Ernestina Coast

Maasai socioeconomic conditions: A cross-border comparison

A single round household survey was conducted between October 1997 and May 1998. Information was collected on 1545 Maasai households in Kenya and Tanzania using a standardized questionnaire. These data represent the first large-scale, cross-border comparable survey of socioeconomic indicators for the Maasai. The structure of the study is similar to that of a natural experiment: one ethnic group living in two very different nation-states. The survey results describe a current “snapshot” of Maasai livelihoods. Living arrangements are described at both the household (olmarei) and multihousehold (enkang) level, together with changes in housing type. The roles of cultivation, transhumant migration, and employment are described, including a consideration of the prevalence of murranism (warriorhood). The implications of rising levels of sedentarization and cash crop production for Maasai economic diversification are explored. Participation by Maasai in the tourism industry is extremely low despite the proximity of Maasai to major international tourist destinations in East Africa. Levels of formal education show a marked sex bias in completed primary school education in both countries, with far fewer women than men having attended school.

Cultural constructions of the concept of household in sample surveys

We analyse the use of the concept of household in sample surveys, with evidence drawn from a review of survey definitions, a series of in-depth interviews with data producers and users, and a systematic study of recent literature. We consider the place of the concept within the discipline of demography, and demonstrate how its definition and use interact with cultural values and core concepts integral to the discipline. Focusing on Tanzania as a case study, we examine the diversity of factors that influence the construction of household-level data from cross-sectional household surveys. Throughout the survey process, contrasting interpretations of the meaning of household and different motivations for using specific definitions of the term interact. This generates data and outputs with potential for undercounting, bias, and misrepresentations, with adverse effects on the quality of data used for monitoring development indicators. Some ways of improving data collection on households are proposed.

Human papillomavirus (HPV) vaccine implementation in low and middle-income countries (LMICs): Health system experiences and prospects

Highlights • Multi-method review of challenges introducing HPV vaccine in developing countries.• HPV vaccine delivery methods can overcome inadequate health systems.• Political will is essential for successful HPV vaccine roll-out.

Suicide and poverty in low-income and middle-income countries: a systematic review

Suicide is the 15th leading cause of death worldwide, with over 75% of suicides occurring in low-income and middle-income countries. Nonetheless, evidence on the association between suicide and poverty in low-income and middle-income countries is scarce. We did a systematic review to understand the association between suicidal ideations and behaviours and economic poverty in low-income and middle-income countries. We included studies testing the association between suicidal ideations and behaviours and economic poverty in low-income and middle-income countries using bivariate or multivariate analysis and published in English between January, 2004, and April, 2014. We identified 37 studies meeting these inclusion criteria. In 18 studies reporting the association between completed suicide and poverty, 31 associations were explored. The majority reported a positive association. Of the 20 studies reporting on the relationship between non-fatal suicidal ideations and behaviours and poverty, 36 associations were explored. Again, almost all studies reported a positive association. However, when considering each poverty dimension separately, we found substantial variations. These findings show a consistent trend at the individual level indicating that poverty, particularly in the form of worse economic status, diminished wealth, and unemployment is associated with suicidal ideations and behaviours. At the country level, there are insufficient data to draw clear conclusions. Available data show a potential benefit in addressing economic poverty within suicide prevention strategies, with particular attention to both chronic poverty and acute economic events.

Wasting semen: Context and condom use among the Maasai

Motivations for condom use are intricate and the behaviour of individuals and couples takes place in complex sociocultural settings. This study examines in detail the sociocultural context of condom use among the Maasai, an east African agropastoralist population. A review of the ethno‐demographic literature demonstrates the sociocultural significance of semen in a range of settings. A detailed description of Maasai values relating to semen is followed by an analysis presenting results from a sample survey and focus group discussions. Whilst reported knowledge of HIV/AIDS was high (100%), unprompted reporting of condoms as a way of preventing HIV infection was low. When asked directly about knowledge of condoms, awareness appeared high but levels of detailed condom knowledge were very low. Of those individuals who reported that they knew what a condom was, only 17% said that they knew how they worked. Focus group discussions reveal strongly held opinions and beliefs connected to condoms and their use, including their contraceptive effects, negative impact on quality of sex, the wasting of semen and the ‘otherness’ of condoms. The implications of these findings for condom provision and uptake are considered.

Poverty in African Households: the Limits of Survey and Census Representations

Abstract African poverty statistics depend on household-level measurements from survey data, making the definition of household of critical importance. Detailed case studies from Tanzania and Burkina Faso explore (1) understandings of household membership and ambiguities, and (2) how well survey definitions capture households as economic units, and the implications for household size and responses to and mitigation of poverty. We develop an analytic framework of ‘open’ and ‘closed’ households. ‘Open’ households cope with poverty using flexibility, movement and extra-household networks, but are poorly represented by survey data. Closed households are likely to be better described by survey data.

Increasing the use of skilled health personnel where traditional birth attendants were providers of childbirth care: a systematic review.

