Jessica D. Gipson

The effect of husbands’ and wives’ fertility preferences on the likelihood of a subsequent pregnancy, Bangladesh 1998–2003

Using cross-sectional and longitudinal data from 3,052 rural Bangladeshi couples, we investigated the influence of husbands’ and wives’ fertility preferences on the likelihood of a subsequent pregnancy in the period 1998–2003. Although reproductive behaviour is relatively consistent with fertility preferences, 17 per cent of couples who reported they did not want more children in 1998 had a subsequent pregnancy by 2003. Wives in this setting appear to be more pronatalist than those in other less developed countries. Moreover, wives’ rather than husbands’ fertility preferences appear to have dominated over the 5-year study period. As expected, the incidence of pregnancy decreased over the study period for most couples, but increased among couples in which only the husband wanted more children. This finding suggests that wives who disagree with their husbands about having more children are either less likely to prevent pregnancy through consistent use of contraception or acquiesce to their husbands’ desire for more children.

The relationship of women’s status and empowerment with skilled birth attendant use in Senegal and Tanzania

BackgroundMaternal mortality remains unacceptably high in sub-Saharan Africa with 179,000 deaths occurring each year, accounting for 2-thirds of maternal deaths worldwide. Progress in reducing maternal deaths and increasing Skilled Birth Attendant (SBA) use at childbirth has stagnated in Africa. Although several studies demonstrate the important influences of women’s status and empowerment on SBA use, this evidence is limited, particularly in Africa. Furthermore, few studies empirically test the operationalization of women’s empowerment and incorporate multidimensional measures to represent the potentially disparate influence of women’s status and empowerment on SBA use across settings.MethodsThis study examined the relationship of women’s status and empowerment with SBA use in two African countries – Senegal and Tanzania – using the 2010 Demographic and Health Surveys (weighted births n = 10,688 in SN; 6748 in TZ). Factor analysis was first conducted to identify the structure and multiple dimensions of empowerment. Then, a multivariate regression analysis was conducted to examine associations between these empowerment dimensions and SBA use.ResultsOverall, women’s status and empowerment were positively related to SBA use. Some sociodemographic characteristics showed similar effects across countries (e.g., age, wealth, residence, marital relationship, parity); however, women’s status and empowerment influence SBA use differently by setting. Namely, women’s education directly and positively influenced SBA use in Tanzania, but not in Senegal. Further, each of the dimensions of empowerment influenced SBA use in disparate ways. In Tanzania women’s higher household decision-making power and employment were related to SBA use, while in Senegal more progressive perceptions of gender norms and older age at first marriage were related to SBA use.ConclusionsThis study provides evidence of the disparate influences of women’s status and empowerment on SBA use across settings. Results indicate that efforts to increase SBA use and to reduce maternal mortality through the improvement of women’s status and empowerment should focus both on improving girls’ education and delaying marriage, as well as transforming gender norms and decision-making power. However, given the multi-dimensional and contextual nature of women’s status and empowerment, it is critical to identify key drivers to increase SBA use in a given setting for contextually tailored policy and programming.

Reducing high maternal mortality rates in western China: a novel approach.

