acase@tulane.edu / Background As a region, Francophone sub-Saharan Africa (SSA) continues to have among the highest fertility rates and lowest contraceptive prevalence rates in the world. As of the latest Demographic and Health Survey (DHS) data available for each country, total fertility rates range from 4.1 (Gabon 2012) to 7.6 births per woman (Niger 2012). Modern contraceptive prevalence rates for married women range from a low of 3.3% (Guinea 2012) to a high of 20.1% (Senegal 2014). Methods Three analyses were completed utilizing nationally representative DHS data available for each Francophone SSA country. For each paper, bivariate and multivariate analyses were performed with weighted data to take into account the two-stage cluster sampling design of the DHS survey. In paper one, we determine whether being Muslim and/or being in a polygynous union impacts the use of modern contraceptives. In paper two, we provide detailed information on the characteristics that define users of specific contraceptive methods in this region. In the final paper, we provide a clearer picture of the reproductive health dynamic in young never married women in Francophone SSA. Results In paper #1, we found that religion and marital type generally were not predictive of modern contraceptive use. The typical predictors – education, age, residence (urban/rural) – were consistently significant across the included countries. In paper #2, profiles of users of the most common contraceptive methods in each country were created. For example, condom users had the most consistent profile across the 12 countries, with marital status, parity and education being clearly associated with condom use. For paper #3, education level was found to be the key predictor of both sexual activity and becoming pregnant for young, never married women in this region. In general, those with primary or secondary and higher education were more likely to be sexually active than those with no education. Conclusion These findings provide valuable information to government, private and nongovernmental organizations working toward increasing the numbers of contraceptive users in Francophone SSA. / 1 / Margaret Farrell

Introdução: Os múltiplos e interativos efeitos protetores do aleitamento materno exclusivo (AME) na saúde e sobrevivência infantil justificam as recomendações universais para promover sua prática. Poucos são os estudos que avaliam a tendência do padrão do AME entre países. Objetivo: Analisar a mudança temporal do AME em cinco países da América Latina e Caribe (ALC) comparando dados das décadas de 1990 e 2000. Métodos: A dissertação é composta por um manuscrito, que avaliou dados de crianças de 0 a 6 meses incluídas nas amostras das pesquisas Demographic Health Survey conduzidas em Brasil, Colômbia, Haiti, Peru e República Dominicana. Foram estimadas as prevalências do AME e suas taxas anuais de variação ponderada, segundo país e ano de inquérito. A duração do AME foi estimada usando a análise de sobrevida de Kaplan-Meier, considerando a idade atual da criança como o tempo de sobrevida e o AME como variável binária, referente à situação da prática no momento da entrevista. As curvas de sobrevivência foram construídas por país, em cada década, e a comparação entre elas usou o teste log-rank. A mediana do tempo de amamentação foi calculada para cada variável independente e a relação entre essas variáveis e o desmame até os seis meses foi analisada pela técnica de regressão de Cox com modelo múltiplo. Resultados: A prevalência de AME aumentou em quatro dos cinco países estudados, com incremento ao ano mais marcante na Colômbia (11 por cento ) e no Haiti (17 por cento ). A duração mediana apresentou duas tendências de evolução: aumento com equidade na Colômbia e no Haiti, e estagnação com distribuição desigual entre os subgrupos populacionais da última década no Brasil, Peru e República Dominicana. No modelo múltiplo de regressão, variáveis de demografia e do perfil de uso dos serviços de saúde associaram-se à duração do AME. A residência em área rural foi a variável reiteradamente associada, de forma negativa no Brasil (HR=1,68; IC 95 por cento :1,06-2,67) e na Colômbia (HR=1,39; IC 95 por cento :1,03-1,87), enquanto que positivamente no Peru (HR=0,40; IC 95 por cento :0,19-0,83). Conclusão: O balanço da tendência do AME na ALC é positivo, embora não uniforme ao longo das duas décadas analisadas. Os achados sinalizam a necessidade de intervenções para a promoção do AME que levem em consideração a localização geográfica das famílias e a qualidade prestada nos serviços de saúde / Introduction: Multiple and interactive protective effects of exclusive breastfeeding (EBF) in health and child survival justify recommendations for promoting universal practice. There are few studies that assess the tendency of the pattern of EBF between countries. Objective: To analyze the temporal change of the AME in five countries in Latin America and Caribbean (LAC) comparing data from 1990 and 2000 decades. Methods: The dissertation consists of a manuscript, which evaluated data from children aged 0 to 6 months in the samples of the Demographic Health Survey conducted research in Brazil, Colombia, Haiti, Peru and the Dominican Republic. Were estimated the prevalence of exclusive breastfeeding and its weighted annual rates of change, according to country and survey