Prevalence and determinants of condom use among the youth in Malawi: evidence from the 2015/16 Malawi Demographic and Health Survey.

BACKGROUND: Unprotected sexual intercourse among the youth is common in Malawi. This has led to high rates of sexually transmitted infections (STIs), Human Immunodeficiency Virus (HIV), and unplanned pregnancies. The study investigated the prevalence and the determinants of male and female condom use for the prevention of sexually transmitted infections and unplanned pregnancies among the youth in Malawi. METHODS: The 2015/2016 Malawi Demographic and Health Survey (MDHS) data were used among 15 to 24-year-old male and female who had sexual intercourse four months preceding the survey. A total of 1543 male and 5143 female were selected from 3226 male and 10,367 female respectively and analyzed with SPSS version 20 using.descriptive, bivariate, and logistic regression. RESULTS: The study found a low prevalence (27.1%) of condom use among the youth in the last sexual intercourse within four months before the survey. More male (55.8%) used condoms than female (18.5%). The significant predictors of condom use among the male and female youth were: being sexually active (OR 0.39 CI 0.33-0.47), aged 20-24 (OR 0.80 CI 0.68-0.95), ever married (OR 0.07 CI 0.06-0.08), coming from central region (OR 0.56 CI 0.40-0.77), and southern region (OR 0.59 CI 0.42-0.83), residing in the rural area (OR 0.74 CI 0.61-0.90) and ever tested of HIV (OR 1.29 CI 1.03-1.55). CONCLUSION: Having established low prevalence of condom use among the youth in Malawi, there is a need to scale up programs and policies that target the youth to practice safe sex, which will assist in addressing the challenges of STIs, including HIV, and preventing unplanned pregnancies in Malawi.

Seeking maternal health care in rural Nigeria: through the lens of negofeminism.

BACKGROUND: Feminist scholarship is acutely aware that health is not dependent on behavioural choices alone but on interlocking social determinants that affect people's capacity to lead healthy lives. Women are situated within social structures that impact their health. but there is limited engagement with interpretive tools such as feminist theories that centre the realities of African women, particularly in the context of maternal health. It is imperative that women's control over their reproductive health and autonomy in seeking care, particularly skilled maternal healthcare are understood within this context. This study seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. Feminist scholarship acknowledges that women are situated within social structures that impact their health. Therefore, this paper seeks to examine pregnant women's socio-cultural realities in a Nigerian context and in congruence with articulations of African feminism. METHOD: This is a cross-sectional qualitative study of a total of 64 participants: 39 women and 25 men in Ewato and Okpekpe communities, two Local Government Areas of Edo State in southern Nigeria. The study presents findings from eight sex-and-age desegregated focus group discussions. This study reports on emergent data related to women's decision-making in accessing skilled maternal care. Data were transcribed and translated to English. Using the NVivo 1.6 software, data were coded and analyzed using a conventional approach to content analysis. RESULTS: Findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism's concepts of alliance, community and connectedness were highlighted through men's constructive involvement in maternal health. Furthermore, women were shown to maneuver patriarchal norms to gain control of their healthcare decisions. CONCLUSION: This study offers a different narrative from the dominant view of non-Western women, specifically African women, as oppressed passive victims who are ineffectual in taking charge of their health. From the perspective of negofeminism, women navigate patriarchal environments to yield the best possible maternal health outcomes. The current study can be useful in informing policy and programming that acknowledges women's social embeddedness.

A qualitative investigation into pregnancy experiences and maternal healthcare utilisation among adolescent mothers in Nigeria.