Abstract Among the Millennium Development Goals, maternal mortality reduction has proven especially difficult to achieve. Unlike many countries, China is on track to meeting these goals on a national level, through a programme of institutionalizing deliveries. Nonetheless, in rural, disadvantaged, and ethnically diverse areas of western China, maternal mortality rates remain high. To reduce maternal mortality in western China, we developed and implemented a three-level approach as part of a collaboration between a regional university, a non-profit organization, and local health authorities. Through formative research, we identified seven barriers to hospital delivery in a rural Tibetan county of Qinghai Province: (1) difficulty in travel to hospitals; (2) hospitals lack accommodation for accompanying families; (3) the cost of hospital delivery; (4) language and cultural barriers; (5) little confidence in western medicine; (6) discrepancy in views of childbirth; and (7) few trained community birth attendants. We implemented a three-level intervention: (a) an innovative Tibetan birth centre, (b) a community midwife programme, and (c) peer education of women. The programme appears to be reaching a broad cross-section of rural women. Multilevel, locally-tailored approaches may be essential to reduce maternal mortality in rural areas of western China and other countries with substantial regional, socioeconomic, and ethnic diversity. Résumé Parmi les objectifs du Millénaire pour le développement, la réduction de la mortalité maternelle s’est révélée particulièrement difficile à réaliser. Contrairement à de nombreux pays, la Chine est dans les temps pour atteindre ces objectifs au niveau national, avec un programme d’institutionnalisation des accouchements. Néanmoins, dans les zones rurales, défavorisées et ethniquement diverses de la Chine occidentale, les taux de mortalité maternelle demeurent élevés. Pour réduire la mortalité maternelle en Chine occidentale, nous avons élaboré et appliqué une approche à trois niveaux dans le cadre d’une collaboration entre une université régionale, une organisation à but non lucratif et les autorités sanitaires locales. Avec une recherche formative, nous avons identifié sept obstacles à l’accouchement en milieu hospitalier dans un comté tibétain rural de la province de Qinghai : 1) difficultés pour se rendre à l’hôpital ; 2) impossibilité pour les parents accompagnants de se loger à l’hôpital ; 3) coût de l’accouchement en milieu hospitalier ; 4) obstacles linguistiques et culturels ; 5) manque de confiance dans la médecine occidentale ; 6) divergences dans la conception de la naissance ; et 7) manque d’accoucheuses communautaires formées. Nous avons appliqué une intervention à trois niveaux : a) un centre de naissance tibétain novateur, b) un programme de sages-femmes communautaires et c) l’éducation des femmes par les femmes. Le programme semble atteindre un vaste segment représentatif des rurales. Des approches à plusieurs niveaux et adaptées au contexte local peuvent être essentielles pour réduire la mortalité maternelle dans les zones rurales de Chine occidentale et d’autres pays avec une diversité régionale, socio-économique et ethnique substantielle. Resumen Entre los Objetivos de Desarrollo del Milenio, ha resultado particularmente difícil lograr la reducción de la mortalidad materna. A diferencia de muchos países, China está bien encaminada para cumplir estos objetivos a nivel nacional, mediante un programa para institucionalizar partos. No obstante, en las zonas rurales, desfavorecidas y con diversidad étnica de China occidental, las tasas de mortalidad materna continúan siendo altas. Para reducir la mortalidad materna en China occidental, formulamos y aplicamos una estrategia de tres niveles como parte de una colaboración entre una universidad regional, una organización sin fines de lucro, y autoridades de salud locales. Por medio de investigación formativa, identificamos siete barreras para el parto hospitalario en un condado rural tibetano de la Provincia de Qinghai: (1) dificultad para viajar a un hospital; (2) los hospitales carecen de alojamiento para las familias acompañantes; (3) el costo del parto hospitalario; (4) barreras idiomáticas y culturales; (5) poca confianza en la medicina occidental; (6) diferencias en los puntos de vista sobre el parto; y (7) pocos asistentes de parto comunitarios capacitados. Realizamos una intervención de tres niveles: (a) un innovador centro de parto en Tibet, (b) un programa comunitario de parteras profesionales, y (c) educación de las mujeres por pares. El programa parece estar llegando a una gran variedad de mujeres rurales. Posiblemente sea esencial aplicar estrategias en múltiples niveles, adaptadas a nivel local, para reducir la mortalidad materna en las zonas rurales de China occidental y en otros países con considerable diversidad regional, socioeconómica y étnica.

Unplanned and assisted conception pregnancies

High prevalence of unplanned pregnancy warrants primary and secondary prevention efforts

Human papillomavirus (HPV) awareness and vaccine receptivity among Senegalese adolescents.

To examine HPV vaccine awareness and receptivity among adolescents and young adults in Senegal.

Tibetan women's perspectives and satisfaction with delivery care in a rural birth center

To identify sociodemographic characteristics and factors involved in Tibetan womens decisions to deliver at the Tibetan Birth and Training Center (TBTC) in rural western China.

Health-related media use among youth audiences in Senegal.

Lower- and middle-income countries (LMICs) are experiencing rapid changes in access to and use of new internet and digital media technologies. The purpose of this study was to better understand how younger audiences are navigating traditional and newer forms of media technologies, with particular emphasis on the skills and competencies needed to obtain, evaluate and apply health-related information, also defined as health and media literacy. Sixteen focus group discussions were conducted throughout Senegal in September 2012 with youth aged 15-25. Using an iterative coding process based on grounded theory, four themes emerged related to media use for health information among Senegalese youth. They include the following: (i) media utilization; (ii) barriers and conflicts regarding media utilization; (iii) uses and gratifications and (iv) health and media literacy. Findings suggest that Senegalese youth use a heterogeneous mix of media platforms (i.e. television, radio, internet) and utilization often occurs with family members or friends. Additionally, the need for entertainment, information and connectedness inform media use, mostly concerning sexual and reproductive health information. Importantly, tensions arise as youth balance innovative and interactive technologies with traditional and conservative values, particularly concerning ethical and privacy concerns. Findings support the use of multipronged intervention approaches that leverage both new media, as well as traditional media strategies, and that also address lack of health and media literacy in this population. Implementing health-related interventions across multiple media platforms provides an opportunity to create an integrated, as opposed to a disparate, user experience.

