Immaculate conceptions in sub‐Saharan Africa: Exploratory analysis of inconsistencies in the timing of first sexual intercourse and first birth

Abstract

Survey data from a number of developing countries show that a considerable proportion of parous women report that they had their first birth one or more years before they first had sexual intercourse. In this paper, I use data from eight African Demographic and Health Surveys to explore factors that contribute to cross‐national differentials in the prevalence of these “immaculate conceptions.” The results suggest that this data problem results not only from recall errors, but also from the fact that some respondents misinterpret the question on first sexual intercourse and report their age at the onset of intercourse with either their first or current husband rather than their age at sexual initiation.     

When ancient meets modern: the relationship between postpartum non-susceptibility and contraception in sub-Saharan Africa

Extended durations of postpartum non-susceptibility (PPNS) comprising lactational amenorrhoea and associated taboos on sex have been a central component of traditional reproductive regimes in sub-Saharan Africa. In situations of rising contraceptive prevalence this paper draws on data from the Demographic Health Surveys to consider the neglected interface between ancient and modern methods of regulation. The analysis reports striking contrasts between countries. At one extreme a woman's natural susceptibility status appears to have little bearing on the decision to use contraception in Zimbabwe, with widespread 'double-protection'. By contrast, contraceptive use in Kenya and Ghana builds directly onto underlying patterns of PPNS. Possible explanations for the differences and the implications for theory and policy are discussed.     

Greater than expected fertility decline in Ghana: untangling a puzzle

This study examines fertility decline that is larger than expected on the basis of recorded increases in contraceptive prevalence in Ghana. The primary sources of data are three Demographic and Health Surveys (DHS) conducted in the country in 1988, 1993 and 1998. First, the trend in fertility and contraceptive prevalence in Ghana is considered and compared with the trend that would be expected on the basis of prior research. Next, an attempt is made to uncover the explanation behind this unexpected trend. Measures of the quality of the survey data are looked at, as well as trends in the proximate determinants of fertility: contraceptive use, marriage and sexual activity, postpartum insusceptibility and induced abortion. Finally, evidence is presented that couples adjust their coital frequency in accordance with their fertility preferences, behaviour that would influence fertility rates but would not be captured by conventional measures of the proximate determinants of fertility.     

Polygyny and child survival in West Africa

This study examines the relationship between polygyny and child survival in light of conflicting findings reported in a number of studies. Using data from the Demographic and Health Surveys from six West African countries, the risks of neonatal, postneonatal, and overall infant mortality are estimated. Controlling for a set of social and bio-demographic factors, it is found that substantial risks of mortality are associated with polygyny. A separate analysis explores the possibility that polygyny's impact could differ from country to country. No significant interaction effects are detected, leading to the conclusion that regardless of the country in which it is practiced, polygyny still poses a challenge to the survival chances of West African children.     

Reliability of current estimates of schistosomiasis prevalence in the Rainforest Zone of the state of Pernambuco, Northeastern Brazil

The Program for Schistosomiasis Control within the Unified Health System (PCE-SUS) was implemented by 1999 in the Rainforest Zone or "Zona da Mata" of Pernambuco (ZMP) aiming to carry out biennial stool surveys of whole populations through municipal health organs followed by treatment of the positives through the local units of the Family Health Program (PSF). Yearly reports from the Health Department of Pernambuco State (SES/PE) from 2002 to 2004 on the PCE-SUS surveys were assessed to evaluate whether the current estimates of prevalence in the municipalities of the ZMP are based on reliable samples so as to allow considerations on the real situation of schistosomiasis in that area. The surveys carried out in that period did not follow the major principles underlying sampling design, thus posing problems in both precision and validity of the estimates. Only 12 out of 43 municipalities had minimally reliable estimates: five with moderate prevalence (10-50%) and seven with low prevalence (< 10%). Surveys with appropriate sampling procedures aimed either at representative target groups (school-aged children) or communities are recommended for the ZMP and other endemic areas not only to provide reliable information on the current situation of schistosomiasis but also to plan adequate control strategies.     