BACKGROUND: Adolescent maternal healthcare utilisation is low in Nigeria, and little is understood about the pregnancy experiences and drivers of maternal healthcare utilisation among of adolescent girls. This study investigated the pregnancy experiences and maternal healthcare utilisation among adolescent mothers across Nigeria. METHODS: The study used the qualitative design. Urban and rural communities in Ondo, Imo and Katsina states were selected as research sites. Fifty-five in-depth interviews were conducted with adolescent girls who were currently pregnant or had given birth to a child recently, and nineteen in-depth interviews were conducted with older women who were either mothers or guardians of adolescent mothers. Additionally, key informant interviews were conducted with five female community leaders and six senior health workers. The interviews were transcribed, and resulting textual data were analysed via framework thematic analysis using a semantic and deductive approach, with the aid of NVivo software. RESULTS: The findings showed that the majority of unmarried participants had unintended pregnancies and stigma against pregnant adolescents was common. Social and financial support from family members, maternal support and influence, as well as healthcare preferences shaped by cultural and religious norms were the major drivers of maternal healthcare use among adolescent mothers, and the choice of their healthcare providers. CONCLUSIONS: Interventions to support adolescent mothers and increase maternal healthcare utilisation among them must focus on ensuring the provision of social and financial support for adolescent mothers, and should be culturally sensitive.

Exploring barriers and facilitators to integrated policy formulation and implementation of family planning and urban development programmes in Nigeria.

BACKGROUND: As more people now live in urban areas than in rural communities in Nigeria, urban development (UD) requires urgent policy and programmatic attention. Although the population factor has been identified as important to achieving national development goals, and evidence suggests that meeting the family planning (FP) and reproductive health (RH) needs of the vulnerable urban population can serve as an important recipe for achieving population growth rates consistent with building sustainable, habitable and prosperous urban settings, FP remains a neglected subject in UD initiatives in Nigeria. This study explored barriers and facilitators in achieving integrated policy formulation and implementation of FP and UD programmes in Nigeria. METHODS: We conducted key informant interviews (n = 37) with relevant FP/RH and UD stakeholders in Ibadan and Kaduna-two megacities that have undergone several UD and FP intervention programmes in the south and north of Nigeria. The sample size was determined by data saturation. Data were organized using ATLAS.ti and NVivo 12 software, and analysis was conducted using a thematic approach. RESULTS: We found that relevant government agencies largely work in silos. Other identified barriers to integrated policy formulation/implementation of FP and UD programmes in Nigeria include lack of knowledge about the FP-UD nexus between professionals, ineffective implementation and monitoring of existing guidelines, lack of policy documentation that clearly links FP and UD, and frequent transfer of government stakeholders. Notwithstanding the identified barriers, the study established ways of achieving synergy between FP and UD sectors, including stakeholder engagement, intersectoral collaborations, sensitization and publicity, roundtable discussion, interdisciplinary research, conferences and other interactive and knowledge-sharing fora. CONCLUSIONS: We conclude that addressing barriers to the intersectoral linkage between FP and UD is fundamental to achieving sustainable urbanization in Nigeria.

Understanding gender dynamics in mHealth interventions can enhance the sustainability of benefits of digital technology for maternal healthcare in rural Nigeria.

Introduction: Nigeria faces enormous challenges to meet the growing demands for maternal healthcare. This has necessitated the need for digital technologies such as mobile health, to supplement existing maternal healthcare services. However, mobile health programs are tempered with gender blind spots that continue to push women and girls to the margins of society. Failure to address underlying gender inequalities and unintended consequences of mobile health programs limits its benefits and ultimately its sustainability. The importance of understanding existing gender dynamics in mobile health interventions for maternal health cannot be overstated. Objective: This study explores the gender dimensions of Text4Life, a mobile health intervention for maternal healthcare in Edo State, Nigeria by capturing the unique perspectives of women who are the primary beneficiaries, their spouses who are all men, and community leaders who oversaw the implementation and delivery of the intervention. Method: This qualitative study used criterion-based purposive sampling to recruit a total of 66 participants: 39 women, 25 men, and two ward development committee chairpersons. Data collection involved 8 age and sex desegregated focus group discussions with women and men and in-depth interviews with ward development committee chairpersons in English or Pidgin English. Translated and transcribed data were exported to NVivo 1.6 and data analysis followed a conventional approach to thematic analysis. Results: Women had some of the necessary resources to participate in the Text4Life program, but they were generally insufficient thereby derailing their participation. The program enhanced women's status and decision-making capacity but with men positioned as heads of households and major decision-makers in maternal healthcare, there remained the possibility of deprioritizing maternal healthcare. Finally, while Text4Life prioritized women's safety in various contexts, it entrenched systems of power that allow men's control over women's reproductive lives. Conclusion: As communities across sub-Saharan Africa continue to leverage the use of mHealth for maternal health, this study provides insights into the gender implications of women's use of mHealth technologies. While mHealth programs are helpful to women in many ways, they are not enough on their own to undo entrenched systems of power through which men control women's access to resources and their reproductive and social lives.

