The effects of reproductive variables on child mortality in Ethiopia: evidence from demographic and health surveys from 2000 to 2016.

BACKGROUND: Child mortality is a crucial indicator reflecting a country's health and socioeconomic status. Despite significant global improvements in reducing early childhood deaths, Southern Asia and sub-Saharan Africa still bear the highest burden of newborn mortality. Ethiopia is one of five countries that account for half of new-born deaths worldwide. METHODS: This study examined the relationship between specific reproductive factors and under-five mortality in Ethiopia. A discrete-time survival model was applied to analyze data collected from four Ethiopian Demographic and Health Surveys (EDHS) conducted between 2000 and 2016. The study focused on investigating the individual and combined effects of three factors: preceding birth interval, maternal age at childbirth, and birth order, on child mortality. RESULTS: The study found that lengthening the preceding birth interval to 18-23, 24-35, 36-47, or 48+ months reduced the risk of under-five deaths by 30%, 46%, 56%, and 60% respectively, compared to very short birth intervals (less than 18 months). Giving birth between the ages 20-34 and 35+ reduced the risk by 34% and 8% respectively, compared to giving birth below the age of 20. The risk of under-five death was higher for a 7th-born child by 17% compared to a 2nd or 3rd-born child. The combined effect analysis showed that higher birth order at a young maternal age increased the risk. In comparison, lower birth order in older maternal age groups was associated with higher risk. Lastly, very short birth intervals posed a greater risk for children with higher birth orders. CONCLUSION: Not only does one reproductive health variable negatively affect child survival, but their combination has the strongest effect. It is therefore recommended that policies in Ethiopia should address short birth intervals, young age of childbearing, and order of birth through an integrated strategy.

Does sex composition of offspring relate to fertility in urban areas? The case of Ouagadougou, Burkina Faso.

With the onset of the demographic transition in sub-Saharan Africa, couples' desired number of children and the sex composition of offspring may become conflicted, with potential effects on future fertility. While intuitively expected, this effect has not been observed in studies in sub-Saharan Africa, where the level of fertility is higher than in other African regions. In this study, the hypothesis of a conflicted situation was examined by assessing the effect of sex composition of offspring on women's intentions regarding additional children and their use of modern contraceptives. A mixed-method analysis was performed using quantitative data regarding 2567 women aged 35-49 years drawn from a 2012 Demtrend retrospective longitudinal population survey, supplemented by qualitative data collected through 23 in-depth interviews of men and women in Ouagadougou. Results showed that the absence of one sex (boy or girl) in the existing offspring was associated with additional demand for children and lower contraceptive use. These results suggest that a desire for a combination of both girls and boys may be the driving factor contributing to larger family size; that is, continued fertility may not be determined by son preference, but rather by overall composition of offspring, when existing children are all girls or all boys. This could explain the stalling of the fertility decline observed in recent years in Ouagadougou.

Knowledge about Autism among Graduate Students in Togo.

Graduate students in healthcare or education programs should have adequate knowledge about autism as they could become professionals in that field. However, we were unable to locate any published studies that examined knowledge about autism among graduate students in francophone sub-Saharan Africa. Thus, the goal of this study was to describe knowledge about autism among 254 graduate psychology, medical, and education students in Togo. Results suggested that only 5% of graduate students had good knowledge about autism. Although graduate psychology students achieved higher scores than others, all subgroups had inadequate knowledge about specific characteristics of autism. The findings highlight the necessity of passing public policies to promote autism research and training in local universities in Togo.

Fertility decline in sub-Saharan Africa: Does remarriage matter?

The interplay between remarriage and fertility is among the most poorly documented subjects in sub-Saharan Africa (SSA), despite remarriage being one of the fundamental aspects of marriage dynamics in this region. We use Demographic and Health Survey data from 34 countries in SSA to document the association between remarriage and fertility during the reproductive years and over the fertility transition. The findings show that in 29 countries, remarried women end up having fewer children than women in intact unions, despite attaining similar or higher levels of fertility at early reproductive ages. However, remarriage is found to have a positive effect on fertility in Sierra Leone. The effects of remarriage on fertility diminish as fertility declines, with smaller effects generally observed in countries that are relatively advanced in their fertility transition and larger effects found elsewhere. These findings shed light on the role that remarriage might play in country-level fertility declines.