Prevalence of human African trypanosomiasis in the Democratic Republic of the Congo

Human African Trypanosomiasis (HAT) is a major public health problem in the Democratic Republic of the Congo (DRC). Active and passive surveillance for HAT is conducted but may underestimate the true prevalence of the disease. We used ELISA to screen 7,769 leftover dried blood spots from a nationally representative population-based survey, the 2007 Demographic and Health Survey. 26 samples were positive by ELISA. Three of these were also positive by trypanolysis and/or PCR. From these data, we estimate that there were 18,592 people with HAT (95% confidence interval, 4,883-32,302) in the DRC in 2007, slightly more than twice as many as were reported.     

Trends in infant and young child feeding practices in Bangladesh, 1993–2011

Background

Optimal infant and young child feeding practices are crucial to improving the health and nutritional status of children. Bangladesh Breastfeeding Foundation, UNICEF and several other organizations are working in the country for the promotion of healthy feeding practices. This article presents trends in breastfeeding and complementary feeding practices in Bangladesh from 1993–2011, based on data in Bangladesh Demographic and Health Surveys. The following Bangladesh Demographic and Health Surveys were studied: BDHS 93–94, BDHS 96–97, BDHS 99–00, BDHS 04, BDHS 07 and BDHS 11. Values of indicators for infant and young child feeding proposed by WHO, along with their 95% confidence intervals, were calculated, and trends were assessed.

Findings

Among the core indicators, early initiation of breastfeeding, exclusive breastfeeding under six months, introduction of solid, semi-solid and soft foods, and consumption of iron-rich foods have improved, while continued breastfeeding at one year does not display a statistically significant development. Of the optional indicators, the prevalence of age-appropriate breastfeeding and children ever breastfed improved, while the prevalence of predominant breastfeeding under six months witnessed a decline. Median duration of breastfeeding declined, and there was no change in the other optional indicators (continued breastfeeding at two years and bottle feeding). Developments in the other optional indicators were not statistically significant. The ratings of early initiation of breastfeeding and complementary feeding have gone up from poor to fair, those of exclusive breastfeeding under six months from fair to good, while those of bottle-feeding are fair.

Conclusion

The developments in breastfeeding and complementary feeding practices in the country have been considerable, but there is still substantial scope for improvement.

     

Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's World Mental Health Survey Initiative

Data are presented on the lifetime prevalence, projected lifetime risk, and age-of-onset distributions of mental disorders in the World Health Organization (WHO)''s World Mental Health (WMH) Surveys. Face-to-face community surveys were conducted in seventeen countries in Africa, Asia, the Americas, Europe, and the Middle East. The combined numbers of respondents were 85,052. Lifetime prevalence, projected lifetime risk, and age of onset of DSM-IV disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI), a fully-structured lay administered diagnostic interview. Survival analysis was used to estimate lifetime risk. Median and inter-quartile range (IQR) of age of onset is very early for some anxiety disorders (7-14, IQR: 8-11) and impulse control disorders (7-15, IQR: 11-12). The age-of-onset distribution is later for mood disorders (29-43, IQR: 35-40), other anxiety disorders (24-50, IQR: 31-41), and substance use disorders (18-29, IQR: 21-26). Median and IQR lifetime prevalence estimates are: anxiety disorders 4.8-31.0% (IQR: 9.9-16.7%), mood disorders 3.3-21.4% (IQR: 9.8-15.8%), impulse control disorders 0.3-25.0% (IQR: 3.1-5.7%), substance use disorders 1.3-15.0% (IQR: 4.8-9.6%), and any disorder 12.0-47.4% (IQR: 18.1-36.1%). Projected lifetime risk is proportionally between 17% and 69% higher than estimated lifetime prevalence (IQR: 28-44%), with the highest ratios in countries exposed to sectarian violence (Israel, Nigeria, and South Africa), and a general tendency for projected risk to be highest in recent cohorts in all countries. These results document clearly that mental disorders are commonly occurring. As many mental disorders begin in childhood or adolescents, interventions aimed at early detection and treatment might help reduce the persistence or severity of primary disorders and prevent the subsequent onset of secondary disorders.     