Exploring underutilization of skilled maternal healthcare in rural Edo, Nigeria: A qualitative study.

INTRODUCTION: Existing studies have acknowledged the underutilization of skilled maternal healthcare services among women in rural Nigeria. Consequently, women in rural areas face a disproportionate risk of poor health outcomes including maternal morbidity and mortality. Addressing the challenge of non-use of skilled maternal healthcare in rural areas necessitates the involvement of multi-stakeholders across different sectors who have vital roles to play in improving maternal health. This study explores the factors contributing to the non-use of maternal healthcare services in rural areas of Edo, Nigeria from the perspectives of community elders and policymakers. METHODS: In this qualitative study, data were collected through 10 community conversations (group discussions) with community elders each consisting of 12 to 21 participants, and six key informant interviews with policymakers in rural areas of Edo State, Nigeria. Participants were purposefully selected. Conversations and interviews occurred in English, Pidgin English and the local language; lasted for an average of 9 minutes; were audio-recorded and transcribed to English. Data were manually coded, and data analysis followed the analytical strategies for qualitative description including an iterative process of inductive and deductive approaches. RESULTS: Policymakers and community elders attributed the non-use of maternal health services to poor quality of care. Notions of poor quality of care included shortages in skilled healthcare workers, apathy and abusive behaviours from healthcare providers, lack of life-saving equipment, and lack of safe skilled pregnancy care. Non-use was also attributed to women's complex utilization patterns which involved a combination of different types of healthcare services, including traditional care. Participants also identified affordability and accessibility factors as deterrents to women's use of skilled maternal healthcare. CONCLUSION: The emerging findings on pregnant women's combined use of different types of care highlight the need to improve the quality, availability, accessibility, and affordability of skilled maternal care for rural women in Nigeria.

Lived experiences of recovered COVID-19 persons in Nigeria: A phenomenological study.

BACKGROUND: Numerous publications have documented the mode of transmission and prevention of COVID-19 but little or no evidence exists on the experiences of people who survived the infection. OBJECTIVE: This study explored the specific experiences of persons who were infected with COVID-19, but have recovered completely. A secondary objective was to identify essential elements in the lived experiences of such persons, which would be useful in designing appropriate policies and programs for managing the virus in Nigeria. METHOD: The data were collected using in-depth interviews with 21 persons who were diagnosed with the virus and recovered. The data were transcribed and analyzed qualitatively using NVivo software. The experiences of the survivors of COVID-19 were examined under six themes: compliance with prevention measures before being infected, perceptions on how they contracted the virus, the symptoms they experienced, the management of the disease, their experiences with the healthcare system, their emotional experiences, and their recommendations on specific strategies to prevent and manage the virus based on their experiences. RESULTS: The commonly perceived means of contracting the virus were through colleagues, patients, and friends who were infected. The most commonly experienced symptoms were anosmia and fever. The health providers were described as courteous but some of the respondents observed avoidance and fear. Not all the interviewees knew the drugs they were treated with, but some, particularly the medical personnel, identified hydroxychloroquine, azithromycin, vitamin C, Augmentin, among others. Some of the participants used herbal remedies. While some respondents recounted good experiences in the isolation centre, others had unpleasant experiences. Direct and indirect encounters which were perceived as stigmatizing and discriminatory were reported by some respondents. CONCLUSION: We conclude that persons who recovered from COVID-19 in Nigeria had varied experiences relating to the mode of infection, the clinical features, methods of treatment, and psychosocial effects of the virus. These experiences would be useful for designing and implementing appropriate interventions, policies, and programs for managing the pandemic in the country.

