Anastasia J. Gage

Factors associated with self-reported HIV testing among men in Uganda

This study examined rates and predictors of self-reported HIV testing and willingness to test among married men aged 15–59 in Uganda. The data are nationally representative and drawn from the 2000–01 Uganda Demographic and Health Survey. The results of multiple regression analyses indicate that knowledge about AIDS, a history of paying for sex, spousal communication about HIV prevention, secondary or higher education, household wealth, and neighbourhood knowledge of a test site are associated with an increased likelihood of HIV testing. The higher the frequency of injection use in the past 3 months and the greater the level of interest in learning how to help ones partner have a safe pregnancy, the higher was the likelihood of willingness to test for HIV. Findings suggest that voluntary counselling and testing programmes need to target older married men aged 30–59 and expand services to the Northern region, where previously untested men indicated significantly higher desires of HIV testing.

Negotiating reproductive outcomes in Uganda

In Uganda, the Negotiating Reproductive Outcomes study is investigating the nature of negotiation within sexual unions. Data were gathered from focus groups held in the Masaka and Lira districts during February and March 1995 and during surveys of women aged 20-44 and their male partners carried out from October 1995 to February 1996. The data suggest that much of the bargaining and negotiating that occurs is indirect and nonverbal and, thus, leads to a great deal of misinterpretation. Even direct communication is fraught with complexity, misinterpretation, and mistrust. These results indicate that male partners are important in influencing the reproductive attitudes and behavior of women and that further work should be undertaken to understand the roles of various actors in reproductive decision-making.

Effects of the physical accessibility of maternal health services on their use in rural Haiti

An analysis of data from the 2000 Demographic and Health Survey shows that little use is made of antenatal and delivery-care services in rural Haiti. After adjusting for individual-level factors, poor road conditions significantly reduce the likelihood of timely receipt of antenatal care and of four or more antenatal care visits, while the availability of a health centre within 5 kilometres significantly increases the odds of each outcome. The odds of being attended at delivery by trained medical personnel and of institutional delivery are significantly reduced by mountainous terrain and distance from the nearest hospital, and are increased if a health worker providing antenatal care is present in the neighbourhood. Neighbourhood poverty reduces the likelihood of safe delivery care. The findings suggest that improving the use made of maternal healthcare services would require, among other things, improvement of the availability of services and road conditions, and the reduction of poverty.

Premarital Childbearing, Unwanted Fertility and Maternity Care in Kenya and Namibia

Analysis of data from the 1993 Kenya and 1992 Namibia Demographic and Health Surveys shows that premarital childbearing is an important risk factor for the under-utilization of maternity care. In both countries, women with premarital births are significantly less likely than those with marital births to seek prenatal care in the first trimester. This relationship is not explained by wantedness or maternal age. Wantedness is not a significant determinant of the timing of the first prenatal visit or the likelihood of institutional delivery, except in Kenya where women are less likely to deliver at a health facility if they are dissatisfied with the timing of the pregnancy. Ethnicity plays an important role in conditioning the premarital birth effect on prenatal and delivery care. This finding suggests that cultural attitudes may shape the level of kin and social support for unwed mothers and, in so doing, have a direct impact on their perceived barriers to care.

Association Between Child Marriage and Reproductive Health Outcomes and Service Utilization: A Multi-Country Study From South Asia

PURPOSE Despite the pervasiveness of child marriage and its potentially adverse consequences on reproductive health outcomes, there is relatively little empirical evidence available on this issue, which has hindered efforts to improve the targeting of adolescent health programs. The purpose of this study was to assess the association of child marriage with fertility, fertility control, and maternal health care use outcomes in four South Asian countries: India, Bangladesh, Nepal, and Pakistan. METHODS Data for the study come from the most recent Demographic and Health Surveys conducted in the study countries; we used a subsample of women aged 20-24 years. Child marriage, defined as first marriage before 18 years of age, is categorized into two groups: first married at ages 15-17 years and first married at age ≤14 years. We used multivariate logistic regression models. RESULTS The results of the study suggest that child marriage is significantly associated with a history of rapid repeat childbirth, current modern contraceptive use, female sterilization, not using contraception before first childbirth, pregnancy termination, unintended pregnancy, and inadequate use of maternal health services, although the associations are not always consistent across countries. Furthermore, women who married in early adolescence or childhood show a higher propensity toward most of the negative outcomes, compared with women who married in middle adolescence. CONCLUSIONS Child marriage adds a layer of vulnerability to women that leads to poor fertility control and fertility-related outcomes, and low maternal health care use.

Sexual activity before marriage in Sub-Saharan Africa.

