Applying a deviance framework to understand modern contraceptive use in sub-Saharan Africa.

Tamar Goldenberg,Rob Stephenson,Philip Anglewicz

doi:10.1371/journal.pone.0216381

Abstract

Increasing modern contraceptive use is important for improving maternal and child health and achieving economic growth and development goals. However, pervasive high unmet need for modern contraceptives in sub-Saharan Africa warrants new understandings of the drivers of modern contraceptive use. A deviance approach (i.e., examining how women’s experiences/characteristics differ from other women in their community) provides an innovative framework for capturing heterogeneity among women in a community. This framework can inform public health programming by both exploring how women avoid adverse health outcomes and understanding the needs of harder-to-reach populations who may experience health risks, despite living in communities where others do not experience vulnerability. Using data from Demographic and Health Surveys from 29 sub-Saharan African countries, we examine how a woman’s deviation from community norms around socioeconomic characteristics and gender and fertility norms and behaviors is associated with modern contraceptive use. Random-effects logistic regression models were fitted for each country to examine relationships between modern contraceptive use and deviance. Some deviance factors were associated with modern contraceptive use in only a few countries, while others were significant across many countries. Cross-country consistency in the direction of the relationship between deviance and modern contraceptive use varied by the specific deviance factor, with some relationships being consistent across countries, and other relationships being more varied. For example, having more education than the community norm was associated with increased modern contraceptive use across countries; however, marrying older than other women in the community was associated with an increase in modern contraceptive use in some countries and a decrease in others. More work is needed to understand the role of deviance on modern contraceptive use; however, this study suggests that using context-specific deviance approaches may be important for further elucidating experiences of modern contraceptive use.

Highlights

Increasing the uptake of modern contraceptive use is an important strategy for improving maternal and child health [1, 2] and is a pathway to achieving developmental goals [3, 4]
The continuing high unmet need for modern contraceptives in sub-Saharan Africa warrants the need for new understandings of what facilitates or hinders modern contraceptive use in the region
Elfstrom and Stephenson (2012) found that community-level economic prosperity, gender norms, fertility norms, and community health knowledge were associated with modern contraceptive use in 21 African countries and that the effects of these community norms varied by country [11]

Summary

Introduction

Increasing the uptake of modern contraceptive use is an important strategy for improving maternal and child health [1, 2] and is a pathway to achieving developmental goals [3, 4]. This study found an association between modern contraceptive use and an individual’s deviation from what they perceived as ideal in the community (e.g., the likelihood of contraceptive use decreased if the perception of a community’s ideal for number of sons was greater than an individual’s actual number of sons). It may not be the characteristics of the community environment that shapes an individual’s modern contraceptive use, and how an individual deviates from their community’s norms and expectations, and how an individual perceives that deviation

Methods

Discussion

Conclusion