Food insecurity and adverse pregnancy outcomes among rural Malawian women.

OBJECTIVE: To investigate whether food insecurity is associated with adverse pregnancy outcomes such as miscarriage, stillbirth, and neonatal mortality among women in rural Malawi. METHODS: We analyzed data from the baseline (July 2014 to February 2015) and follow-up (January 2018 to May 2018) waves of a longitudinal study of reproductive-age women in rural Malawi. We sampled women from villages from the catchment area of a community hospital in rural Lilongwe district of Malawi using stratified cluster sampling. We classified women as food secure or insecure at baseline. Using unadjusted and adjusted log-binomial models, we used baseline data to examine the cross-sectional association between food insecurity and ever experiencing an adverse pregnancy outcome. We used baseline and follow-up data to assess the longitudinal association between food insecurity and experiencing a new adverse pregnancy outcome during follow-up. In a subgroup analysis, we repeated the longitudinal analysis after restricting the sample to women who had no adverse pregnancy outcomes at baseline. RESULTS: We observed no significant cross-sectional association between baseline food insecurity and ever experiencing an adverse pregnancy outcome (adjusted prevalence ratio: 1.09; 95% confidence interval [CI]: 0.78-1.53). Baseline food insecurity was not associated with experiencing a new adverse pregnancy outcome during follow-up (adjusted risk ratio [aRR]: 1.14, 95% CI: 0.60-2.20) or in the subgroup analysis (aRR: 1.52, 95% CI: 0.78-2.96). CONCLUSIONS: While food insecurity is a critical issue, in this cohort of rural Malawian women, food insecurity was not associated with adverse pregnancy outcomes.

Are rural Malawian women using their preferred contraceptive method and that of their male partners?

OBJECTIVES: To measure the agreement between women's current contraceptive use and her preferred method, as well as her partner's preferred method. STUDY DESIGN: We used the fourth wave of survey data (2017-2018) from the Umoyo wa Thanzi (UTHA) cohort study of sexual and reproductive health decision making. The prevalence of concordance between women's current method and her preferred method was calculated (n = 818). Among partnered women, we calculated prevalence of concordance between women's current method and her partner's preferred method (n = 719). We used multivariate logistic regression analyses to assess the relationship between women's characteristics and the outcomes. RESULTS: Despite high prevalence of modern contraceptive use (74.4%), many women were using methods that did not match their preferences (62.6%) or those of their partners (62.3%). Fifty-five percent of women with preference-use discordance preferred methods that were more effective than theirs. Satisfaction with current family planning choice (adjusted odds ratio [aOR], > 5.5 each) and pregnancy desires (aOR, >1.5 each) were strong predictors of both concordance between women's current method and her preferred method and her partner's preferred method. Women who reported higher sexual frequency in past month had elevated odds of concordance between her current and preferred method (aOR: 1.97 for 9+times in past months) than women who had not had sex. CONCLUSIONS: Many Malawian women are not using methods they or their partners prefer. Women desiring pregnancy, women reporting infrequent sex, and women who are not satisfied with their method are likely to prefer a different method than the one they are currently using. IMPLICATIONS: Understanding women's preferences can assist with family planning service provision. Health care providers and researchers should consider the specific methods that women and their partners prefer to use, besides whether they are using any method.

Reducing underreporting of abortion in surveys: Results from two test applications of the list experiment method in Malawi and Senegal.

BACKGROUND: Accurately measuring abortion incidence poses many challenges. The list experiment is a method designed to increase the reporting of sensitive or stigmatized behaviors in surveys, but has only recently been applied to the measurement of abortion. To further test the utility of the list experiment for measuring abortion incidence, we conducted list experiments in two countries, over two time periods. MATERIALS AND METHODS: The list experiment is an indirect method of measuring sensitive experiences that protects respondent confidentiality by hiding individual responses to a binary sensitive item (i.e., abortion) by combining this response with answers to other non-sensitive binary control items. Respondents report the number of list items that apply to them, not which ones. We conducted a list experiment to measure cumulative lifetime incidence of abortion in Malawi, and separately to measure cumulative five-year incidence of abortion in Senegal, among cisgender women of reproductive age. RESULTS: Among 810 eligible respondents in Malawi, list experiment results estimated a cumulative lifetime incidence of abortion of 0.9% (95%CI: 0.0, 7.6). Among 1016 eligible respondents in Senegal, list experiment estimates indicated a cumulative five-year incidence of abortion of 2.8% (95%CI: 0.0, 10.4) which, while lower than anticipated, is seven times the proportion estimated from a direct question on abortion (0.4%). CONCLUSIONS: Two test applications of the list experiment to measure abortion experiences in Malawi and Senegal likely underestimated abortion incidence. Future efforts should include context-specific formative qualitative research for the development and selection of list items, enumerator training, and method delivery to assess if and how these changes can improve method performance.

