Contraception In sub-Saharan Africa Research Articles

75. Extreme Precipitation Events and Adolescent Contraception in Sub-Saharan Africa

75. Extreme Precipitation Events and Adolescent Contraception in Sub-Saharan Africa

Intention to Use Postpartum Contraceptive and Its Determinants in Sub-Saharan Africa: Systematic Review and Meta-Analysis.

The postpartum period is a critical moment for the delivery of family planning services. However, the utilization of family planning among women in sub-Saharan Africa is not optimal. Therefore, the current study aims to assess the intention to use postpartum contraception and its related determinants in the sub-Saharan African setting. This study utilized a comprehensive search strategy that involved searching several databases, including PubMed, Scopus, EMBASE, Science Direct, Google Scholar, and online research institutional repository homes. Data extraction was performed using Microsoft Excel, and statistical analysis was conducted using STATA software (version 14). To assess publication bias, a forest plot, Begg's rank test, and Egger's regression test were employed. Heterogeneity was evaluated using the I2 statistic, and an overall estimated analysis was conducted. In addition, sensitivity analysis was performed to examine the impact of each study on the overall estimate. Meta-regression analysis was conducted to identify potential sources of heterogeneity. Finally, the pooled odds ratio (OR) for associated factors was calculated. After reviewing 1,321 articles, 14 studies were deemed eligible for inclusion in this meta-analysis. The final analysis comprised a total of 39,936 study participants. The overall intention to use postpartum contraception in sub-Saharan Africa was found to be 62.21% (95% confidence interval [CI]: 55.532-68.875). In subgroup analysis, the highest prevalence of intention was observed in Ethiopia (66.71%; 95% CI: 50.36-83.05), while the lowest prevalence was reported in Ghana (59.39%; 95% CI: 50.22-68.57). The intention to use contraception was found to be 67.22% (95% CI: 62.37-72.07) and 54.53% (95% CI: 46.61-62.45) for institutional and community-based studies, respectively. Maternal educational status (OR = 1.22; 95% CI: 1.09-1.38) and husbands' approval of contraceptive use (OR = 2.395; 95% CI: 1.256-4.567) were identified as predictors of intention to use postpartum contraception. In conclusion, the results of our study show a comparatively low intention toward the use of postpartum contraception, in contrast to findings reported in other countries. As such, we recommend that stakeholders prioritize maternal education and encourage male partner involvement in family planning decisions.

Glucocorticoids and medroxyprogesterone acetate synergize with inflammatory stimuli to selectively upregulate CCL20 transcription

The pro-inflammatory cytokine, chemokine (C-C motif) ligand 20 (CCL20), is emerging as a therapeutic target for immune-based therapies. Cooperative regulation of CCL20 by glucocorticoids and progestins used in endocrine therapy and pro-inflammatory mediators could modulate immune function and affect disease outcomes. We show that glucocorticoids as well as medroxyprogesterone acetate (MPA), the progestin widely used in injectable contraception in sub-Saharan Africa, cooperate with pro-inflammatory mediators to upregulate CCL20 protein and/or mRNA in human peripheral blood mononuclear cells (PBMCs) and human cervical cell lines. Changes in CCL20 mRNA levels were shown to be synergistic, as assessed by Chou analysis, cell- and gene-specific and to involve transcriptional regulation, with a requirement for a nuclear factor kappa B (NF-κB) site and glucocorticoid receptor (GR) involvement. The novel results suggest a mechanism whereby MPA, like glucocorticoids, may impact inflammation both systemically and in the genital tract in patients using MPA and/or glucocorticoid therapy.

Provision of injectable contraceptives by community health workers in sub-Saharan Africa: a systematic review of safety, acceptability and effectiveness