Reproductive change in Zimbabwe and Kenya: the role of the proximate determinants in recent fertility trends

This study examines trends in proximate determinants of fertility in Zimbabwe and Kenya. Findings from the four Demographic and Health Surveys conducted in these countries show that the dramatic fall in fertility in these countries is consistent with the underlying trends in the most important proximate determinants of fertility. In Zimbabwe, contraceptive use far exceeds other proximate determinants in influencing fertility levels and trends. The results show that the fertility inhibiting effects of contraception are more important than the effects of postpartum infecundability, marriage patterns, or sterility. The results also show that contraceptive use has its greatest suppressing effects in the middle and younger age groups. However, in Kenya, the dominant fertility inhibiting effect is postpartum infecundability, with contraception coming in second.     

Sex ratios at birth in African populations: a review of survey data

This study analyzes the distribution of sex ratio at birth in African populations using data collected in birth histories in sample demographic surveys (Demographic and Health Surveys and World Fertility Surveys). The average sex ratio from 56 surveys, totaling 1.130 million births, was 1.033 (95% CI, 1.029-1.037), significantly different from the world average of 1.055. The distribution of sex ratios across surveys was found to be heterogeneous, and different from what could have been expected from random fluctuations due to sample size. Three subsets were identified: a subset with lower sex ratios, primarily in countries of eastern and southern Africa of Bantu populations (1.010), a subset with average sex ratios (1.035), and a subset of countries with higher sex ratios, in particular Nigeria and Ethiopia (1.070). Further analysis revealed that African populations are as diverse as other populations, with sex ratios ranging from low values (below 1.00) to high values (above 1.08). Results are discussed in light of independent data sources and in comparison with other human populations.     

Spousal agreement on preferred waiting time to next birth in sub-Saharan Africa

This study investigates how various social, demographic and economic factors affect spousal agreement on preferred waiting time to next birth. Data for matched cohabiting couples from ten Demographic and Health Surveys in sub-Saharan Africa (Benin, Burkina Faso, Ghana, Guinea, Mali, Ethiopia, Kenya, Mozambique, Zambia and Zimbabwe), conducted between 2003 and 2006, were analysed to compare reported waiting time to next birth by the husband and the wife. Couples where the reported waiting time to next birth was the same for both partners (difference is 0 months) were defined as having agreement on waiting time to next birth. In sub-Saharan Africa, spousal agreement on waiting time to next birth was found to be associated with wanting the next child sooner. When the spouses disagree on waiting time to next birth, the wives want to wait longer than their husbands in most cases. Additionally, the study found that demographic factors are the primary determinants of spousal agreement on waiting time to next birth, not socioeconomic factors. The strongest predictors of spousal agreement on waiting time to next birth were number of living children, difference between the number of ideal and living children and wife's age. Couples with fewer children, a younger wife and those with a difference of five or more children between ideal and living number of children were more likely to agree on waiting time to next birth. Effects of socioeconomic factors, such as education and wealth status, on spousal agreement on waiting time to next birth were generally weak and inconsistent. The findings highlight some of the challenges in developing programmes to promote spousal communication and birth spacing and underscore the need for programmes to be gender-sensitive.     

Improving the Quality of Adult Mortality Data Collected in Demographic Surveys: Validation Study of a New Siblings' Survival Questionnaire in Niakhar,Senegal

Background

In countries with limited vital registration, adult mortality is frequently estimated using siblings'' survival histories (SSHs) collected during Demographic and Health Surveys (DHS). These data are affected by reporting errors. We developed a new SSH questionnaire, the siblings'' survival calendar (SSC). It incorporates supplementary interviewing techniques to limit omissions of siblings and uses an event history calendar to improve reports of dates and ages. We hypothesized that the SSC would improve the quality of adult mortality data.

Methods and Findings

We conducted a retrospective validation study among the population of the Niakhar Health and Demographic Surveillance System in Senegal. We randomly assigned men and women aged 15–59 y to an interview with either the DHS questionnaire or the SSC. We compared SSHs collected in each group to prospective data on adult mortality collected in Niakhar. The SSC reduced respondents'' tendency to round reports of dates and ages to the nearest multiple of five or ten (“heaping”). The SSC also had higher sensitivity in recording adult female deaths: among respondents whose sister(s) had died at an adult age in the past 15 y, 89.6% reported an adult female death during SSC interviews versus 75.6% in DHS interviews (p = 0.027). The specificity of the SSC was similar to that of the DHS questionnaire, i.e., it did not increase the number of false reports of deaths. However, the SSC did not improve the reporting of adult deaths among the brothers of respondents. Study limitations include sample selectivity, limited external validity, and multiple testing.

