Contraceptive use and method mix dynamics in Sub-saharan Africa: time trends and the influence of the HIV pandemic.

BACKGROUND: Contraceptive use dynamics continue to be of priority in sub-Saharan Africa because of persistently high levels of fertility. This paper focuses on the use of barrier versus non-barrier contraceptive use in sub-Saharan Africa hypothesizing that the HIV pandemic in the region would be responsible for increases in the use of barrier methods over time. METHODS: This paper uses Demographic and Heath Survey (DHS) data from 32 countries to conduct extensive analysis of trends in contraceptive use and method mix that refers to the distribution of contraceptive methods use among the sexually active population. The paper examines how contraceptive method mix dynamics have changed over time and whether the trends differ by marital status and gender using cross-tabulations. It furthers examines the determinants of method choice using logistic regressions. RESULTS: The findings indicate that the use of barrier methods, most markedly for unmarried women and men, rose substantially between the late 1980s and late 2000s in the region in tandem with trends in HIV prevalence. The results further show marked differences in method mix by gender with men being more likely to report barrier method use than women. CONCLUSIONS: The findings indicate shifting preferences in contraceptive choice. The time trend analyses highlight the importance of expanding the focus of contraceptive use studies beyond women in this context as the study finds differing trends for men.

Phenotyping urban built and natural environments with high-resolution satellite images and unsupervised deep learning.

Cities in the developing world are expanding rapidly, and undergoing changes to their roads, buildings, vegetation, and other land use characteristics. Timely data are needed to ensure that urban change enhances health, wellbeing and sustainability. We present and evaluate a novel unsupervised deep clustering method to classify and characterise the complex and multidimensional built and natural environments of cities into interpretable clusters using high-resolution satellite images. We applied our approach to a high-resolution (0.3 m/pixel) satellite image of Accra, Ghana, one of the fastest growing cities in sub-Saharan Africa, and contextualised the results with demographic and environmental data that were not used for clustering. We show that clusters obtained solely from images capture distinct interpretable phenotypes of the urban natural (vegetation and water) and built (building count, size, density, and orientation; length and arrangement of roads) environment, and population, either as a unique defining characteristic (e.g., bodies of water or dense vegetation) or in combination (e.g., buildings surrounded by vegetation or sparsely populated areas intermixed with roads). Clusters that were based on a single defining characteristic were robust to the spatial scale of analysis and the choice of cluster number, whereas those based on a combination of characteristics changed based on scale and number of clusters. The results demonstrate that satellite data and unsupervised deep learning provide a cost-effective, interpretable and scalable approach for real-time tracking of sustainable urban development, especially where traditional environmental and demographic data are limited and infrequent.

Partner support and women's contraceptive use: insight from urban poor communities in Accra, Ghana.

BACKGROUND: Despite the benefits associated with contraceptive use, there is a low prevalence of contraceptive use in sub-Saharan Africa and Ghana. Previous studies have partly and consistently attributed the low prevalence of contraceptive use to partner opposition. However, little is known about the influence of men in contraceptive related choices of their partners, particularly within the context of urban poverty. This study examines the influences of partners on women's contraceptive choices. METHODS: The study utilized a cross-sectional household survey data of 1578 currently married women and women in a union of reproductive ages 16-44 years. Women who were pregnant and those trying to be pregnant were excluded from the analysis. The dependent variables for the study were current use of any contraceptive method, types of contraceptive methods and types of modern contraceptive methods. The independent variable for the study was a woman's report of partner support in contraceptive related choices. A binary logistic regression model was used to examine the associations between partner support in contraceptive related choices and contraceptive use of women. RESULTS: The results of the study show that partner support of contraceptive related choices has a significant influence on contraceptive use of women. Women who indicated support from their partners were more likely to be current users of any contraceptive method, yet were less likely to use modern contraceptive methods. CONCLUSION: The study highlights the need to involve men in family planning programs and research, as well as educating them on the various contraceptive modern methods and the side effects.