Demand-side barriers to access and utilization of skilled birth care in low and lower-middle-income countries: A scoping review of evidence.

A myriad of demand-side factors hamper childbearing women from utilizing needed skilled birth care in low and lower-middle-income countries. The objective of this scoping review is to explore the extent of evidence available on the subject matter and identify knowledge gaps in the reviewed literature. We used the Arksey and O'Malley scoping review framework as a guide for this review and conducted searches on four electronic databases: PubMed, Embase, PsycInfo and Google Scholar. Eligible studies were those published in English and French languages between 2013 and 2022 that discussed demand-side barriers to access and utilization of skilled birth care in low and lower-middle-income countries. Five themes emerged as major types of barriers influencing the utilization of skilled birth care in low and lower-middle-income countries. These were socio-economic and socio-demographic status of women; lack of access to healthcare facilities; cost of healthcare services; ineffective healthcare systems and socio-cultural/religious factors. The identified gap in the literature was the lack of studies on the influence of women's behaviour and psychological traits as barriers to the use of skilled birth care among reviewed publications. To design effective interventions, it is important to consider all influential factors that determine the utilization of skilled birth care by women in low-resource settings.

Enablers and barriers to the acceptability of mHealth for maternal healthcare in rural Edo, Nigeria.

Objective: Acceptability has become a key consideration in designing, implementing and evaluating digital health interventions. Current evidence points to acceptability as a crucial factor in sustaining mobile health programs for maternal health across sub-Saharan Africa particularly in Nigeria where the burden of maternal mortality is high. This paper describes the enablers and barriers to the acceptance of Text4Life, a mobile phone-based health intervention that extends maternal healthcare services to rural areas of Edo State Nigeria. Method: This is a cross-sectional qualitative study of women who used Text4Life, their spouses who were all men and Ward Development Committee chairpersons who oversaw the implementation of Text4Life. This study was set in Etsako East and Esan Central Local Government Areas of Edo State, Nigeria. Between September 2021 and January 2022, eight focus groups were conducted with 64 participants: 39 women and 25 men. Two in-depth interviews were conducted with Ward Development Committee chairpersons. Data collection was conducted in English and Pidgin English. Discussions and interviews were digitally recorded and translated to English from Pidgin English where necessary. Data analysis followed a mainly deductive approach to thematic analysis, however, emergent information from the data was also considered and reported. Results: The results show that participants' positive attitudes towards the intervention, the involvement of the community, participants' understanding of the intervention, and perceived effectiveness of the Text4Life program were enablers to women's acceptance of Text4Life and enablers to Ward Development Committee chairpersons' assistance with the program. On the other hand, limited resources and a clash with the community's value system presented barriers to the acceptability of the Text4Life program. Conclusion: Our findings demonstrate the importance of alleviating the burdens associated with participating in mobile health interventions while noting that the risk of obstructing the gains from mobile health interventions is high if plans for sustaining it are not incorporated early enough in the design phase.

"We have either obsolete knowledge, obsolete equipment or obsolete skills": policy-makers and clinical managers' views on maternal health delivery in rural Nigeria.

OBJECTIVE: The objective of this paper is to explore policy-makers and clinical managers' views on maternal health service delivery in rural Nigeria. DESIGN: This is a qualitative study using key informant interviews. Participants' responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery. SETTING: The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria. PARTICIPANTS: The study participants consisted of 13 key informants who are policy-makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter. RESULTS: Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents' notion of quality of service delivery encompassed factors such as patient-provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints. CONCLUSION: This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies.

Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria.