BackgroundInjectable contraceptives are the most popular method of contraception in sub-Saharan Africa (SSA), but their availability in clinical settings has been severely limited, despite the scarcity of health care providers and limited access to health facilities. WHO and USAID have endorsed the community-based distribution of injectable contraceptives as a promising option for improving access to family planning services and expanding the method mix for women who want to limit the number of births. Studies have shown that community health workers (CHWs) can provide women with injectable contraceptives that meet acceptable quality standards. The goal of this study is to identify, evaluate and synthesize evidence supporting the use of community-based administration of injectable contraceptives in SSA. MethodsThis review's guidance was based on a previously developed protocol. Nine international electronic databases and the websites of organizations known to support community-based reproductive health initiatives in SSA were searched systemically. Experts in this area were also contacted for the identification of unpublished literature and ongoing studies. The reference lists of eligible studies were reviewed. The Effective Public Practice Project tool was used to assess the quality and risk of bias in eligible studies. Data were extracted and analysed using a custom data extraction form and a narrative synthesis. ResultsThe search strategy identified a total of 1358 studies with 12 studies meeting the inclusion criteria. One unpublished study was provided by an expert making a total of 13 studies. The results showed that irrespective of the study designs, well-trained CHWs can competently administer injectable contraceptives safely and community-based delivery of injectable contraceptives is acceptable in SSA. Also, the use of community health workers in the provision of depot-medroxyprogesterone acetate expanded access to inhabitants of hard-to-reach areas and led to an overall uptake of injectable contraceptives as well as family planning. Studies that compared CHWs to clinic-based providers revealed equivalent or higher levels of performance in favour of CHWs. ConclusionsThe CHWs can competently provide injectable contraceptives within SSA communities if appropriately trained and supervised. Hence, SSA policymakers should give this initiative due consideration as a way of improving access to family planning services.

Determinants of modern contraceptive utilization among married women in sub-Saharan Africa: multilevel analysis using recent demographic and health survey

BackgroundFamily planning is a low-cost, high-impact public health and development strategy to improve child and maternal health. However, there is a lack of evidence on modern contraceptive use and determinants in sub-Saharan Africa. Hence, this study aimed at determining the pooled prevalence and determinants of modern contraceptive utilization among married women of sub-Saharan Africa.MethodsThirty-six sub-Saharan African countries' demographic and health survey (DHS) data were used for pooled analysis. A total weighted sample of 322,525 married women was included. Cross tabulations and summary statistics were done using STATA version 14 software. The pooled prevalence of modern contraceptive utilization with a 95% Confidence Interval (CI) was reported. Multilevel regression analysis was used to identify the determinants of modern contraceptive use among married women. Four models were fitted to select the best-fitted model using the Likelihood Ratio (LLR) and Deviance test. Finally, the model with the highest LLR and the smallest deviance was selected as the best-fitted model.ResultsThe pooled estimate of modern contraception use in sub–Saharan African countries was 18.36% [95% CI: 18.24, 18.48], with highest in Lesotho (59.79%) and the lowest in Chad (5.04%). The odds of modern contraception utilization were high among women living in East Africa [AOR = 1.47 (1.40, 1.54)], urban areas [AOR = 1.18 (1.14, 1.24)], and women with primary [AOR = 1.49 (1.44, 1.55)] and secondary and above educational level [AOR = 1.66 (1.58, 1.74)]. Moreover, husbands with primary educational level [AOR = 1.38 (1.33, 1.42)], middle [AOR = 1.17, (1.14, 1.21)], rich wealth status [AOR = 1.29 (1.25, 1.34)], media exposure [AOR = 1.25 (1.22, 1.29)], and postnatal care (PNC) utilization [AOR = 1.25 (1.22, 1.29)] had higher odds of modern contraceptive utilization compared with their counter parts. Furthermore, deliver at health facility [AOR = 1.74 (1.69, 1.79)] and birth order 2–4 [AOR = 1.36 (1.31, 1.41)] had higher odds of modern contraceptive utilization. On the other hand, women living in Central [AOR = 0.23 (0.22, 0.24)], Western regions [AOR = 0.46 (0.40, 0.54)], women who decided with husband [AOR = 0.90 (0.87, 0.93)], and decisions by husband alone [AOR = 0.73 (0.71, 0.75)] decreased the odds of modern contraceptive utilization.ConclusionThe uptake of modern contraception in sub-Saharan Africa is low. Modern contraceptive utilization is affected by different factors. More attention needs to be given to rural residents, illiterate women, and communities with low wealth status.