Quantifying within-city inequalities in child mortality across neighbourhoods in Accra, Ghana: a Bayesian spatial analysis.

OBJECTIVE: Countries in sub-Saharan Africa suffer the highest rates of child mortality worldwide. Urban areas tend to have lower mortality than rural areas, but these comparisons likely mask large within-city inequalities. We aimed to estimate rates of under-five mortality (U5M) at the neighbourhood level for Ghana's Greater Accra Metropolitan Area (GAMA) and measure the extent of intraurban inequalities. METHODS: We accessed data on >700 000 women aged 25-49 years living in GAMA using the most recent Ghana census (2010). We summarised counts of child births and deaths by five-year age group of women and neighbourhood (n=406) and applied indirect demographic methods to convert the summaries to yearly probabilities of death before age five years. We fitted a Bayesian spatiotemporal model to the neighbourhood U5M probabilities to obtain estimates for the year 2010 and examined their correlations with indicators of neighbourhood living and socioeconomic conditions. RESULTS: U5M varied almost five-fold across neighbourhoods in GAMA in 2010, ranging from 28 (95% credible interval (CrI) 8 to 63) to 138 (95% CrI 111 to 167) deaths per 1000 live births. U5M was highest in neighbourhoods of the central urban core and industrial areas, with an average of 95 deaths per 1000 live births across these neighbourhoods. Peri-urban neighbourhoods performed better, on average, but rates varied more across neighbourhoods compared with neighbourhoods in the central urban areas. U5M was negatively correlated with multiple indicators of improved living and socioeconomic conditions among peri-urban neighbourhoods. Among urban neighbourhoods, correlations with these factors were weaker or, in some cases, reversed, including with median household consumption and women's schooling. CONCLUSION: Reducing child mortality in high-burden urban neighbourhoods in GAMA, where a substantial portion of the urban population resides, should be prioritised as part of continued efforts to meet the Sustainable Development Goal national target of less than 25 deaths per 1000 live births.

Methods women use for induced abortion and sources of services: insights from poor urban settlements of Accra, Ghana.

BACKGROUND: Increasing access to safe abortion methods is crucial for improving women's health. Understanding patterns of service use is important for identifying areas for improvement. Limited evidence is available in Ghana on factors associated with the type of method used to induce abortion. This paper examined the methods and sources of services used for abortion by women living in poor urban settings of Accra. METHODS: Data are from a survey that was conducted in 2018 among 1233 women aged 16-44 years who reported ever having had an induced abortion. We estimated a multinomial logistic regression model to examine factors associated with the type of abortion methods women used. We further generated descriptive statistics for the source of abortion services. RESULTS: About 50% women used surgical procedures for their last abortion, 28% used medication abortion (MA), 12% used other pills, 3% used injection, and 7% used non-medical methods. However, nearly half (46%) of the women who terminated a pregnancy within the year preceding the survey used medication abortion (MA), 32% used surgical procedures, while 5% used non-medical methods. Women who terminated a pregnancy within three years preceding the survey had a 60% lower chance of using surgical procedures if they did not use MA compared to those who terminated a pregnancy more than 3 years before the survey (Relative Risk Ratio [RRR] 0.4; 95% CI 0.3-0.5). The vast majority (74%) of women who used MA obtained services from pharmacies. CONCLUSIONS: The use of MA pills to terminate pregnancies has increased in recent years in Ghana and these pills are mostly accessed from pharmacies. This suggests a need for a review of the national guidelines to include pharmacists and chemists in the provision of MA services.

Dynamics of Emergency Contraceptive Use in Accra, Ghana.