BACKGROUND: The uptake of skilled pregnancy care in rural areas of Nigeria remains a challenge amid the various strategies aimed at improving access to skilled care. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country's very high maternal mortality rates. The perceptions of key stakeholders on the use of skilled care will provide a broad understanding of factors that need to be addressed to increase women's access to skilled pregnancy care. The objective of this study was therefore, to explore the perspectives of policymakers and health workers, two major stakeholders in the health system, on facilitators and barriers to women's use of skilled pregnancy care in rural Edo State, Nigeria. METHODS: This paper draws on qualitative data collected in Edo State through key informant interviews with 13 key stakeholders (policy makers and healthcare providers) from a range of institutions. Data was analyzed using an iterative process of inductive and deductive approaches. RESULTS: Stakeholders identified barriers to pregnant women's use of skilled pregnancy care and they include; financial constraints, women's lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system. Study participants suggested health insurance schemes, community support for skilled pregnancy care, favourable financial and governance policies, as necessary to facilitate women's use of skilled pregnancy care. CONCLUSIONS: This study adds to the literature, a rich description of views from policymakers and health providers on the deterrents and enablers to skilled pregnancy care. The views and recommendations of policymakers and health workers have highlighted the importance of multi-level factors in initiatives to improve pregnant women's health behaviour. Therefore, initiatives seeking to improve pregnant women's use of skilled pregnancy care should ensure that important factors at each distinct level of the social and physical environment are identified and addressed.

Community perceptions on causes of high dizygotic twinning rate in Igbo-Ora, South-west Nigeria: A qualitative study.

BACKGROUND: Dizygotic (DZ, non-identical) twinning rates vary widely across different regions in the world. With a DZ twinning rate of 45 per 1000 live births, Igbo-Ora Community in South-west Nigeria has the highest dizygotic (DZ) twinning rate in the world. Although several postulations exist on the causes of high DZ twinning rates in Igbo-Ora, no study has yet been conclusive on a definite causative agent. OBJECTIVE: Using qualitative methods, this study explored the perceptions and beliefs of Igbo-Ora residents about the causes of high DZ twinning rates. METHODS: Focus group discussion sessions and key informant interviews were organized among fathers and mothers of twins, those without twins, and health care providers. Key informant interviews were also held with persons considered to be custodians of culture who may have knowledge relevant to twinning such as traditional rulers, and traditional birth attendants; as well as health care providers, mothers and fathers of twins, and adult twins. RESULTS: The results showed three factors featuring as the leading perceived causes of twinning in the community. These included twinning being an act of God, hereditary, and being due to certain foods consumed in the community. Contrary to reports that the consumption of a species of yam (Dioscorea rotundata) may be responsible for the DZ twinning in this Community; yam was not prioritized by the respondents as associated with twinning. In contrast, participants repeatedly mentioned the consumption of "ilasa" a soup prepared with okra leaves (Abelmoschus esculenta) with water that is obtained from the community, and "amala" a local delicacy produced from cassava (Manihot esculenta) as the most likely dietary factors responsible for twinning in the community. CONCLUSION: Since the same foods are consumed in neighboring communities that have lower rates of twinning, we conjecture that nutritional and other environmental factors may produce epigenetic modifications that influence high DZ twinning rates in Igbo-Ora community. We conclude that more directed scientific studies based on these findings are required to further elucidate the etiology of the high rate of DZ twinning in Igbo-Ora.

Characteristics of men who engage in cross-generational sexual behaviour in Nigeria.