The demand for family planning to limit childbearing satisfied with female permanent contraception in Sub-Saharan Africa: a meta-analysis of demographic and health surveys

Objective To assess the percentage of the demand for family planning to limit childbearing satisfied with female permanent contraception (FPC) in sub-Saharan Africa (SSA) and the disparities by sociodemographic characteristics (educational status, wealth, religion, and area of residence). Study design This study was a secondary data analysis of Demographic and Health Surveys conducted in SSA. Countries with a standard DHS conducted between 2010 and 2019 were eligible for inclusion. We performed a meta-analysis with a random-effects model to estimate the percentage of the demand for family planning to limit childbearing satisfied with FPC and differences by sociodemographic characteristics. Results Demographic and Health Surveys (2010–2018) of 33 countries, with a total of 67,476 women with a demand for family planning to limit childbearing were included in this study. The pooled percentage of the demand for family planning to limit childbearing satisfied with FPC was 4.13% (95%CI = 2.43–6.23%, I = 99.36%, p = 0.001). The percentage ranged from 0.26% (95%CI = 0.10–0.67) in Angola to 26.85% (95%CI = 25.86–27.85%) in Malawi. The demand for family planning to limit childbearing satisfied with FPC was significantly higher in women from rich households (PR = 1.41, 95%CI = 1.21–1.65, p < 0.001). However, the differences by educational status, religion, or area of residence were not statistically significant. Conclusions The uptake of FPC among women with a demand for family planning to limit childbearing is low in many countries in SSA. Multilevel interventions are needed to address the barriers that may be limiting informed and voluntary uptake of FPC in SSA.

Antigen Presenting Cells Link the Female Genital Tract Microbiome to Mucosal Inflammation, With Hormonal Contraception as an Additional Modulator of Inflammatory Signatures.

The microbiome of the female genital tract (FGT) is closely linked to reproductive health outcomes. Diverse, anaerobe-dominated communities with low Lactobacillus abundance are associated with a number of adverse reproductive outcomes, such as preterm birth, cervical dysplasia, and sexually transmitted infections (STIs), including HIV. Vaginal dysbiosis is associated with local mucosal inflammation, which likely serves as a biological mediator of poor reproductive outcomes. Yet the precise mechanisms of this FGT inflammation remain unclear. Studies in humans have been complicated by confounding demographic, behavioral, and clinical variables. Specifically, hormonal contraception is associated both with changes in the vaginal microbiome and with mucosal inflammation. In this study, we examined the transcriptional landscape of cervical cell populations in a cohort of South African women with differing vaginal microbial community types. We also investigate effects of reproductive hormones on the transcriptional profiles of cervical cells, focusing on the contraceptive depot medroxyprogesterone acetate (DMPA), the most common form of contraception in sub-Saharan Africa. We found that antigen presenting cells (APCs) are key mediators of microbiome associated FGT inflammation. We also found that DMPA is associated with significant transcriptional changes across multiple cell lineages, with some shared and some distinct pathways compared to the inflammatory signature seen with dysbiosis. These results highlight the importance of an integrated, systems-level approach to understanding host-microbe interactions, with an appreciation for important variables, such as reproductive hormones, in the complex system of the FGT mucosa.

Sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa: Evidence from demographic and health surveys.