Recent data suggest increasing rates of emergency contraception (EC) use in Ghana, particularly in urban areas. In 2018, we collected survey data from 3,703 sexually experienced women aged 16-44 years living in low-income settlements of Accra. We estimated the prevalence of lifetime and current EC use. Multivariate logistic regression was used to assess factors associated with current use of EC. Retrospective monthly calendar data on contraceptive use were analyzed to identify patterns of EC use, including repeat and continuous use, and uptake of other contraceptive methods in the months following EC use. Nearly 15 percent of women had ever used EC. About half of recent EC users (52 percent) used EC for at least four months cumulatively within a 12-month window. There was no evidence of adoption of other modern methods in the months after using EC. Our results suggest that EC is a common method for pregnancy prevention in Accra, particularly among young, unmarried, highly educated women. Counseling on effective EC use and strategies that promote equitable access should be prioritized.

Contraceptive method use, discontinuation and failure rates among women aged 15-49 years: evidence from selected low income settings in Kumasi, Ghana.

BACKGROUND: This paper provides estimates of contraceptive discontinuation and failure rates in a poor urban setting in Ghana. Contraceptive use is for the purposes of preventing unintended or mistimed pregnancies. Unfortunately, evidence abounds in many parts of the world where there is considerable levels of contraceptive failure and high levels of discontinuation resulting in unintended pregnancies. METHODS: We estimated discontinuation rates during a 12-month period since starting use by applying single and multiple decrement life table methods to the contraceptive calendar data collected in a survey of women in reproductive age of 15-49 years. RESULTS: Modern contraceptive method use was estimated to be 13.7% at the time of the survey. The results show that contraceptive method discontinuation vary markedly by type of contraceptive method but are high for almost all methods, except for implants (23.7%). Discontinuation rate for emergency contraception was estimated at 88.5%, withdrawal 87.6%, and male condom use 80.9%. However, discontinuation rates were moderately high for rhythm (63.6%), pills (65.6%) and injectables (56%). In terms of failure rates, overall contraceptive failure for all methods was estimated at 7.9%. The factors significantly associated with method failure include being within age bracket 40-44 years (OR = 0.3, p < 0.05), having secondary/higher education (OR = 0.4, p < 0.01), belonging to the richest household wealth scale (OR = 3.3, p < 0.01), currently in union with a partner (OR = 2.2, p < 0.01), and using contraceptive methods such as rhythm (OR = 5.6, p < 0.01) and withdrawal (OR = 3.7, p < 0.01). On the flip side, the odds for method discontinuation were significantly higher for women in their 20s and mid 30s, formerly in union (OR = 1.9, p < 0.05) and use of withdrawal method (OR = 1.4, p < 0.05) and lower for women formerly in union (OR = 0.4, p < 0.01) and use of implants (OR = 0.2, p < 0.01) and injectables (OR = 0.6, p < 0.01). CONCLUSION: While contraceptives use is low, both discontinuation and failure rates are high and variable among different methods. Failure and discontinuation rates are lowest for long-acting methods such as implants while higher failure rates are more prevalent among women who rely on withdrawal and the rhythm methods.

Contraception before and after induced abortion: Trajectories of women in selected urban-poor settlements of Accra, Ghana.

This paper examined women's pre- and post-induced abortion contraceptive use and predictors of post-abortion modern contraceptive uptake in selected poor settlements of Accra, Ghana. Data from a cross-sectional study of 251 women aged 16-44 years were used. Patterns of contraceptive use were analysed descriptively while the predictors of modern contraceptive use in the month following induced abortion were examined using a binary logistic regression model. Majority of women (60%) were not using any method of contraception when they became pregnant before their abortion. Just over 30% of these women switched to using any method in the month immediately after abortion (22% modern and 9% traditional). Women who had became pregnant while using a modern method before their abortion had higher odds of using a modern method post-abortion than women who had not been using any method of contraception when they became pregnant. Following induced abortion, many women remained at potential risk of future unintended pregnancy. Our findings suggest the need for improved contraceptive counselling for women who seek abortion services, both during post-abortion care for facility-based abortions or at the time of obtaining medication abortion pills for those who are self-managing their abortion.