Conclusions

The SSC has the potential to collect more accurate SSHs than the questionnaire used in DHS. Further research is needed to assess the effects of the SSC on estimates of adult mortality rates. Additional validation studies should be conducted in different social and epidemiological settings.

Trial Registration

Controlled-Trials.com ISRCTN06849961 Please see later in the article for the Editors'' Summary     

Fertility intentions: are the undecided more like those who want more or want no more children?

In fertility surveys often women (and sometimes men) are asked their fertility desires, i.e. whether they want a/nother birth or not. Some respond that they are undecided. This study examines whether these persons are more like those who say they want more births or like those who say they want no more births. Data on married men and women in 29 Demographic and Health Surveys with sample sizes ranging from 300 to 3000 are used. A logistic regression equation is estimated within each country for those with known desires and then used to classify each person who was undecided. In all sub-Saharan African countries (n=20) and for both sexes, 50% or more of the undecided persons are classified as wanting more children (with one exception of wives in Kenya). By contrast in all five Latin American countries for both sexes less than 50% of the undecided were classified in the 'want more' group (with an exception of husbands in the Dominican Republic). Generally, the undecided tend to be classified the same as the majority among those in the survey with stated desires.     

Consanguineous marriage and differentials in age at marriage, contraceptive use and fertility in Pakistan

Fertility rates in Pakistan have remained consistently high over the past three decades. While numerous studies have examined sociodemographic determinants, the role of biological factors, and particularly consanguinity, has received little attention, even though marriage between close biological relatives continues to be the norm in Pakistan. Reproductive behaviour among women in consanguineous (first cousin) and non-consanguineous unions was compared, using data from a 1995 study of multi-ethnic communities in Karachi and the 1990-91 Pakistan Demographic & Health Survey (PDHS). The results show that, although female age at first marriage has been gradually rising in both study samples, women in consanguineous unions married at younger ages and were less likely to use modern contraceptive methods. In the Karachi sample, women in first cousin unions experienced a higher mean number of pregnancies and also reported a higher mean number of children ever born (CEB). However, their mean number of surviving children did not differ from those born to women in non-consanguineous unions, implying higher prenatal and/or postnatal losses in couples related as first cousins. On the other hand, the PDHS showed both lower CEB values for women in consanguineous marriages and a lower number of surviving children. Given the continuing popularity of consanguineous marriage, these findings have important implications for future fertility reduction in Pakistan.     

Early marriage and maternal health care utilisation: Evidence from sub-Saharan Africa

We use the recursive bivariate probit (RBVP) model to estimate the effects of early marriage on the utilisation of maternal health services in five sub-Saharan countries: Burkina Faso, Guinea, Mali, Niger and Chad. Based on recent Demographic and Health Surveys (DHS), we find that a woman who married before age 15 was 17 percentage points less likely to use prenatal services; and marrying before age 16 reduced that likelihood by 9.6 percentage points. We have not found any statistically significant reduction in maternal health care utilisation for women who married at age 17 or older.     

Impact of HIV infection on mortality in young men in a London health authority.

OBJECTIVE--To determine the number of deaths attributable to HIV infection among men aged 15-64 in a geographically defined population in the United Kingdom. DESIGN--Retrospective review of death certificates and linkage with local and national HIV and AIDS surveillance data. SETTING--Riverside District Health Authority, London. MAIN OUTCOME MEASURES--Numbers of deaths attributed to HIV infection in male residents of Riverside aged 15-64 and 15-44 over a six month period. Proportion of attributed deaths were (i) identified from death certificates by the Office of Population Censuses and Surveys as being due to HIV infection and (ii) reported as cases of AIDS or HIV related deaths to the Public Health Laboratory Service Communicable Disease Surveillance Centre. RESULTS--34 of 213 (16%) deaths in men aged 15-64 and 27 of 69 (39%) deaths in men aged 15-44 were attributed to HIV infection. Six of 33 (18%) attributed deaths were identified by the Office of Population Censuses and Surveys and 32/34 (94%) were reported to the Communicable Disease Surveillance Centre. CONCLUSIONS--HIV infection was the leading cause of death in male residents of Riverside aged 15-44 and the third commonest cause of death in those aged 15-64. Most individuals dying of known HIV infection were reported to the Communicable Disease Surveillance Centre but identification of the true cause of death from the process of death certification was poor. Measures to improve the certification of HIV and AIDS or the use of AIDS surveillance information correctly to code the cause of death needs to be considered to ensure that the true impact of HIV infection is reflected in routine mortality statistics.     

