Background An estimated one-third of women in Ghana use contraceptives without the knowledge of t... more Background An estimated one-third of women in Ghana use contraceptives without the knowledge of their partners, a phenomenon known as Covert Contraceptive Use (CCU). Most research on CCU to date has focused on individual women to the neglect of the role of health system. This study explores CCU in urban poor communities of Accra, Ghana, from the experiences and perspectives of health providers. Methods Qualitative in-depth interviews were conducted with health care providers in both the public and private sectors at multiple levels, from the community clinic to the tertiary hospital, to gain insights into the strategies women use and the ways in which the health system supports the practice of CCU. Results Five major thematic areas emerged: use of easily concealed-methods, discrete-access-and-information-keeping, time-of-day, non-verbal-communication and use of relationships. The study further revealed that fear, mistrust, shyness, myths, and misperceptions regarding contraceptives ...
Introduction Adolescent pregnancy contributes significantly to the high maternal mortality in Nig... more Introduction Adolescent pregnancy contributes significantly to the high maternal mortality in Nigeria. Research evidence from developing countries consistently underscores Antenatal Care (ANC) among childbearing adolescents as important to reducing high maternal mortality. However, more than half of pregnant adolescents in Nigeria do not attend ANC. A major gap in literature is on the influence of family context in pregnant adolescent patronage of ANC services. Methods The study utilized a cross-sectional survey with data collected among adolescent mothers in urban slums in three Nigerian states namely, Kaduna, Lagos, and Oyo. The survey used a multi-stage sampling design. The survey covered a sample of 1,015, 1,009 and 1,088 childbearing adolescents from each of Kaduna, Lagos, and Oyo states respectively. Data were analyzed at the three levels: univariate, bivariate and multivariate. Results Overall, about 70 percent of female adolescents in our sample compared with 75 percent in t...
Background: Postpartum contraceptive use reduces unintended pregnancies and results in better hea... more Background: Postpartum contraceptive use reduces unintended pregnancies and results in better health outcomes for children and women. However, there is a dearth of knowledge on postpartum contraceptive use in Ghana, particularly among women in low-income urban settings. To shed light on strategies that might enhance access to postpartum family planning services in low-income urban settings, we examined contraceptive use among postpartum women in Accra, Ghana, at 1, 3, 6, and 12 months following the birth and the methods used. The predictors of modern contraceptive use in the 12-month postpartum period were also examined. Methods: Data come from a cross-sectional survey conducted in 2018 among 624 women aged 16–44 years who reported giving birth in the past 13–31 months prior to the interview. We generated descriptive statistics to examine the prevalence of contraceptive use among postpartum women at 1, 3, 6, and 12 months after birth. We further estimated a binary logistic regressio...
Background There is limited evidence between contraceptive use, availability of commodities and d... more Background There is limited evidence between contraceptive use, availability of commodities and distance to the facility in developing countries. Distance to the facility is an essential determinant of contraceptive use. Still, women may not seek family planning services from the nearest facility and may be prepared to travel the farthest distance to receive quality family planning services. Methods We analyzed women's survey data linked to health facility data and applied an alternate specific conditional logit model to examine the distance a woman is prepared to travel and the quality of services offered by facilities in urban areas in Karachi, Pakistan. Results This study analyzed data from 336 women and 28 facilities and identified that the mean distance to the nearest facility was 0.44 km; the chosen facility was, on average, 5 km away. Women preferred facilities that offered a range of contraceptive methods and additional services provided by female healthcare providers on...
This study examines the relationship between fertility intentions and subsequent childbearing usi... more This study examines the relationship between fertility intentions and subsequent childbearing using event history analysis (EHA). All married women who were born during 1955 to 1985 were followed from July 2001 to August 2004. Their pregnancy histories were recorded on a monthly basis during this period using Laing’s Calendar. A total of 1,912 women were included in the event history analysis. The results suggest that fertility intention and socio-demographic characteristics can predict subsequent fertility behavior. Intention to have additional children shortens the time until the subsequent birth occurred. About one fourth of the women took approximately two years from intention to have a child. It is also indicated that subsequent childbearing is more likely to occur among the women who are younger, who married late, who have fewer living children, and who are non-Thai. The analysis indicates that it is challenging to facilitate fertility intentions and thus more effort is needed...