The Enduring Case for Fertility Desires.

Persistently high levels of unintended fertility, combined with evidence that over- and underachieved fertility are typical and not exceptional, have prompted researchers to question the utility of fertility desires writ large. In this study, we elaborate this paradox: widespread unintendedness and meaningful, highly predictive fertility desires can and do coexist. Using data from Malawi, we demonstrate the predictive validity of numeric fertility timing desires over both four-month and one-year periods. We find that fertility timing desires are highly predictive of pregnancy and that they follow a gradient wherein the likelihood of pregnancy decreases in correspondence with desired time to next birth. This finding holds despite the simultaneous observation of high levels of unintended pregnancy in our sample. Discordance between desires and behaviors reflects constraints to achieving one's fertility and the fluidity of desires but not their irrelevance. Fertility desires remain an essential-if sometimes blunt-tool in the demographers' toolkit.

Community Influences on Female Genital Mutilation/Cutting: A Comparison of Four Francophone West African Countries.

Despite long-term efforts to encourage abandonment of female genital mutilation/cutting (FGMC), the practice remains widespread globally. FGMC is situated in specific social and historical contexts, and both prevalence and rates of decline vary widely across practicing countries. However, cross-national comparative research on the determinants of FGMC is sparse. This paper adds to the limited body of rigorous, theoretically grounded quantitative studies of FGMC and takes a step toward advancing cross-national comparative research. We apply an integrated theoretical framework that brings together norms-based and gender-based explanations of community-level influences on FGMC. We test this framework in four francophone West African countries, drawing on comparable nationally representative data from the Demographic and Health Surveys in Burkina Faso (2010), Côte d'Ivoire (2011-2012), Guinea (2012), and Mali (2012-2013). Results show that community-level FGMC norms and community-level gendered opportunities are associated with girls' risk of FGMC, but that the direct and moderating associations vary qualitatively across countries. Our findings highlight the contribution of context-specific social and institutional processes to the decline or persistence of FGMC.

Changing Childbearing Norms During an Era of ART Expansion in Malawi, 2009 to 2015.

Community norms shape the childbearing goals and behaviors of persons living with HIV/AIDS (PLWHA) but little is known about how norms around HIV-positive childbearing have changed with expanded access to antiretroviral treatment (ART). We analyze data collected in 2009 and 2015 by the Tsogolo la Thanzi (TLT) project-a longitudinal, population-based study of young adults in southern Malawi. Respondents were asked about the acceptability of childbearing using vignettes that varied a hypothetical couple's HIV status and number of children. We assess mean differences in support for childbearing over time and by respondent gender and serostatus. The acceptability of childbearing for PLWHA increased dramatically over the 6-year period; however, support levels varied based on a couple's current number of children and whether they were seropositive concordant or discordant. Differences in attitudes by gender and HIV status diminished over time, pointing to a population-level convergence in norms about acceptable childbearing.

An Assessment of Risk Factors for Herpes Simplex Virus Type 2 Infection in Malawian Women Using 2 Classifications for the HerpeSelect 2 Test.

BACKGROUND: The HerpeSelect 2 ELISA IgG test for herpes simplex virus type 2 (HSV-2) infection is widely used, convenient, and inexpensive. However, it has been shown to have lower specificity among populations in Sub-Saharan Africa compared with HSV-2 tests regarded as criterion standards. METHODS: In 2016, we collected blood and survey data from 248 women participating in a community-based cohort study in rural Malawi (the Umoyo wa Thanzi project). Using multinomial logistic regression accounting for village-level clustering, we examined unadjusted associations between select demographic and sexual risk factors and HSV-2 serostatus. Because increasing the index value cutpoint for a positive result improves specificity, we coded HSV-2 serostatus in 2 ways: the manufacturer's recommended cutpoints (<0.9, negative; 0.9-1.1, indeterminate; >1.1, positive) and modified cutpoints with improved specificity (<0.9, negative; 0.9-3.5, indeterminate; >3.5, positive). We aimed to investigate whether associations between select risk factors and HSV-2 serostatus varied under the 2 approaches. RESULTS: The prevalence of HSV-2 in this sample was 67% under the manufacturer's cutpoint and 22% under the modified cutpoint. Under both cutpoints, age, household size, number of marriages, and number of pregnancies were associated with HSV-2-positive serostatus. Using modified cutpoints, current bacterial vaginosis (odds ratio [OR], 3.17; 95% confidence interval [CI], 1.35-7.47), partner concurrency (OR, 4.88; 95% CI, 2.54-9.37) and unsure about partner concurrency (OR, 1.91; 95% CI, 1.08-3.38) were associated with HSV-2 seropositivity. Household size, education, and marital status were the only variables significantly associated with indeterminate HSV-2 serostatus using the modified cutpoints. CONCLUSION: HSV-2-focused interventions informed by identifying individuals likely to have or acquire HSV-2 must be aware that different target populations may emerge depending on which cutpoints are adopted.