Understanding how young African adults interact with peer-generated sexual health information on Facebook and uncovering strategies for successful organic engagement.

BACKGROUND: The use of social media for sexual health communication is gaining intense discussion both globally and in Africa. Despite this reality, it remains unclear whether and how young African adults use digital innovations like social media to access sexual health information. More importantly, the unique properties of messages that increase message reach and propagation are not well understood. This study aims to fill the gaps in scholarship by identifying post features and content associated with greater user engagement. METHODS: We analyzed a corpus of 3533 sexual and reproductive health messages shared on a public Facebook group by and for young African adults between June 1, 2018, and May 31, 2019, to understand better the unique features associated with higher engagement with peer-generated sexual health education. Facebook posts were independently classified into thematic categories such as topic, strategy, and tone of communication. RESULTS: The participants generally engaged with posts superficially by liking (x̃ = 54; x̄ = 109.28; σ = 159.24) rather than leaving comments (x̃ = 10; x̄ = 32.03; σ = 62.65) or sharing (x̃ = 3; x̄ = 11.34; σ = 55.12) the wallposts. Messages with fear [IRR:0.75, 95% CI: 0.66-0.86] or guilt [IRR:0.82, 95% CI: 0.72-0.92] appeals received a significantly lower number of reactions compared to neutral messages. Messages requesting an opinion [IRR:4.25, 95% CI: 3.57-5.10] had a significantly higher number of comments compared to status updates. The use of multimedia and storytelling formats were also significantly associated with a higher level of engagement and propagation of sexual health messages on the group. CONCLUSION: Young adults in our sample tend to superficially interact with peer-communicated sexual health information through likes than engage (comments) or propagate such messages. Message features that increase engagements and propagation of messages include multimedia and engaging styles like storytelling. Our findings provide valuable insight and pave the way for the design of effective and context-specific sexual health information use of features that attract young African adults.

Does economic growth reduce childhood stunting? A multicountry analysis of 89 Demographic and Health Surveys in sub-Saharan Africa.

Background: There is mixed evidence and lack of consensus on the impact of economic development on stunting, and likewise there is a dearth of empirical studies on this relationship in the case of sub-Saharan Africa. Thus, this paper examines whether economic growth is associated with childhood stunting in low-income and middle-income sub-Saharan African countries. Methods: We analysed data from 89 Demographic and Health Surveys conducted between 1987 and 2016 available as of October 2018 using multivariable multilevel logistic regression models to show the association between gross domestic product (GDP) per capita and stunting. We adjusted the models for child's age, survey year, child's sex, birth order and country random effect, and presented adjusted and unadjusted ORs. Results: We included data from 490 526 children. We found that the prevalence of stunting decreased with increasing GDP per capita (correlation coefficient=-0.606, p<0.0001). In the unadjusted model for full sample, for every US$1000 increase in GDP per capita, the odds of stunting decreased by 23% (OR=0.77, 95% CI 0.76 to 0.78). The magnitude of the association between GDP per capita and stunting was stronger among children in the richest quintile. After adjustment was made, the association was not significant among children from the poorest quintile. However, the magnitude of the association was more pronounced among children from low-income countries, such that, in the model adjusted for child's age, survey year, child's sex, birth order and country random effect, the association between GDP per capita and stunting remained statistically significant; for every US$1000 increase in GDP per capita, the odds of stunting decreased by 12% (OR=0.88, 95% CI 0.87 to 0.90). Conclusion: There was no significant association between economic growth and child nutritional status. The prevalence of stunting decreased with increasing GDP per capita. This was more pronounced among children from the richest quintile. The magnitude of the association was higher among children from low-income countries, suggesting that households in the poorest quintile were typically the least likely to benefit from economic gains. The findings could serve as a building block needed to modify current policy as per child nutrition-related programmes in Africa.

Effects of birth spacing on adverse childhood health outcomes: evidence from 34 countries in sub-Saharan Africa.