The European Journal of Contraception & Reproductive Health Care, 2021
Abstract Objective The primary aim of the study was to examine the relationship between self-repo... more Abstract Objective The primary aim of the study was to examine the relationship between self-reported ethnic identity, region of birth and contraceptive use, in Istanbul, Turkey. Methods Cross-sectional data from a random sample of 3038 married women of reproductive age living in two urban districts of Istanbul were used in a series of logistic regression models to assess key relationships. Results Kurdish ethnic minority women were less likely than Turkish ethnic majority women to use traditional contraceptive methods over no method (relative risk ratio [RRR] 0.69; 95% confidence interval [CI] 0.50, 0.96). However, there were no significant differences between ethnicities (i.e., Turkish, Kurdish and other) and modern method use. Among Turkish women, those born in regions farther away from the western region were more likely to use traditional methods (RRRnorthern 2.06; 95% CI 1.31, 3.22). Conclusion While Kurdish ethnic minority women were less likely to use traditional methods, compared with Turkish ethnic majority women, the difference might have been due to the length of time living in a neighbourhood. Regional variations in contraceptive use were concentrated only among Turkish ethnic majority women and for traditional methods. Regional norms of traditional method use may be a barrier to modern contraceptive use in Turkey.
OBJECTIVE: To examine the prevalence and predictors of family planning (FP) know-do gaps among ma... more OBJECTIVE: To examine the prevalence and predictors of family planning (FP) know-do gaps among married women of reproductive age (MWRA) in low socio-economic urban areas of Karachi, Pakistan.DESIGN: This was a cross-sectional survey of randomly selected 7288 MWRA (16–49 years) to identify predictors of the know-do gap in FP using a logistic regression model.RESULTS: More than one third (35.5%) of MWRA had FP know-do gap, i.e., despite having a knowledge of contraceptives and desire to limit or delay childbearing, they were not using contraceptives. Women were less likely to use FP if they were getting older (25–35 years: OR 1.45, 95% CI 1.09–1.94; >35 years: OR 3.02, 95% CI 1.90–4.80), from certain ethnicities (Sindhi: OR 1.64, 95% CI 1.11–2.42; Saraiki: OR 1.66, 95% CI 1.01–2.71; other minorities: OR 2.37, 95% CI 1.63–3.44); did not receive FP counselling: OR 1.43, 95% CI 1.13–1.80; and had not made a joint decision on FP: OR 1.44, 95% CI 1.06–1.98). Conversely, women were more ...
BackgroundIntegration of maternal care and family planning services has the potential to reduce u... more BackgroundIntegration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery.MethodsWe applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.ResultsFindings indicated that providers were willing to adopt the interventio...
It is generally believed that extended families encourage high fertility but a review of the theo... more It is generally believed that extended families encourage high fertility but a review of the theoretical discussions and empirical research examining the relationship between family type and fertility fails to show any support for the customary belief. Nuclear families consist of husband wife and their immediate children. The extended family is broadly defined as any group of related persons living together which includes but is larger than the nuclear family. The main theoretical discussions of extended family and fertility are by Davis (1957); Davis and Blake (1956); Lorimer (1954); and Goode (1963; 1964). In the patrilocal extended family the wife wants to have offspring as early as possible to strengthen the family line and her own status in the household. In a truly joint household the authority of the elders continues after marriage; the reproductive behavior of a couple is subject to their influence. Less intimate or less intense interspousal communication precludes the possibility of discussion on fertility-related problems and family planning. Younger age at marriage and lack of privacy contributes to higher fertility. According to Goode extended family behavior is characterized by more rules for behavior while nuclear families emphasize the conjugal bond. Since most affinal and consanguineal kin are excluded from day-to-day decisions in the nuclear family there are weaker reciprocal controls.
International perspectives on sexual and reproductive health, 2020
CONTEXT Many community-based reproductive health programs use their program data to monitor progr... more CONTEXT Many community-based reproductive health programs use their program data to monitor progress toward goals. However, using such data to assess programmatic impact on outcomes such as contraceptive use poses methodological challenges. Inverse probability weighting (IPW) may help overcome these issues. METHODS Data on 33,162 women collected in 2013-2015 as part of a large-scale community-based reproductive health initiative were used to produce population-level estimates of the contraceptive prevalence rate (CPR) and modern contraceptive prevalence rate (mCPR) among married women aged 15-49 in Pakistan's Korangi District. To account for the nonrandom inclusion of women in the sample, estimates of contraceptive prevalence during the study's four seven-month intervention periods were made using IPW; these estimates were compared with estimates made using complete case analysis (CCA) and the last observation carried forward (LOCF) method-two approaches for which modeling assumptions are less flexible. RESULTS In accordance with intervention protocols, the likelihood that women were visited by intervention personnel and thus included in the sample differed according to their past and current contraceptive use. Estimates made using IPW suggest that the CPR increased from 51% to 64%, and the mCPR increased from 34% to 53%, during the study. For both outcomes, IPW estimates were higher than CCA estimates, were generally similar to LOCF estimates and yielded the widest confidence intervals. CONCLUSION IPW offers a powerful methodology for overcoming estimation challenges when using program data that are not representative of the population in settings where cost impedes collection of outcome data for an appropriate control group.
