CI) 2.20-7.09) and ten times greater for women who experienced the most severe pregnancy coercion (aRRR = 10.42, 95% CI 6.14-17.71). The risk of overt use with delayed couple discussion also increased two-fold among women who experienced pregnancy coercion compared to those who did not (less severe aRRR = 2.05, 95% CI 1.39-2.99; more severe aRRR = 2.89, 95% CI 1.76-4.73). Conclusion: When experiencing pregnancy coercion, women may avoid or delay contraceptive conversations with their partners. Increased pregnancy coercion severity has the greatest association with covert use and couple contraceptive discussions. Implications: The presence and timing of couple discussions about contraception are critical for ensuring safety for women experiencing pregnancy coercion. Screening for pregnancy coercion must be included within contraceptive counseling so that women can choose methods that maximize their reproductive autonomy.

Self-injected contraceptives: does the investment reflect women's preferences?

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is an innovative contraceptive method aimed at meeting women's unique circumstances and needs, largely due to its ability to be self-injected. Substantial research and advocacy investments have been made to promote roll-out of DMPA-SC across sub-Saharan Africa. To date, research on the demand for DMPA-SC as a self-injectable method has been conducted largely with healthcare providers, via qualitative research, or with highly specific subsamples that are not population based. Using three recent rounds of data from Performance Monitoring for Action, we examined population-representative trends in demand, use, and preference for self-injection among current non-users in Burkina Faso, the Democratic Republic of Congo (Kinshasa and Kongo Central regions), Kenya, and Nigeria (Lagos and Kano States). We found that while over 80.0% of women had heard of injectables across settings, few women had heard of self-injection (ranging from 13.0% in Kenya to 24.8% in Burkina Faso). Despite initial increases in DMPA-SC prevalence, DMPA-SC usage began to stagnate or even decrease in all settings in the recent three years (except in Nigeria-Kano). Few (0.0%-16.7%) current DMPA-SC users were self-injecting, and the majority instead were relying on a healthcare provider for administration of DMPA-SC. Among current contraceptive non-users wishing to use an injectable in the future, only 1.5%-11.4% preferred to self-inject. Our results show that self-injection is uncommon, and demand for self-injection is very limited across six settings, calling for further qualitative and quantitative research on women's views on DMPA-SC and self-injection and, ultimately, their contraceptive preferences and needs.

Product-access challenges to menstrual health throughout the COVID-19 pandemic among a cohort of adolescent girls and young women in Nairobi, Kenya.

Background: Access to menstrual hygiene products enables positive health for adolescent girls and young women (AGYW). Among AGYW in Nairobi, Kenya, this prospective mixed-methods study characterised menstrual health product-access challenges at two time points during the COVID-19 pandemic; assessed trajectories over the pandemic; and examined factors associated with product-access trajectories. Methods: Data were collected from an AGYW cohort in August-October 2020 and March-June 2021 (n=591). The prevalence of menstrual health product-access challenges was calculated per timepoint, with trajectories characterizing product-access challenges over time. Logistic regression models examined associations with any product-access challenge throughout the pandemic; multinomial and logistic regressions further assessed factors associated with trajectories. Qualitative data contextualize results. Findings: In 2020, 52·0% of AGYW experienced a menstrual health product-access challenge; approximately six months later, this proportion dropped to 30·3%. Product-access challenges during the pandemic were heightened for AGYW with secondary or lower education (aOR=2·40; p<0·001), living with parents (aOR=1·86; p=0·05), not the prime earner (aOR=2·27; p=0·05); and unable to meet their basic needs (aOR=2·25; p<0·001). Between timepoints, 38·0% experienced no product-access challenge and 31·7% resolved, however, 10·2% acquired a challenge and 20·1% experienced sustained challenges. Acquired product-access challenges, compared to no challenges, were concentrated among those living with parents (aOR=3·21; p=0·05); multinomial models further elucidated nuances. Qualitative data indicate deprioritization of menstrual health within household budgets as a contributor. Interpretation: Menstrual health product-access challenges are prevalent among AGYW during the pandemic; barriers were primarily financial. Results may reflect endemic product-access gaps amplified by COVID-specific constraints. Ensuring access to menstrual products is essential to ensure AGYW's health needs. Funding: This work was supported, in whole, by the Bill & Melinda Gates Foundation [010481].

Gendered time use during COVID-19 among adolescents and young adults in Nairobi, Kenya.

Background: Gender disparities in time use contribute to poor outcomes in women. Large-scale disruptions can affect time use. The objectives of this study were to characterize time use across the pandemic by gender and to assess how gender associates with 2021-time use, overall and by 2020 economic dependency status. Methods: A prospective cohort of youth in Nairobi, Kenya, completed phone-based surveys in August-October 2020 and April-May 2021. Time use was characterized at both time points and 1,777 participants with complete time use data at both time points were included in the analysis. 2021-time use was regressed on gender and stratified by 2020 economic dependency status. Findings: At both time points, significant gender differences in time use found young men with more time on paid work and less time on domestic work [1·6 h; 95% CI: 1·1, 2·2] and [-1·9 h; 95% CI: -1·1, -1·5], respectively; 2021. In adjusted models, the gender differential in unpaid domestic work were significant overall and at all levels of economic dependency (dependent, semi-dependent, independent). The gender differential in paid work was evident among semi-dependent and independent. Interpretation: Young women spent less time on paid work and more time on domestic duties than male counterparts, consistently across a six-month period during the pandemic, suggesting gendered time poverty. Resulting gendered gaps in earnings can contribute to women's longer-term economic vulnerability. Funding: This work was supported by the Bill & Melinda Gates Foundation [010481].