Cross-generational sexual relationships are a major route of transmitting HIV and STI between older and younger generations. However, previous research has focused mainly on the young women in these relationships. This study examined the characteristics of men engaging in non-marital sexual relationships with girls aged 15-19 in Nigeria. The data were drawn from the 2013 Nigeria Demographic and Health Survey, and the analysis was restricted to a sub-sample of 7557 men aged 30-49 who were sexually active in the 12 months prior to the survey. Data analysis was carried out using frequency distributions, chi-squared tests of association and binary logistic regression. It was found that 9.5% of men aged 30-49 reported engaging in cross-generational sexual relationships. Also, being older (OR = 0.35), married (OR = 0.37), having secondary or higher education (OR = 0.70; 0.59) and having sexual debut between ages 18 and 30 (OR = 0.73) were associated with a lower likelihood of having cross-generational sexual relationships. However, Muslim men (OR = 2.10), men from Igbo (OR = 1.90), Hausa/Fulani (OR = 8.47) and Northern and Southern minority tribes (OR = 4.73; 2.49), men living in rural areas (OR = 1.34), men who were over the age of 30 at sexual debut (OR = 2.67) and those with 2-4 and 5 or more lifetime sexual partners (OR = 1.43; 1.58) were significantly more likely to engage in cross-generational sexual relationships. Addressing the challenges of cross-generational sexual relationships can be an effective strategy to reduce the menace of HIV and STI transmission. Men who have low education, those aged 30-34 years, those who initiated sex at an older age, rural dwellers and those who have had several lifetime sexual partners need to be targeted while designing and implementing programmes and policies to reduce cross-generational sexual relationships in Nigeria. These interventions must also take into account the religious and cultural attitudes towards cross-generational sexual relationships, and further investigations should identify men's motives for engaging in the practice.

Women at risk: Gender inequality and maternal health.

Gender inequality has been documented as a key driver of negative health outcomes, especially among women. However, studies have not clearly examined the role of gender inequality in maternal health in an African setting. Therefore, the authors of this study examined the role of gender inequality, indicated by lack of female autonomy, in exposing women to maternal health risk. Data were obtained from the 2007 Zambia Demographic and Health Survey on a weighted sample of 3,906 married or partnered women aged 15-49 years. Multivariable analyses revealed that low autonomy in household decision power was associated with maternal health risk (Odds Ratio (OR) = 1.52, p < .001). Autonomy interacted with household wealth showed that respondents who were in the wealthier households and had low autonomy in household decision power (OR = 2.03, p < .05) were more likely to be exposed to maternal health risk than their counterparts who had more autonomy. Efforts to lower women's exposure to maternal mortality and morbidity in Zambia should involve interventions to alter prevailing gender norms that limit women's active participation in decisions about their own health during pregnancy and delivery.

Health effects of single motherhood on children in sub-Saharan Africa: a cross-sectional study.

BACKGROUND: Although progress has been made toward reducing child morbidity and mortality globally, a large proportion of children in sub-Saharan Africa still die before age five and many suffer chronic malnutrition. This study investigated the influence of single motherhood on stunting and under-5 mortality in Cameroon, Nigeria and Democratic Republic of the Congo (DRC). Particular attention was paid to the influence of mother's economic resources, parental care and health behaviour on the difference in children's health in single and two-parent families. METHODS: Data were obtained from most recent Demographic and Health Surveys in Cameroon (2011), Nigeria (2008) and DRC (2007). The sample included women aged 15-49 years old and their under-5 children 11,748 in Cameroon, 28,100 in Nigeria, and 8,999 in DRC. Logistic regression and Cox proportional hazard analysis were used to estimate stunting and under-5 mortality, respectively. RESULTS: The result showed that compared with children whose mothers were in union, children of single mothers who were not widows were more likely to be stunted (OR 1.79 p < 0.01 in Cameroon and 1.69 p < .01 in DRC). Economic resources and parental care significantly influenced the higher odds of stunting in single mother households in Cameroon and DRC. Relative to children of mothers in union, the risk of under-5 mortality in single mother families was higher in the three countries (HR 1.40 p < .05 in Cameroon, 1.27 p < 0.10 in DRC, 1.55 p < .01 in Nigeria). Economic resources, parental care and health behaviour accounted for the difference in Nigeria and Cameroon; in DRC, only economic resources had marginal influence. CONCLUSIONS: Single motherhood is a risk factor for children's nutritional status and chances of survival before age 5 years in sub-Saharan Africa. To achieve improved reduction in children's exposure to stunting and under-5 mortality, there is the need for public health interventions targeted at single mother households in sub-Saharan Africa.