IntroductionContraception plays a significant role in fertility regulation and determines the reproductive health rights of women. Studies in other parts of the world have found that sexual violence has negative effects on unmet need for contraception. There has not been any study on the association between these two phenomena in sub-Saharan Africa using current nationally-representative survey data. We investigated the association between sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa.Materials and methodsThis study was based on secondary datasets from 26 sub-Saharan African countries’ Demographic and Health Surveys conducted between 2010 and 2018. A sample of 101,968 women in sexual unions (married and cohabiting) with complete information on sexual violence and all the variables of interest were included in the analyses. Both bivariate and multilevel logistic regression analyses were carried out to examine the association between sexual violence and unmet need for contraception. Other individual and contextual level socio-economic and demographic variables were considered as covariates. Crude odds ratios [cOR] and adjusted odds ratios [aOR] with their corresponding 95% confidence intervals [CI], signifying precision, were presented. Level of statistical significance was declared at p<0.05.ResultsThe overall prevalence of sexual violence and unmet need for contraception in the 26 sub-Saharan African countries were 8.7% and 28.7% respectively. Experience of sexual violence within the last 12 months resulted in 10% increase in unmet need for contraception [OR = 1.10, CI = 1.03–1.14] and 5% increase in unmet need for contraception after controlling for individual and contextual level factors [aOR = 1.05, CI = 1.01–1.11]. With the individual level factors, women with 4 or more births [aOR = 4.85, CI = 4.41–5.33], those cohabiting [aOR = 1.43, CI = 1.37–1.47], those in female headed households [aOR = 1.22, CI = 1.18–1.27] and those who watched television at least once a week [aOR = 1.12, CI = 1.07–1.16] had higher odds of unmet need for family planning. However, those aged 30–34 [aOR = 0.56, CI = 0.52–0.61], those with secondary/higher level of education [AOR = 0.80, CI = 0.77–0.84], those who read newspaper less than once a week [aOR = 0.75, CI = 0.71–0.79] and those who listened to radio at least once a week [aOR = 0.94, CI = 0.90–0.97] had lower odds of unmet need for contraception. In terms of the contextual factors, women in rural areas [aOR = 0.87, CI = 0.84–0.91] and those in the richest wealth quintile households [aOR = 0.80, CI = 0.75–0.85] had lower odds of unmet need for contraception.ConclusionOur study has shown an association between sexual violence and unmet need for contraception in sub-Saharan Africa. Experiencing sexual violence increases the likelihood of unmet need for contraception in sub-Saharan Africa. It is also worthy to note that having four or more children, cohabiting with a male partner, and living in female-headed households are some of the key variables associated with unmet need for contraception in sub-Saharan Africa. Our study recommends that, successful contraceptive initiatives should focus on reducing sexual violence, while taking into consideration other significant factors that increase unmet need for contraception. Meanwhile, in doing this, contextual factors ought to be prioritised.

Improving Adolescent Access to Contraception in Sub-Saharan Africa: A Review of the Evidence.

Global commitments to and support for sexual and reproductive health (SRH) have increased over the past 10 years. Adolescent access to contraception has emerged as a crucial area of focus within this agenda, particularly in sub-Saharan Africa (SSA), where there is the greatest unmet need for contraception. Yet there is little synthesized knowledge around adolescents' use and knowledge of, and access to contraception in SSA. This review summarizes and analyzes literature on the subject in order to determine implications for policy and program development, and to guide future research. The majority of existing research focuses on South Africa, with numerous studies from East Africa also present. Most of this research is qualitative, with few mixed method studies, and only one randomized control trial of an intervention. Findings from multiple countries confirm that adolescents in SSA have a significant unmet need for contraception. Most adolescents get their information about contraception from the media or peers. Persistent myths regarding effectiveness and side effects, as well as cultural and gender norms, impede access to and demand for contraception. Other determinants of access and use include education level and socio-economic status. As a result, intervention evaluations note that cultural barriers and socio-economic conditions limit SRH outcomes.

Integration of contraceptive services into anticoagulation management services improves access to long-acting reversible contraception

ObjectiveIntegration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use. Study designWe performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3 months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. ResultsOf 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use. ConclusionIntegrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management. ImplicationsA model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.

Prospects for Fertility Decline in Africa

Prospects for Fertility Decline in Africa

Trend in the use of modern contraception in sub-Saharan Africa: does women's education matter?

BackgroundExisting literature revealed positive association between women's education and modern contraceptive use in sub-Saharan Africa (SSA). Overall modern contraception prevalence (MCP) and proportion of women with formal education have increased in region. However, little is known about how much the change in the prevalence of modern contraceptive methods is relative to the compositional change in population and how much of the change is actually due to increases in the number of women adopting the new behavior. Objective(s)This study aims to (1) describe trends in modern contraception prevalence by female education; and (2) identify the source of changes in modern contraceptive use by educational attainment (changes in structure or in population behavior). Study DesignThis is a cross-sectional study using Demographic and Health Surveys from 27 SSA countries where at least two comparable surveys have been conducted. ResultsOverall modern contraception prevalence (MCP) has increased in SSA over the study period. The ongoing increase in the contraceptive use is due to changes in behavior consistent with the ongoing family planning promotion over the past 30 years. By contrast, an increase in the proportion of women with secondary education does not explain the change in MCP in most SSA countries. Conclusion(s)To achieve universal access to family planning, efforts in promoting female education should be complemented with economic, cultural and geographical access to MCP. Household-based sensitization, general hospitals, mobile family planning clinics, and community-based distributors of modern contraceptive methods are key strategies to improve access to modern contraceptive use. ImplicationFindings from this study suggest that countries should combine social investments, including health services and education, with family planning programs using reproductive health services, mobile family planning clinics and community-based distributors of modern contraceptive methods. Therefore, governments' legislation measures that promote universal secondary education as well as universal access to modern contraception can be put in place.