year. The duration of EBF was estimated using survival analysis Kaplan-Meier method, considering the current age of the child as the survival time and EBF as binary variable, concerning the state of practice at the time of the interview. The survival curves were constructed for each country, in every decade, and the comparison between them used the log-rank test. The median duration of breastfeeding was calculated for each independent variable and the relationship between these variables and weaning at six months was analyzed using Cox regression model. Results: The prevalence of EBF increased in four of the five countries studied, increasing the most remarkable years in Colombia (II per cent ) and Haiti (17 per cent ). The median duration of evolution showed two trends: growth with equity in Colombia and Haiti, and stagnation with unequal distribution among the population subgroups of the last decade in Brazil, Peru and the Dominican Republic. In the multiple model of regression variables and the demographic profile of use of health services were associated with duration of EBF. The residence in a rural area was the variable consistently associated negatively in Brazil (HR = 1.68, CI 95 per cent : 1,06-2,67) and Colombia (HR = 1.39, CI 95 per cent : 1,03-1,87), while positively in Peru (HR = 0.40, CI 95 per cent : 0,19-0,83). Conclusion: The balance of the trend of EBF in LAC is positive, though not uniform throughout the two decades analyzed. The findings suggest the need for interventions for the promotion of exclusive breastfeeding taking into account the geographical location of families and provided quality health services

Introdução: Os múltiplos e interativos efeitos protetores do aleitamento materno exclusivo (AME) na saúde e sobrevivência infantil justificam as recomendações universais para promover sua prática. Poucos são os estudos que avaliam a tendência do padrão do AME entre países. Objetivo: Analisar a mudança temporal do AME em cinco países da América Latina e Caribe (ALC) comparando dados das décadas de 1990 e 2000. Métodos: A dissertação é composta por um manuscrito, que avaliou dados de crianças de 0 a 6 meses incluídas nas amostras das pesquisas Demographic Health Survey conduzidas em Brasil, Colômbia, Haiti, Peru e República Dominicana. Foram estimadas as prevalências do AME e suas taxas anuais de variação ponderada, segundo país e ano de inquérito. A duração do AME foi estimada usando a análise de sobrevida de Kaplan-Meier, considerando a idade atual da criança como o tempo de sobrevida e o AME como variável binária, referente à situação da prática no momento da entrevista. As curvas de sobrevivência foram construídas por país, em cada década, e a comparação entre elas usou o teste log-rank. A mediana do tempo de amamentação foi calculada para cada variável independente e a relação entre essas variáveis e o desmame até os seis meses foi analisada pela técnica de regressão de Cox com modelo múltiplo. Resultados: A prevalência de AME aumentou em quatro dos cinco países estudados, com incremento ao ano mais marcante na Colômbia (11 por cento ) e no Haiti (17 por cento ). A duração mediana apresentou duas tendências de evolução: aumento com equidade na Colômbia e no Haiti, e estagnação com distribuição desigual entre os subgrupos populacionais da última década no Brasil, Peru e República Dominicana. No modelo múltiplo de regressão, variáveis de demografia e do perfil de uso dos serviços de saúde associaram-se à duração do AME. A residência em área rural foi a variável reiteradamente associada, de forma negativa no Brasil (HR=1,68; IC 95 por cento :1,06-2,67) e na Colômbia (HR=1,39; IC 95 por cento :1,03-1,87), enquanto que positivamente no Peru (HR=0,40; IC 95 por cento :0,19-0,83). Conclusão: O balanço da tendência do AME na ALC é positivo, embora não uniforme ao longo das duas décadas analisadas. Os achados sinalizam a necessidade de intervenções para a promoção do AME que levem em consideração a localização geográfica das famílias e a qualidade prestada nos serviços de saúde / Introduction: Multiple and interactive protective effects of exclusive breastfeeding (EBF) in health and child survival justify recommendations for promoting universal practice. There are few studies that assess the tendency of the pattern of EBF between countries. Objective: To analyze the temporal change of the AME in five countries in Latin America and Caribbean (LAC) comparing data from 1990 and 2000 decades. Methods: The dissertation consists of a manuscript, which evaluated data from children aged 0 to 6 months in the samples of the Demographic Health Survey conducted research in Brazil, Colombia, Haiti, Peru and the Dominican Republic. Were estimated the prevalence of exclusive breastfeeding and its weighted annual rates of change, according to country and survey year. The duration of EBF was estimated using survival analysis Kaplan-Meier method, considering the current age of the child as the survival time and EBF as binary variable, concerning the state of practice at the time of the interview. The survival curves were constructed for each country, in every decade, and the comparison between them used the log-rank test. The median duration of breastfeeding was calculated for each independent variable and the relationship between these variables and weaning at six months was analyzed using Cox regression