Background: Interpregnancy intervals (IPI) are independently associated with maternal, perinatal, infant and child outcomes. Birth spacing is a recommended tool to reduce adverse health outcomes especially among children. This study aims to determine the prevalence of adverse child health outcomes in sub-Saharan Africa (SSA) countries and to examine the association between the length of preceding birth interval child health outcomes.Methods: Secondary data from Demographic and Health Survey (DHS) in 34 SSA countries with 299 065 births was used in this study. The outcome variables were infant mortality, low birth weight, stunting, underweight, wasting, overweight and anemia. Percentage was used in univariate analysis. Cox proportional hazard regression was used to examine association between the adjusted model of preceding birth interval and infant mortality. Multinomial and binary logistic regression models were used to examine the association between under-five children adverse health outcomes and interpregnancy birth interval.Results: Infant mortality was lowest in Gambia (3.4%) and highest in Sierra Leone (9.3%). Comoros (16.8%) accounted for the highest percentage of low birth weight (<2.5 kg). Child stunting was as high as 54.6% in Burundi. IPIs of <24 months, 24-36 months, 37-59 months and ≤60 months accounted for 19.3, 37.8, 29.5 and 13.4% respectively. Median IPI was 34 months. Results from Cox proportional hazard regression showed that children with preceding birth interval <24 months had 57% higher risk of infant mortality, compared to children with IPI of 24-36 months (Hazard ratio (HR) = 1.57; 95%CI: 1.45, 1.69). However, there were 19% and 10% reduction in the risk of infant mortality at IPIs of 37-59 months and ≥60 months, compared to 24-36 months IPI (37-59 months: HR = 0.81; 95%CI: 0.75, 0.87; ≥60 months: HR = 0.90; 95%CI: 0.81, 0.99).Conclusion: The findings of this study suggest the need for urgent intervention to promote the recommended interpregnancy interval of 24-36 months to reduce adverse child health outcomes. These data also bring into limelight the importance of exclusive breastfeeding to enhance proper nutritional approach and to prolong lactational amenorrhea. Health care system stakeholders would find this study interesting as a base for policy formulation and implementation.

Exposure to tobacco use in pregnancy and its determinants among sub-Saharan Africa women: analysis of pooled cross-sectional surveys.

Background: Tobacco use in any form and exposure to second-hand smoking are major threat to human health globally. Worse still, it is an important threat to the health of pregnant women and their children. However, the prevalence of tobacco use among pregnant women in sub-Saharan Africa countries remains uncertain. This study assessed the prevalence and factors of tobacco use among pregnant women in sub-Saharan Africa countries.Methods: This study utilized data from Demographic and Health Surveys (DHS) conducted in 31 sub-Saharan Africa countries between 2008 and 2017, comprising 44,715 pregnant women (aged 15-49 years). We calculated sampling weights to account for differentials in probabilities of selection and estimated proportions and 95% CIs for tobacco use in pregnant women across various countries. The factors associated with tobacco use were examined using multivariable binary logistic regression models at a significant level of 5%.Results: Prevalence of tobacco use among pregnant women was ∼2%. In Madagascar, the prevalence of tobacco use was 11.0%, while Lesotho (5.4%), Sierra Leone (4.8%), Namibia (4.4%) and Burundi (4.2%) were among the leading countries with high tobacco use pregnancy. The results of multivariable binary logistic regression model showed that pregnant women aged 25-34 years and ≥35 years were 2.26 times (OR = 2.26; 95%CI: 1.23, 4.15) and 2.45 times (OR = 2.45; 95%CI: 1.10, 5.45) as likely to use tobacco products, compared to women aged ≤24 years. The religious beliefs of pregnant women, who belong to other religion besides Islam, were 2.26 times as likely to use tobacco products compared to Christian women (OR = 2.26; 95%CI: 1.19, 4.31). In addition, pregnant women from households with middle-class wealth index had 64% reduction in tobacco products use among pregnant women, compared to those from poor households (OR = 0.36; 95%CI: 0.15-0.87).Conclusion: Overall, tobacco use in pregnant women in sub-Saharan Africa was low; however high prevalence estimates were noted in some countries. Prevention and management of tobacco use and exposure to second-hand smoke during pregnancy is crucial to protect maternal and child health in Africa continent. Pregnant women should be examined about their tobacco use preferably with a biochemical test and those who use tobacco products be encouraged to use cessation supports such as nicotine replacement therapy (NRT) where available. Health professionals should identify tobacco products users and advise to quit, most importantly by offer cessation support. When tobacco products users become pregnant, the health benefits of cessation of tobacco use should be well discussed with them especially during antenatal care. The tobacco use of other members of the household is also crucial, as having a user partner could widely predict the exposure of a pregnant woman.