Background Improved access to skilled health personnel for childbirth is a priority strategy to improve maternal health. This study investigates interventions to achieve this where traditional birth attendants were providers of childbirth care and asks what has been done and what has worked? Methods and Findings We systematically reviewed published and unpublished literature, searching 26 databases and contacting experts to find relevant studies. We included references from all time periods and locations. 132 items from 41 countries met our inclusion criteria and are included in an inventory; six were intervention evaluations of high or moderate quality which we further analysed. Four studies report on interventions to deploy midwives closer to communities: two studies in Indonesia reported an increase in use of skilled health personnel; another Indonesian study showed increased uptake of caesarean sections as midwives per population increased; one study in Bangladesh reported decreased risk of maternal death. Two studies report on interventions to address financial barriers: one in Bangladesh reported an increase in use of skilled health personnel where financial barriers for users were addressed and incentives were given to skilled care providers; another in Peru reported that use of emergency obstetric care increased by subsidies for preventive and maternity care, but not by improved quality of care. Conclusions The interventions had positive outcomes for relevant maternal health indicators. However, three of the studies evaluate the village midwife programme in Indonesia, which limits the generalizability of conclusions. Most studies report on a main intervention, despite other activities, such as community mobilization or partnerships with traditional birth attendants. Many authors note that multiple factors including distance, transport, family preferences/support also need to be addressed. Case studies of interventions in the inventory illustrate how different countries attempted to address these complexities. Few high quality studies that measure effectiveness of interventions exist.

Maternity care services and culture: a systematic global mapping of interventions.

Background A vast body of global research shows that cultural factors affect the use of skilled maternity care services in diverse contexts. While interventions have sought to address this issue, the literature on these efforts has not been synthesised. This paper presents a systematic mapping of interventions that have been implemented to address cultural factors that affect womens use of skilled maternity care. It identifies and develops a map of the literature; describes the range of interventions, types of literature and study designs; and identifies knowledge gaps. Methods and Findings Searches conducted systematically in ten electronic databases and two websites for literature published between 01/01/1990 and 28/02/2013 were combined with expert-recommended references. Potentially eligible literature included journal articles and grey literature published in English, French or Spanish. Items were screened against inclusion and exclusion criteria, yielding 96 items in the final map. Data extracted from the full text documents are presented in tables and a narrative synthesis. The results show that a diverse range of interventions has been implemented in 35 countries to address cultural factors that affect the use of skilled maternity care. Items are classified as follows: (1) service delivery models; (2) service provider interventions; (3) health education interventions; (4) participatory approaches; and (5) mental health interventions. Conclusions The map provides a rich source of information on interventions attempted in diverse settings that might have relevance elsewhere. A range of literature was identified, from narrative descriptions of interventions to studies using randomised controlled trials to evaluate impact. Only 23 items describe studies that aim to measure intervention impact through the use of experimental or observational-analytic designs. Based on the findings, we identify avenues for further research in order to better document and measure the impact of interventions to address cultural factors that affect use of skilled maternity care.

Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries

This study systematically maps, assesses and aggregates research relating to postnatal depression (PND) and poverty in low and lower middle income countries (LLMICs). Our search of 12 databases yielded 2202 articles, of which 47 items from 17 countries were included in our mapping. We highlight mechanisms for the relationships between poverty and PND in LLMICs. The research base on the relationships between poverty and PND in LLMIC is limited, but has recently expanded. It is dominated by studies that consider whether poverty is a risk factor for PND. Income, socio-economic status and education are all inconsistent risk factors for PND. Clues to better ways of framing and capturing economic stress in PND research is found in the qualitative studies included in our mapping. Evidence focuses overwhelmingly on individual-level analyses. To understand the scale and implications of PND in LLMICs, research has to take account of neighbourhoods, communities, and localities.

These things are dangerous: Understanding induced abortion trajectories in urban Zambia

Unsafe abortion is a significant but preventable cause of global maternal mortality and morbidity. Zambia has among the most liberal abortion laws in sub-Saharan Africa, however this alone does not guarantee access to safe abortion, and 30% of maternal mortality is attributable to unsafe procedures. Too little is known about the pathways women take to reach abortion services in such resource-poor settings, or what informs care-seeking behaviours, barriers and delays. In-depth qualitative interviews were conducted in 2013 with 112 women who accessed abortion-related care in a Lusaka tertiary government hospital at some point in their pathway. The sample included women seeking safe abortion and also those receiving hospital care following unsafe abortion. We identified a typology of three care-seeking trajectories that ended in the use of hospital services: clinical abortion induced in hospital; clinical abortion initiated elsewhere, with post-abortion care in hospital; and non-clinical abortion initiated elsewhere, with post-abortion care in hospital. Framework analyses of 70 transcripts showed that trajectories to a termination of an unwanted pregnancy can be complex and iterative. Individuals may navigate private and public formal healthcare systems and consult unqualified providers, often trying multiple strategies. We found four major influences on which trajectory a woman followed, as well as the complexity and timing of her trajectory: i) the advice of trusted others ii) perceptions of risk iii) delays in care-seeking and receipt of services and iv) economic cost. Even though abortion is legal in Zambia, girls and women still take significant risks to terminate unwanted pregnancies. Levels of awareness about the legality of abortion and its provision remain low even in urban Zambia, especially among adolescents. Unofficial payments required by some providers can be a major barrier to safe care. Timely access to safe abortion services depends on chance rather than informed exercise of entitlement.