Fourteen million women with limited options: HIV/AIDS and highly effective reversible contraception in sub-Saharan Africa

An estimated 14 million women in sub-Saharan Africa are HIV infected and these women deserve access to evidence-based family planning services. Increasing contraceptive use in HIV-infected women can reduce the numbers of unintended pregnancies and thus reduce maternal death and vertical transmission of HIV. A delicate balance exists between risks associated with pregnancy and any theoretical risks of acquiring, transmitting or worsening HIV attributable to using a contraceptive. This commentary reviews interactions between hormonal, intrauterine and barrier contraception in HIV-infected women, with a focus on sub-Saharan Africa. Unfortunately, the evidence on these interactions to guide family planning providers is limited and more research in this area is urgently needed.

Tolerance and Acceptability of an Efavirenz-Based Regimen in 740 Adults (Predominantly Women) in West Africa

In sub-Saharan Africa, the position of efavirenz as a first-line nonnucleoside reverse transcriptase inhibitor remains to be discussed. We report here the 6-month efficacy and tolerance of an efavirenz-containing highly active antiretroviral therapy in a large cohort of HIV-1-infected adults. Seven hundred forty highly active antiretroviral therapy-naive adults (74% women; 14% with positive serum HBs antigen and 21% with abnormal baseline transaminase value) started zidovudine + lamivudine + efavirenz. At month 6, 1.2% of them were dead, 87% had undetectable viral load, and 7% had abnormal transaminase value. From months 1 to 6, the percentage of women who were actually using a contraceptive method increased from 58% to 80% (65% intramuscular progesterone and 35% oral estrogen/progesterone combination). The incidence of pregnancy was 2.6/100 woman-years (95% confidence interval, 0.67-4.51), and 86% of pregnant women voluntarily interrupted the pregnancy with no intervention on our part. Before month 6, only 0.8% of patients permanently discontinued efavirenz for severe adverse effects (neurologic, 0.6%; cutaneous, 0.1%; and hepatic, 0.1%). The leading cause of severe morbidity was tuberculosis. Considering the very high hepatic and cutaneous tolerance, efavirenz could be considered as a valuable first-line drug for women of childbearing age who agree to use contraception in sub-Saharan Africa, provided that the risk of teratogenicity should be closely monitored.

Developing Countries Show Sizable Cross-National Variations in Unmet Need, Demand for Contraception

This article summarizes a recent report on demand for contraception among 27 developing countries during 1990-94. Unmet need for contraceptive services is based on data from Demographic and Health Surveys. Unmet demand is determined by whether women were pregnant or amenorrheic whether women reported a mistimed or unwanted pregnancy or whether nonpregnant fecund women wished to postpone or avoid further childbearing. Researchers found that unmet need was higher in sub-Saharan African countries (29%) than other countries (19%). The reasons for contraceptive use varied by region. Demand for contraception in sub-Saharan Africa was mainly for limiting childbearing rather than ending childbearing. The range in demand for contraception was from 23% of currently married women in Niger to 81% in Peru. At least 62% of unmet demand for contraception was met in the sample countries with the exception of sub-Saharan countries and Pakistan. Unmet need for contraception varied from 14% or lower in Colombia to 36% or higher in Kenya Malawi or Rwanda. Asian unmet need varied widely. The lowest levels of unmet need were in Latin America and the Caribbean. Unmet need for spacing of 70% or more was found in 10 of the 14 sub-Saharan African countries (Burkina Faso Cameroon Malawi Namibia Niger Nigeria Senegal Sudan Tanzania and Zambia). Variation in unmet need for spacing varied by womens age. In most countries women aged younger than 30 years had greater need for contraception for spacing. Unmet need for limiting rose with number of children particularly after four children. Unmet need was found to be higher among rural women in countries other than sub-Saharan African ones and Pakistan. Unmet need tended to decline with increased levels of education among women in countries other than sub-Saharan African ones. About 37% of unmet need was due to women being pregnant or amenorrheic. The proportion with unmet need who were not sexually active ranged from 4% in Rwanda to 38% in Burkina Faso. Levels of unmet need among the never-married and the formerly married were also estimated.