Background An estimated one-third of women in Ghana use contraceptives without the knowledge of t... more Background An estimated one-third of women in Ghana use contraceptives without the knowledge of their partners, a phenomenon known as Covert Contraceptive Use (CCU). Most research on CCU to date has focused on individual women to the neglect of the role of health system. This study explores CCU in urban poor communities of Accra, Ghana, from the experiences and perspectives of health providers. Methods Qualitative in-depth interviews were conducted with health care providers in both the public and private sectors at multiple levels, from the community clinic to the tertiary hospital, to gain insights into the strategies women use and the ways in which the health system supports the practice of CCU. Results Five major thematic areas emerged: use of easily concealed-methods, discrete-access-and-information-keeping, time-of-day, non-verbal-communication and use of relationships. The study further revealed that fear, mistrust, shyness, myths, and misperceptions regarding contraceptives ...
Introduction Adolescent pregnancy contributes significantly to the high maternal mortality in Nig... more Introduction Adolescent pregnancy contributes significantly to the high maternal mortality in Nigeria. Research evidence from developing countries consistently underscores Antenatal Care (ANC) among childbearing adolescents as important to reducing high maternal mortality. However, more than half of pregnant adolescents in Nigeria do not attend ANC. A major gap in literature is on the influence of family context in pregnant adolescent patronage of ANC services. Methods The study utilized a cross-sectional survey with data collected among adolescent mothers in urban slums in three Nigerian states namely, Kaduna, Lagos, and Oyo. The survey used a multi-stage sampling design. The survey covered a sample of 1,015, 1,009 and 1,088 childbearing adolescents from each of Kaduna, Lagos, and Oyo states respectively. Data were analyzed at the three levels: univariate, bivariate and multivariate. Results Overall, about 70 percent of female adolescents in our sample compared with 75 percent in t...
Background: Postpartum contraceptive use reduces unintended pregnancies and results in better hea... more Background: Postpartum contraceptive use reduces unintended pregnancies and results in better health outcomes for children and women. However, there is a dearth of knowledge on postpartum contraceptive use in Ghana, particularly among women in low-income urban settings. To shed light on strategies that might enhance access to postpartum family planning services in low-income urban settings, we examined contraceptive use among postpartum women in Accra, Ghana, at 1, 3, 6, and 12 months following the birth and the methods used. The predictors of modern contraceptive use in the 12-month postpartum period were also examined. Methods: Data come from a cross-sectional survey conducted in 2018 among 624 women aged 16–44 years who reported giving birth in the past 13–31 months prior to the interview. We generated descriptive statistics to examine the prevalence of contraceptive use among postpartum women at 1, 3, 6, and 12 months after birth. We further estimated a binary logistic regressio...
Background There is limited evidence between contraceptive use, availability of commodities and d... more Background There is limited evidence between contraceptive use, availability of commodities and distance to the facility in developing countries. Distance to the facility is an essential determinant of contraceptive use. Still, women may not seek family planning services from the nearest facility and may be prepared to travel the farthest distance to receive quality family planning services. Methods We analyzed women's survey data linked to health facility data and applied an alternate specific conditional logit model to examine the distance a woman is prepared to travel and the quality of services offered by facilities in urban areas in Karachi, Pakistan. Results This study analyzed data from 336 women and 28 facilities and identified that the mean distance to the nearest facility was 0.44 km; the chosen facility was, on average, 5 km away. Women preferred facilities that offered a range of contraceptive methods and additional services provided by female healthcare providers on...
This study examines the relationship between fertility intentions and subsequent childbearing usi... more This study examines the relationship between fertility intentions and subsequent childbearing using event history analysis (EHA). All married women who were born during 1955 to 1985 were followed from July 2001 to August 2004. Their pregnancy histories were recorded on a monthly basis during this period using Laing’s Calendar. A total of 1,912 women were included in the event history analysis. The results suggest that fertility intention and socio-demographic characteristics can predict subsequent fertility behavior. Intention to have additional children shortens the time until the subsequent birth occurred. About one fourth of the women took approximately two years from intention to have a child. It is also indicated that subsequent childbearing is more likely to occur among the women who are younger, who married late, who have fewer living children, and who are non-Thai. The analysis indicates that it is challenging to facilitate fertility intentions and thus more effort is needed...