Education as policy: the impact of education on marriage, contraception, and fertility in Colombia, Peru, and Bolivia

Using data from the World Fertility and Demographic and Health Surveys of Colombia, Peru, and Bolivia, we model the effects of education on three demographic outcomes: the timing of first sexual union, contraceptive use, and fertility. These effects are examined over time and across geographic areas using a multivariate framework. We find substantial improvements in female educational attainment over the last fifty years and a strong relationship between education and the demographic outcomes. Each successive increment in education is associated with declines in the marriage rate, increased contraceptive use, and lower fertility. Education accounts for some of the changes over time in the demographic outcomes, but the pattern varies by outcome, time period, and geographic area. In support of the social diffusion hypothesis, our results indicate that educational differences in reproductive behavior are reduced as the level of development increases and societies pass through their demographic transition.     

Overweight and obesity in military personnel: sociodemographic predictors

In the United States, nationally representative civilian studies have shown that BMI is associated with select sociodemographic characteristics. Active-duty military personnel are not included in these surveys and the persistence of these associations in military personnel is unknown. Data from the worldwide, representative 2002 and 2005 Department of Defense (DoD) Surveys of Health-Related Behaviors Among Active Duty Military Personnel were used to assess the prevalence of overweight and obesity and, the association of BMI with sociodemographic characteristics. The final response bases included 12,756 (2002) and 16,146 (2005) personnel. Results indicated that the combined prevalence of overweight and obesity in military personnel increased to an all-time high in 2005 (60.5%) with higher prevalence of obesity in 2005 compared to 2002 (12.9% vs. 8.7, respectively, P ≤ 0.01). Holding other variables constant, regression analysis indicated that women were significantly less likely than men to be overweight or obese in both survey years (P ≤ 0.0001), which is contrary to civilian data. Similar to civilian data, the prevalence of obesity was significantly associated with increased age, black or Hispanic/Latino race/ethnicity, and being married (P ≤ 0.01). US military personnel are not immune to the US obesity epidemic. Demographic characteristics associated with being overweight should be considered when developing military-sponsored weight management programs.     

The role of place in shaping contraceptive use among women in Africa

Background

Contraceptive prevalence is low in the African region despite considerable family planning programmatic efforts. This study is the first to examine how community factors shape contraceptive use for married women in an entire region, comparing results across 21 African countries with a DHS in the last 5 years. The analysis builds on previous studies through an examination of the individual, household and community level factors that shape contraceptive use.

Methods

The data used in this analysis were from nationally representative Demographic and Health Surveys completed between 2005 and 2009. A separate multi-level logistic model was fitted for the outcome of current modern contraceptive use in each country.

Results

After controlling for individual and household level factors, community level factors of demographics and fertility norms, gender norms and inequalities, and health knowledge remain significantly associated with contraceptive use, although the magnitude and direction of these community effects varied significantly across countries.

Conclusions

The results highlight the importance of harnessing community level factors in planning interventions for increasing access to and utilization of modern contraceptive methods.     

Ideal versus actual: the contradiction in number of children born to Nigerian women

Although desired family size is often different from actual family size, the dynamics of this difference are not well understood. This paper examines the patterns and determinants of the difference between desired and actual number of children (unmet fertility desires) among women aged 15-49 years using pooled data from the 1990, 1999 and 2003 Nigeria Demographic and Health Surveys (NDHSs). The results show that more than two-thirds of the sample have unmet fertility desires (18.1% have more while 52.4% have fewer than desired). It was found that early and late childbearing increased the odds of unmet fertility desires. Also, women with low levels of education, from poor households, rural residents as well as those who had experienced child death were at a higher risk of unmet fertility desires in the multivariate context. The study highlights the policy and programme implications of the findings.