Throughout sub-Saharan Africa there is notable concern about the consequences of premarital sexual intercourse, such as illegal abortions and pregnancy-related school dropouts, and the potential risk of HIV infection. Using data from the Demographic and Health Surveys, the authors investigated sexual activity among never-married women aged 15-24 in Botswana, Burundi, Ghana, Kenya, Liberia, and Zimbabwe. While there are important cross-country differentials, in most countries the majority of unmarried adolescents have been sexually active. Contrary to the common belief that teenage premarital sexual activity is a new phenomenon caused by socioeconomic development, particularly Western education, the data show that in most countries sexual activity among unmarried adolescents was also common in the past, and that increases across cohorts have occurred mostly in countries where the prevalence was already high. For most countries, there is little support for theories claiming that education is associated with loose morals and high levels of premarital sexual activity. The findings highlight the importance of family-planning services for unmarried adolescents and of family-life education in primary schools to reach children before they become sexually active.

Attitudes toward the discontinuation of female genital cutting among men and women in Guinea

To investigate socioeconomic correlates of and gender differences in attitudinal support for the discontinuation of FGC in Guinea.

Association of Child Marriage With Suicidal Thoughts and Attempts Among Adolescent Girls in Ethiopia

PURPOSE Little information exists on the mental health implications of child marriage in Africa. This study examined the association between child marriage and suicidal ideation and suicide attempt among girls aged 10-17 years. METHODS Data were drawn from a 2007 cross-sectional survey conducted in the Amhara region, Ethiopia. Multilevel logistic regression was used to analyze risk factors for suicidality. RESULTS Approximately 5.2% of girls reported ever being married, 5.4% were promised in marriage, and 9.3% reported receiving marriage requests. Girls who were ever married (odds ratio [OR] = 1.81; 95% confidence interval [CI] = 1.03-3.18), were promised in marriage (OR = 2.35; 95% CI = 1.38-4.01) or had received marriage requests (OR = 2.29; 95% CI = 1.46-3.59) were significantly more likely than girls who were never in the marriage process to have had suicidal thoughts in the past 3 months. Residence in communities with high involvement in stopping child marriage was protective of suicidal ideation. The odds of suicide attempt were twice as high among girls with marriage requests as among those with none. CONCLUSIONS Child marriage was associated with increased odds of suicidality. Findings call for stronger community engagement in child marriage prevention and mental health support for child brides.

CHANGES IN PERCEPTIONS OF QUALITY OF, AND ACCESS TO, SERVICES AMONG CLIENTS OF A FRACTIONAL FRANCHISE NETWORK IN NEPAL

With declining levels of international donor funding for financing reproductive health programmes, developing country governments and international donors are looking towards private sector strategies to expand the supply of quality reproductive health services. One of the challenges of a health franchise is to improve the quality of services provided by independent private practitioners. Private providers are more likely to abide by the quality standards set by a franchiser if they see a financial benefit resulting from franchise participation. This study was conducted to measure whether (a) there were improvements in perceived quality of care and perceived access to health facilities once these facilities became part of a franchise and (b) improvements in perceived quality and perceived access were associated with increased client loyalty to franchised clinics. Franchisees were given basic reproductive health training for seven days and services marketing training for two days. Exit interviews were conducted with male and female clients at health facilities. A pre-test measurement was taken in April 2001, prior to the start of project activities. A post-test measurement was taken in February/March 2002, about 9 months after the pre-test. Multilevel regression analysis, which takes the hierarchical structure of the data into account, was used for the analysis. After taking provider-level variation into account and controlling for client characteristics, the analyses showed significant improvements in perceived quality of care and perceived access to services. Private provider participation in a franchise network helps improve client perceptions of quality of, and access to, services. Improvements in client perceptions of quality and access contribute to increased client loyalty to franchised clinics. Once increased client loyalty translates into higher client volumes, providers are likely to see the benefits of franchise participation. In turn, this should lead to increased provider willingness to remain part of the franchise and to abide by the standards of quality set by the franchiser.

Preparing adolescents for adulthood

Pregnancy-related school dropouts have become a matter of public concern throughout sub-Saharan Africa. In most cases, schoolgirls who become pregnant either have to resort to unsafe illegal abortions, or they face official school expulsion. Because girls who drop out of school due to pregnancy usually do not return to school to complete their education after the birth of their child, their opportunities for socioeconomic advancement are limited. Many African governments have included family life education programs in the school curriculum in an attempt to educate adolescents about the consequences and responsibilities associated with sexual activity. The high rates of schoolgirl pregnancies suggest that these programs have their shortcomings, and indicate that educational policies should attempt not only to reduce the incidence of schoolgirl pregnancies, but also to assist pregnant schoolgirls to complete their education. In this paper, we use data from a sample of 154 Kenyan primary and secondary schools to study differentials in the extent to which various types of schools are affected by pregnancy-related school dropouts, and to examine the opinions of the head teachers regarding teaching about contraceptive methods and readmittance of pregnancy-related dropouts.