The European Journal of Contraception & Reproductive Health Care, 2021
Abstract Objective The primary aim of the study was to examine the relationship between self-repo... more Abstract Objective The primary aim of the study was to examine the relationship between self-reported ethnic identity, region of birth and contraceptive use, in Istanbul, Turkey. Methods Cross-sectional data from a random sample of 3038 married women of reproductive age living in two urban districts of Istanbul were used in a series of logistic regression models to assess key relationships. Results Kurdish ethnic minority women were less likely than Turkish ethnic majority women to use traditional contraceptive methods over no method (relative risk ratio [RRR] 0.69; 95% confidence interval [CI] 0.50, 0.96). However, there were no significant differences between ethnicities (i.e., Turkish, Kurdish and other) and modern method use. Among Turkish women, those born in regions farther away from the western region were more likely to use traditional methods (RRRnorthern 2.06; 95% CI 1.31, 3.22). Conclusion While Kurdish ethnic minority women were less likely to use traditional methods, compared with Turkish ethnic majority women, the difference might have been due to the length of time living in a neighbourhood. Regional variations in contraceptive use were concentrated only among Turkish ethnic majority women and for traditional methods. Regional norms of traditional method use may be a barrier to modern contraceptive use in Turkey.
OBJECTIVE: To examine the prevalence and predictors of family planning (FP) know-do gaps among ma... more OBJECTIVE: To examine the prevalence and predictors of family planning (FP) know-do gaps among married women of reproductive age (MWRA) in low socio-economic urban areas of Karachi, Pakistan.DESIGN: This was a cross-sectional survey of randomly selected 7288 MWRA (16–49 years) to identify predictors of the know-do gap in FP using a logistic regression model.RESULTS: More than one third (35.5%) of MWRA had FP know-do gap, i.e., despite having a knowledge of contraceptives and desire to limit or delay childbearing, they were not using contraceptives. Women were less likely to use FP if they were getting older (25–35 years: OR 1.45, 95% CI 1.09–1.94; >35 years: OR 3.02, 95% CI 1.90–4.80), from certain ethnicities (Sindhi: OR 1.64, 95% CI 1.11–2.42; Saraiki: OR 1.66, 95% CI 1.01–2.71; other minorities: OR 2.37, 95% CI 1.63–3.44); did not receive FP counselling: OR 1.43, 95% CI 1.13–1.80; and had not made a joint decision on FP: OR 1.44, 95% CI 1.06–1.98). Conversely, women were more ...
BackgroundIntegration of maternal care and family planning services has the potential to reduce u... more BackgroundIntegration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery.MethodsWe applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.ResultsFindings indicated that providers were willing to adopt the interventio...
It is generally believed that extended families encourage high fertility but a review of the theo... more It is generally believed that extended families encourage high fertility but a review of the theoretical discussions and empirical research examining the relationship between family type and fertility fails to show any support for the customary belief. Nuclear families consist of husband wife and their immediate children. The extended family is broadly defined as any group of related persons living together which includes but is larger than the nuclear family. The main theoretical discussions of extended family and fertility are by Davis (1957); Davis and Blake (1956); Lorimer (1954); and Goode (1963; 1964). In the patrilocal extended family the wife wants to have offspring as early as possible to strengthen the family line and her own status in the household. In a truly joint household the authority of the elders continues after marriage; the reproductive behavior of a couple is subject to their influence. Less intimate or less intense interspousal communication precludes the possibility of discussion on fertility-related problems and family planning. Younger age at marriage and lack of privacy contributes to higher fertility. According to Goode extended family behavior is characterized by more rules for behavior while nuclear families emphasize the conjugal bond. Since most affinal and consanguineal kin are excluded from day-to-day decisions in the nuclear family there are weaker reciprocal controls.
International perspectives on sexual and reproductive health, 2020
CONTEXT Many community-based reproductive health programs use their program data to monitor progr... more CONTEXT Many community-based reproductive health programs use their program data to monitor progress toward goals. However, using such data to assess programmatic impact on outcomes such as contraceptive use poses methodological challenges. Inverse probability weighting (IPW) may help overcome these issues. METHODS Data on 33,162 women collected in 2013-2015 as part of a large-scale community-based reproductive health initiative were used to produce population-level estimates of the contraceptive prevalence rate (CPR) and modern contraceptive prevalence rate (mCPR) among married women aged 15-49 in Pakistan's Korangi District. To account for the nonrandom inclusion of women in the sample, estimates of contraceptive prevalence during the study's four seven-month intervention periods were made using IPW; these estimates were compared with estimates made using complete case analysis (CCA) and the last observation carried forward (LOCF) method-two approaches for which modeling assumptions are less flexible. RESULTS In accordance with intervention protocols, the likelihood that women were visited by intervention personnel and thus included in the sample differed according to their past and current contraceptive use. Estimates made using IPW suggest that the CPR increased from 51% to 64%, and the mCPR increased from 34% to 53%, during the study. For both outcomes, IPW estimates were higher than CCA estimates, were generally similar to LOCF estimates and yielded the widest confidence intervals. CONCLUSION IPW offers a powerful methodology for overcoming estimation challenges when using program data that are not representative of the population in settings where cost impedes collection of outcome data for an appropriate control group.
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Papers by Iqbal Shah