Potential effectiveness of Community Health Strategy to promote exclusive breastfeeding in urban poor settings in Nairobi, Kenya: a quasi-experimental study.

Early nutrition is critical for later health and sustainable development. We determined potential effectiveness of the Kenyan Community Health Strategy in promoting exclusive breastfeeding (EBF) in urban poor settings in Nairobi, Kenya. We used a quasi-experimental study design, based on three studies [Pre-intervention (2007-2011; n=5824), Intervention (2012-2015; n=1110) and Comparison (2012-2014; n=487)], which followed mother-child pairs longitudinally to establish EBF rates from 0 to 6 months. The Maternal, Infant and Young Child Nutrition (MIYCN) study was a cluster randomized trial; the control arm (MIYCN-Control) received standard care involving community health workers (CHWs) visits for counselling on antenatal and postnatal care. The intervention arm (MIYCN-Intervention) received standard care and regular MIYCN counselling by trained CHWs. Both groups received MIYCN information materials. We tested differences in EBF rates from 0 to 6 months among four study groups (Pre-intervention, MIYCN-Intervention, MIYCN-Control and Comparison) using a χ(2) test and logistic regression. At 6 months, the prevalence of EBF was 2% in the Pre-intervention group compared with 55% in the MIYCN-Intervention group, 55% in the MIYCN-Control group and 3% in the Comparison group (P<0.05). After adjusting for baseline characteristics, the odds ratio for EBF from birth to 6 months was 66.9 (95% CI 45.4-96.4), 84.3 (95% CI 40.7-174.6) and 3.9 (95% CI 1.8-8.4) for the MIYCN-Intervention, MIYCN-Control and Comparison group, respectively, compared with the Pre-intervention group. There is potential effectiveness of the Kenya national Community Health Strategy in promoting EBF in urban poor settings where health care access is limited.

Polygyny and reproductive behavior in sub-Saharan Africa: a contextual analysis.

In this paper I examine the effect of polygyny on aggregate reproductive behavior. I argue that within countries there exist different polygyny regimes, each exhibiting a unique reproductive pattern. Using the 1988/1989 Kenya Demographic and Health Survey (KDHS1) data, I identify three distinct regimes: low-polygyny, mid-polygyny, and high-polygyny regimes. The results of the bivariate and multivariate analyses reveal strong differences in reproductive preferences and behaviors across polygyny regimes. High-polygyny regimes, for instance, maintain a value orientation that favors and encourages high reproductive performance. The force of this pronatalism operates equally for men and women; but whereas men in this regime attain their reproductive goals by marrying multiple wives, women attain theirs by maximizing their reproductive capabilities. This maximization occurs through early initiation of sexual/reproductive activity, universal marriage and minimal interruption of marriage, nonuse of contraception within a union, and a positive attitude toward high fertility.

Estimates and explanations of gender differentials in contraceptive prevalence rates.

This article examines gender differentials in the reporting of contraceptive use and offers explanations regarding the sources of these differences. Data from five countries where DHS surveys were conducted recently among men and women are used in exploring these differences. The gap exists in all five countries, with men (or husbands) reporting greater practice of contraception than women (or wives). Results from the bivariate analysis suggest that the gap is attributable to polygyny and to gender differences in how the purpose of contraception is understood, rather than to male extramarital sexual relations. Additionally, gender differences in the definition of certain contraceptive methods and differences in the interpretation of questions about contraception contribute to the observed gap. These findings are also consistent with results of the multivariate analysis.

PIP: An analysis of Demographic and Health Survey data from Central African Republic, Ghana, Haiti, Kenya, and Zimbabwe revealed large gender differentials in the reporting of contraceptive use. In all five countries, men/husbands reported greater practice of contraception than women/wives. This gap ranged from 5 percentage points in Ghana to 25 percentage points in Kenya. The reporting of contraceptive use by only one partner of a couple may result from multiple sexual relationships, secret contraceptive use, or differential perceptions of what constitutes contraception. In these five countries, most of the gender gap was associated with condoms, abstinence, and (in Zimbabwe) the pill. An analysis of these differentials suggests more overreporting of current use among husbands than underreporting among wives. To the extent that polygynous men are more likely than their wives to report use of methods of which the wife would have equal or more knowledge than the husband (e.g., the pill), a polygyny effect is indicated in Zimbabwe. The results for Ghana and Kenya (the only surveys where information on knowledge of the ovulatory cycle is available for husbands) suggest the gap in reporting of periodic abstinence results mainly from husband's inaccurate knowledge of the reproductive cycle and this method. Finally, if all the gaps in condom use between marital partners are attributed to the assumption of the differential role of condom use (pregnancy and sexually transmitted disease prevention), this factor would explain 12% (Haiti) to 38% (Ghana and Zimbabwe) of the net gap in contraceptive prevalence rate estimates. More detailed questioning on the use of condoms and periodic abstinence would improve the reliability of these surveys.

The influence of spouses over each other's contraceptive attitudes in Ghana.

To what extent do spouses influence each other's reproductive goals? This question was investigated in Ghana with particular reference to family planning attitudes. Two mechanisms were identified as plausible explanations for why an individual's characteristics may affect a partner's beliefs and behavior. Quantitative evidence from the Ghana Demographic and Health Survey and qualitative information from focus-group research in Ghana were used in the analysis. Results from both data sources show that spousal influence, rather than being mutual or reciprocal, is an exclusive right exercised only by the husband. The study attributed the limited impact of family planning programs in Ghana and most of sub-Saharan Africa to the continued neglect of men as equal targets of such programs.

PIP: Quantitative information from 1010 matched husband-wife pairs derived from Ghana Demographic and Health Survey (DHS) data collected in 1988 and qualitative information from focus group research in Ghana were used in the analysis. 2 possible mechanisms that might affect a spouse's beliefs and/or behavior include the selection effect and the dominance effect. These 2 effects together comprise the spousal influence effect, which measures the extent to which an individual influences a spouse's reproductive attitudes. The distribution in the Ghana DHS of the individual variables for husbands and wives that were used in the regression analysis indicated that 60% of the men had some form of formal education, but only about 43% of their wives had gone to school. Among 54% of couples, both spouses approved of family planning (FP) and 21% disapproved of it. 49% of uneducated and 54% of educated wives of uneducated men, respectively, approved of FP. For husbands with primary education, this proportion rose to 62 and 82% for uneducated and educate wives. The net of the effects of education or being married to a man who wanted no more children increased a woman's odds of contraceptive approval by as much as 80%. For uneducated wives, the probability of contraceptive approval for those married to uneducated husbands was 0.48, compared with 0.65 for those married to husbands with only primary education. The corresponding probability for educated wives was 0.69 and 0.82, respectively. The probability of contraceptive approval among men with secondary or higher education increased from 0.84, if their wives were uneducated, to 0.88, if their wives had some formal education. Results from both data sources showed that spousal influence, rather than being mutual or reciprocal, was an exclusive right exercised only by the husband. The limited impact of FP programs in Ghana and most of sub-Saharan Africa was attributable to the continued neglect of men as equal targets of such programs.