Scarcity mindset in reproductive health decision making: a qualitative study from rural Malawi.

Poverty has widespread impacts on health. In dealing with resource scarcity, individuals' thoughts are narrowed to address immediate resource limitations, thus crowding out other information, a phenomenon called the scarcity mindset. To assess for indication of a scarcity mindset in sexual and reproductive decision making in rural Malawi, a setting with extreme resource scarcity, we collected qualitative data in the form of eight focus group discussions and 28 semi-structured, in-depth interviews with women and men of varying ages and marital status. Participants, who were of low socioeconomic status, described constant tradeoffs that they made to secure their daily needs. They articulated both the challenges of supporting many children and the need to bear many children to guarantee their own future support. While participants described wealthy people as being concerned with preserving resources (often through the practice of limiting childbearing), they described poor people as working to increase their probability of success against an uncertain economic future (without due consideration of contraceptive behaviours). We found qualitative evidence that a scarcity mindset may influence reproductive decision making among women and men in rural Malawi and may preclude the use of contraception in low-resource settings.

Community Influences on Female Genital Mutilation/Cutting in Kenya: Norms, Opportunities, and Ethnic Diversity.

Female genital mutilation/cutting (FGMC) is a human rights violation with adverse health consequences. Although prevalence is declining, the practice persists in many countries, and the individual and contextual risk factors associated with FGMC remain poorly understood. We propose an integrated theory about contextual factors and test it using multilevel discrete-time hazard models in a nationally representative sample of 7,535 women with daughters who participated in the 2014 Kenya Demographic and Health Survey. A daughter's adjusted hazard of FGMC was lower if she had an uncut mother who disfavored FGMC, lived in a community that was more opposed to FGMC, and lived in a more ethnically diverse community. Unexpectedly, a daughter's adjusted FGMC hazard was higher if she lived in a community with more extrafamilial opportunities for women. Other measures of women's opportunities warrant consideration, and interventions to shift FGMC norms in more ethnically diverse communities show promise to accelerate abandonment.

The Relationship Between Ambivalent and Indifferent Pregnancy Desires and Contraceptive Use Among Malawian Women.

CONTEXT: Pregnancy ambivalence and pregnancy indifference are thought to be associated with nonuse of contraceptives, but their conceptualization and measurement vary, and their relationship to contraceptive use in developing countries is poorly understood. METHODS: Data from the Umoyo wa Thanzi research program in rural Lilongwe, Malawi, were used to classify the pregnancy desires of 592 women aged 15-39 as antinatal, pronatal, ambivalent or indifferent, according to both the women's desire to conceive and their desire to avoid pregnancy. Logistic regression was used to assess the relationship between each of the four pregnancy desire categories and use of modern contraceptives. RESULTS: Overall, 12% of women were classified as ambivalent, 32% as indifferent, 44% as antinatal and 12% as pronatal. In the logistic regression analysis, the odds of contraceptive use among women with indifferent pregnancy desires (having both a desire not to avoid pregnancy and a desire not to conceive) were twice those of women with pronatal desires (odds ratio, 2.2) and were similar to those among women with antinatal desires (2.7). In contrast, the odds of contraceptive use among women with ambivalent pregnancy desires (having both a desire to avoid pregnancy and a desire to conceive) did not differ from those of women who had pronatal desires. CONCLUSIONS: Ambivalent and indifferent pregnancy desires are common in Malawi and are associated with modern contraceptive use in different ways. Understanding the complex nature of pregnancy desires may be valuable in improving family planning programs.