Spatial analysis of child mortality and welfare differentials in South Africa: evidences from the 2011 Census

Background: Welfare differential is a common phenomenon among South African population which can be manifested in terms of various economic and health outcomes. Using child mortality (CM) as one of a key measure of the country's health system, the study attempted to show its spatial distribution and the association with economic disparities in the country.Methods: The study primarily aimed to derive estimates of CM rates for the municipalities and provinces of South Africa and assessed the results in relation to some welfare measures such as poverty and inequality. The estimation of CM rates was achieved through the use of direct synthetic cohort methods with Bayesian spatial smoothing. The smoothing process helped to generate accurate municipal level estimates of CM. The model utilized information from neighboring municipalities by controlling the effects of women's education and HIV. Results: It was found that there were clear spatial differentials of CM in the country, where at province level under-five mortality (U5M) rate (deaths per 1000 live births) ranges from 26 in Western Cape to 71 in KwaZulu-Natal. At municipal level, it ranges from 24 in City of Cape Town to 109 in uPhongolo. It was also shown that CM was higher in poorer and more unequal areas, although there were cases which had inverse relationship. For instance, several municipalities in Limpopo province scored relatively lower child mortality rates though the level of poverty is very high Conclusions: The study revealed significant spatial differentials of CM in the country, which were also associated with the level of poverty and income inequality. The findings may help local and national government to implement policies more effectively and make more focused decisions for a better health outcome

The effect of partners' education on women's reproductive and maternal health in developing countries.

The effect of partners' education on women's and children's health in developing countries has received relatively little attention to date. This study uses couple data from 37 recent Demographic and Health Surveys fielded in sub-Saharan African and Asian countries to assess the effect of partners' schooling on women's modern contraceptive use, frequency of antenatal care visits, and skilled birth attendance. Using multilevel logistic regressions, the study shows that partners' schooling has strong effects on their spouses' maternal healthcare utilization; especially when partners had secondary or higher levels of schooling. Overall, women whose partners had an above secondary level of education were 32% more likely to use modern contraceptives, 43% more likely to attend at least four antenatal care visits, and 55% more likely to deliver their most recent baby with a health professional, compared to women whose partner had no education, after controlling for individual and community-level covariates. Finally, interacting the partners' years of schooling, we found that an additional year of partners' schooling was 1) positively associated with modern contraceptive use when the women had low educational attainment (substitution effect), but negatively associated when women were better educated, 2) positively and increasingly associated with the frequency of antenatal care visits as women's education increased (multiplicative effect), and 3) positively and significantly associated with skilled birth attendance for less educated women (substitution effect). This study highlights the importance of male education in shaping their wife's health behaviours in developing countries and provides strong impetus for male education beyond primary level (as well as for women), something that has been neglected in past policy discourse.

Household environmental health hazards' effect on under-five mortality in sub-Saharan Africa: What can we learn from the Demographic and Health Survey?

Household environmental health hazards or simply household health hazards (HHH) are pathogens and chemicals in the household that can cause health problems. In this study, we assess their effect on under-five mortality (U5MR) in 12 sub-Saharan African countries, using data from the Demographic and Health Surveys. Referring to the principal component analysis approach, we measure the HHH by the following indicators: source of water and its location, type of toilet facility, flooring material, type of wall, type of roof and type of cooking fuel. In an unadjusted multilevel discrete-time hazard model, we find that HHH affect positively child mortality in 9 of the 12 countries, whereas this effect presented itself only in 4 countries when controlling for other covariates. However, using a model with interaction between the child's age and HHH, we find it interesting that increasing levels of the HHH are consistently associated with increasing risk of death during 24-59 months after birth in eight countries. Future researches are needed to decipher the mechanisms behind these findings, whether explained by the accumulation of hazardous environment in early childhood, or frequent contact with noxious environments at a later stage of childhood, or both.

