Navigating fertility, reproduction and modern contraception in the fragile context of South Kivu, Democratic Republic of Congo: 'Les enfants sont une richesse'.

Modern contraception has created new possibilities for reimagining reproductive norms and has generated new socio-cultural uncertainties in South Kivu province, Democratic Republic of Congo. Using inductive analysis of women's reproductive narratives, this paper explores how women in a high fertility context encounter and integrate recently introduced family planning and modern contraceptive education and services into their lives. As foundational socio-cultural norms confront the new reproductive possibilities offered by contraception, power dynamics shift and norms are called into question, re-interpreted and re-negotiated. Reproduction is located as a socially constructed process at the intersection of fertility norms, power dynamics, institutional practices, embodied realties and personal desires. In many ways the possibilities created by contraception - meant to increase certainty in the lives of users - actually increase uncertainty. The complexity of reproductive navigation reveals the shortcomings of reproductive theory and health and development discourses which view women and men as autonomous decision makers, removing them from the multiplicity of influencing factors, histories and power dynamics within which they realise their reproductive lives.

Evaluating the comparative effectiveness of different demand side interventions to increase maternal health service utilization and practice of birth spacing in South Kivu, Democratic Republic of Congo: an innovative, mixed methods approach.

BACKGROUND: In this protocol we describe a mixed methods study in the province of South Kivu, Democratic Republic of Congo evaluating the effectiveness of different demand side strategies to increase maternal health service utilization and the practice of birth spacing. Conditional service subsidization, conditional cash transfers and non-monetary incentives aim to encourage women to use maternal health services and practice birth spacing in two different health districts. Our methodology will comparatively evaluate the effectiveness of different approaches against each other and no intervention. METHODS/DESIGN: This study comprises four main research activities: 1) Formative qualitative research to determine feasibility of planned activities and inform development of the quantitative survey; 2) A community-based, longitudinal survey; 3) A retrospective review of health facility records; 4) Qualitative exploration of intervention acceptability and emergent themes through in-depth interviews with program participants, non-participants, their partners and health providers. Female community health workers are engaged as core members of the research team, working in tandem with female survey teams to identify women in the community who meet eligibility criteria. Female community health workers also act as key informants and community entry points during methods design and qualitative exploration. Main study outcomes are completion of antenatal care, institutional delivery, practice of birth spacing, family planning uptake and intervention acceptability in the communities. Qualitative methods also explore decision making around maternal health service use, fertility preference and perceptions of family planning. DISCUSSION: The innovative mixed methods design allows quantitative data to inform the relationships and phenomena to be explored in qualitative collection. In turn, qualitative findings will be triangulated with quantitative findings. Inspired by the principles of grounded theory, qualitative analysis will begin while data collection is ongoing. This "conversation" between quantitative and qualitative data will result in a more holistic, context-specific exploration and understanding of research topics, including the mechanisms through which the interventions are or are not effective. In addition, engagement of female community health workers as core members of the research team roots research methods in the realities of the community and provides teams with key informants who are simultaneously implicated in the health system, community and target population.