Dual protection to address the global syndemic of HIV and unintended pregnancy in Brazil

Background Syndemic HIV and unintended pregnancy is prevalent in Brazil, where 79% of female HIV cases occur in women of reproductive age and 55% of all pregnancies are unintended. Although increasing condom use to prevent HIV may decrease non-barrier contraception and increase unintended pregnancy, few studies focus on dual protection or dual methods (condoms with another modern contraceptive). Aim To describe the correlates of dual method use and consistent condom use in women of reproductive age in Brazil. Method Data are from the 2006 Pesquisa Nacional de Demografia e Saúde da Mulher e da Criança, a decennial nationally representative household survey of women of reproductive age in Brazil. Multivariate logistic regression models identify the socio-demographic, sexual debut, fertility and relationship factors associated with dual method use and consistent condom use. Results Two-thirds of contracepting women in Brazil used dual protection (40% exclusive condoms, 27% dual methods). Consistent condom use in the past year occurred among 61% of exclusive condom users and 27% of dual method users. Dual methods (vs exclusive condoms) was associated with some high school education [relative risk ratio (RRR)=1.69, p<0.05], living in the Southern region (RRR=1.59, p<0.01), and number of children (RRR=1.22, p<0.01), net of other factors. Consistent condom use was associated with condom use at sexual debut [adjusted odds ratio (AOR)=1.84, p<0.001], wants no (more) children (AOR=1.86, p<0.001), single/separated relationship status (AOR=2.77/2.45, p<0.001) and using exclusive condoms (vs dual methods: AOR=0.19, p<0.001). Conclusions Findings highlight that targeting and delivering integrated HIV and family planning services should focus on completed/large families. single/separated individuals, and promoting dual protection at sexual debut.

Preventing syndemic Zika virus, HIV/STIs and unintended pregnancy: dual method use and consistent condom use among Brazilian women in marital and civil unions

Abstract Syndemic Zika virus, HIV and unintended pregnancy call for an urgent understanding of dual method (condoms with another modern non-barrier contraceptive) and consistent condom use. Multinomial and logistic regression analysis using data from the Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS), a nationally representative household survey of reproductive-aged women in Brazil, identified the socio-demographic, fertility and relationship context correlates of exclusive non-barrier contraception, dual method use and condom use consistency. Among women in marital and civil unions, half reported dual protection (30% condoms, 20% dual methods). In adjusted models, condom use was associated with older age and living in the northern region of Brazil or in urban areas, whereas dual method use (versus condom use) was associated with younger age, living in the southern region of Brazil, living in non-urban areas and relationship age homogamy. Among condom users, consistent condom use was associated with reporting Afro-religion or other religion, not wanting (more) children and using condoms only (versus dual methods). Findings highlight that integrated STI prevention and family planning services should target young married/in union women, couples not wanting (more) children and heterogamous relationships to increase dual method use and consistent condom use.

GIPSON AND HINDIN RESPOND

We appreciate the opportunity to respond to the issues raised by Burnie et al. regarding our mixed-method analysis of pregnancy termination in Bangladesh. With respect to ascertainment of pregnancy status, all women within the Sample Registration System (SRS) households are asked to report on their menstrual status during the quarterly visits. If amenorrheic, women are queried as to the possible cause (e.g., use of injectable contraception, suspected pregnancy). If a woman is unsure of her pregnancy status, her record is flagged in the SRS database for follow-up. If her pregnancy is confirmed, she is asked for the date of her last menstrual period. Albeit imperfect, this method is less subject to recall bias as compared with retrospective reporting of pregnancies and pregnancy loss.1,2 A more detailed explanation of the SRS and pregnancy ascertainment are described elsewhere.3,4 Attrition over the study period was relatively low as compared with other longitudinal data sets. The sample was comprised of couples in which both spouses answered the 1998 fertility questions. Of these couples, over 82% remained active through the 5-year study period. Even when comparing the sample women to all women who participated in the 1998 survey (n = 5 273), there were no significant differences (P < .05) apart from a slightly higher mean number of children among our sample (2.45 vs 2.37 children; P value = 0.035). We agree with Burnie et al. that walking distance does not wholly define access. However, given the existing secondary data available for this analysis and literature linking higher mobility with lower fertility among Bangladeshi women,5 we felt walking distance to be the most appropriate available proxy measure to assess the potential physical and psychological barriers for women in accessing health services in this context. During qualitative data collection, there were nightly staff meetings in the field, in addition to further crystallization of study findings by the entire study team through peer review of transcripts and memo-writing on emerging and dominant themes. The themes identified during the fieldwork served as a basis for the results presented. Lastly, we would like to concur with Burnie et al. that this study is not meant to be representative of all of Bangladesh, or even all of rural Bangladesh. Despite limitations, these data shed light on the contextual circumstances of pregnancy termination. We hope that our study prompts further investigation and a more holistic understanding of pregnancy termination within and outside of Bangladesh.