Exploring the Paradox of Intimate Partner Violence and Increased Contraceptive Use in sub-Saharan Africa.

We question the positive effect of intimate partner violence on women's modern contraceptive use in sub-Saharan Africa found in previous studies. The explanations offered for this counter-intuitive result are either that women make greater efforts to avoid childbearing in conflictual relationships, or that endogeneity bias exists. Endogeneity bias stems from the inability of researchers to attribute a specific cause to one variable when they are unable to control for related missing covariates. Demographic and Health Survey data from 13 countries in sub-Saharan Africa provide evidence for the latter but not the former. Indeed, using simple probit regression models, we observe a positive relationship between intimate partner violence and modern contraceptive use in Burkina Faso, Mali, Nigeria, Tanzania, and Zimbabwe. This effect remains unchanged when controlling for various measures of women's autonomy in the household, showing that these two variables interact with contraceptive use independently. However, the use of recursive bivariate probit and Rosenbaum bounds sensitivity analysis to control for endogeneity biases erodes the initial positive effect in the five countries, although only partially in Burkina Faso. Our research shows that the previously reported findings arise from poor model specification and highlights the need for more appropriate data to assess the effect of intimate partner violence on modern contraceptive use in sub-Saharan Africa.

Gender inequality and the use of maternal healthcare services in rural sub-Saharan Africa.

In this study, we measure gender inequality both at individual level by women׳s household decision-making and at contextual level by permissive gender norms associated with tolerance of violence against women and assess their impact on maternal healthcare services utilisation in rural Africa. We apply multilevel structural equation modelling to Demographic and Health Survey (DHS) data from Ghana, Kenya, Tanzania and Uganda to gain better measure and effect of the gender norms construct. The results show that women in Ghana and Uganda, who live in areas where gender norms are relatively tolerant of violence against women, are less likely to use skilled birth attendants and timely antenatal care. In Tanzania, women who live in this type of environment are less likely to attend four or more antenatal visits. In contrast, the effects of a woman׳s decision-making authority on maternal health service use are less pronounced in the same countries.

Does antenatal care matter in the use of skilled birth attendance in rural Africa: a multi-country analysis.

While the importance of antenatal care for maternal and child health continues to be debated, several researchers have documented its impact on intermediate variables affecting survival such as birth weight. These studies have also highlighted the problems of causality that are typically not taken into account when estimating the effects of antenatal care on skilled birth attendance. In this study, we revisit this relation in the rural areas of four countries: Ghana, Kenya, Uganda and Tanzania. Using a structural equation modeling approach that corrects for endogeneity, in all four countries we find that the usual simpler probit (or logit) models tend to underestimate the direct effect of antenatal care on skilled birth attendance. Furthermore, in two of the countries, this estimated effect is mediated by the range of services offered to women during antenatal care. These results suggest that governments and NGOs should place more importance on the role of antenatal care providers and on the services they offer, in efforts to promote skilled birth attendance.

Correlates of and couples' concordance in reports of recent sexual behavior and contraceptive use.

This study uses couple-level data to measure couples' concordance of self-reported time since last coitus and of condom and other contraceptive use at last sexual intercourse among monogamous couples in Liberia (N = 1,673), Madagascar (N = 4,138), and Namibia (N = 588). The study also examines the characteristics associated with sexual behavior and contraceptive use occurring in the 28 days prior to the interviews among couples whose reports are concordant. Overall, our study finds less than 75 percent concordance in reporting of time since last coitus. Use of condoms and other contraceptives yielded fair (0.27) to substantial (0.67) agreement on the kappa index. Factors predicting a shorter time since last coitus among concordant couples in at least two of the countries included wealth, spousal age difference, education, and both partners wanting another child. The discordant reports of recent sexual behavior and contraceptive use suggest that caution should be exercised when inferring couples' behavior from the report of one spouse, that concordant reports should be examined when possible, that methodological changes to improve the validity of spousal reports should be pursued, and that family planning and HIV-prevention programs should target those groups found to be using condoms and other contraceptives less frequently, particularly poorer couples.