model. Results: The prevalence of EBF increased in four of the five countries studied, increasing the most remarkable years in Colombia (II per cent ) and Haiti (17 per cent ). The median duration of evolution showed two trends: growth with equity in Colombia and Haiti, and stagnation with unequal distribution among the population subgroups of the last decade in Brazil, Peru and the Dominican Republic. In the multiple model of regression variables and the demographic profile of use of health services were associated with duration of EBF. The residence in a rural area was the variable consistently associated negatively in Brazil (HR = 1.68, CI 95 per cent : 1,06-2,67) and Colombia (HR = 1.39, CI 95 per cent : 1,03-1,87), while positively in Peru (HR = 0.40, CI 95 per cent : 0,19-0,83). Conclusion: The balance of the trend of EBF in LAC is positive, though not uniform throughout the two decades analyzed. The findings suggest the need for interventions for the promotion of exclusive breastfeeding taking into account the geographical location of families and provided quality health services

Introduction HIV infection is a global health concern and the epidemic is particularly serious in sub-Saharan Africa. Understanding HIV-related knowledge, attitude and behavior is a key element for prevention programs. Because of rural-urban variations in social and economic factors, this study was conducted to assess urban-rural disparities in HIV-related knowledge, attitude and behavior in Burkina Faso. Methods This study is based on a nationally representative data from the 2010 Burkina Faso Demographic and Health Survey. Odds ratios from the logistic regression analyses were used to determine the association between HIV-related knowledge, attitude and behaviors with residence (urban /rural). Results More rural residents were uneducated (82.13%), illiterates (80.13%), and poor (94.54%) compared to urban residents with values of 17.87%, 19.87% and 5.45%, respectively. The prevalence of HIV residents was significantly lower among rural residents (0.65%) as compared with urban residents (1.88%). Rural residents compared to urban residents were more likely to have incomplete knowledge or inappropriate HIV-related attitude and behavior: incomplete knowledge about HIV (OR = 3.38, 95% CI 3.15 – 3.63), incomplete knowledge of MTCT prevention methods (OR = 2.01, 95% CI 1.88 – 2.16), non-accepting attitude toward people living with HIV (OR = 3.01, 95% CI 2.78 – 3.26), unfavorable for youth education on condom use (OR = 1.53, 95% CI 1.41 – 1.65), first sex before 15 years old (OR = 1.54, 95% CI 1.96 – 1.21), multiple sex partnership among men (OR = 1.52, 95% CI 1.33 – 1.75), don’t know any source of condoms (OR = 3.02, 95% CI 2.67 – 3.42) and don’t know any source of female condoms (OR = 3.27 95% CI 3.04 – 3.51). Conclusion Compared to urban residents, Burkina Faso rural residents tend to have limited HIV knowledge, limited access to condom. Also, compared to urban residents, more Burkina Faso rural residents had inappropriate HIV attitude and behavior. However, the HIV prevalence was lower among rural residents. The disparities between urban and rural residents of Burkina Faso with respect to HIV knowledge, attitude and behaviors calls for appropriate public health measures to increase HIV awareness in rural areas.

Master of Public Health - MPH / Background:Theoutcomeofpregnanciesinmanyinstancesislargelypredicatedon availabilityofSkilledBirthAttendants(SBAs).Despitethisphenomenon,illiteracyand financialdisadvantagehavebeenvariouslycitedastwinfactorspromotingtheinterest andpatronageofTraditionalBirthAttendants(TBAs)bywomenfolk.Itistherefore expected thatwomenhavingtertiarylevelofeducationandpossessing adequate economic resources would naturally prefer to use the SBAs.However,these http://etd.uwc.ac.za/ 9 observationshavenotsignificantlyreflected therealityin thechoiceofmaternal healthcareprovidersinNigeriaandthecityofLagosinparticular.Yet,accessto maternalservicesoftheSBAshasbeenwidelyacceptedasoneoftheleadingwaysof loweringmaternalmortality.Therefore,inordertoimprovethepatronageofSBAsand correspondinglylowermaternaldeathrates,itbecomesimperativetounderstandthe rationalebehindthepreferencefortheTBAs’usebywomenwhoarenotordinarily expectedtodosobyvirtueoftheirhighlevelofeducationandgoodfinancialcapacity. Aim:Theaim ofthisstudywastoexploreandunderstandtheexperiences,perception and beliefsystems influencing well-educated,middle income women and their reasoningfortheuseofTraditionalBirthAttendantsratherthanSkilledBirthAttendants fordeliveryservicesinLagos,Nigeria. Methodology:ThisisaqualitativestudyconductedinAlimoshoLocalGovernmentArea ofLagosinNigeria.Tenwomenwithtertiarylevelofeducationandbelongingtomiddle incomeeconomiccategorieswereenrolledasparticipants.Inaddition,itinvolved3 FocusGroupDiscussionscomprising7TraditionalBirthAttendantspergroup. Results:Behaviouraland attitudinalshortcomings by the SBAs;misconceptions regardingsurgicaldeliverybywomen;bureaucraticdelaysandbottlenecksexperienced attheSBAs’centres;thebeliefbythewomenthatpregnancyisasacredandspiritual eventwhichonlytheTBAshaveabilitytomanage;women’sconfidenceintheTBAsas havingbettercapacitytomanagecertaincoexistingmedicalconditionsinpregnancy; andmisinformationonmanagementmodalitiesforcertainconditionslikeinfertilityand fibroidallcombinetoinfluencepreferenceforutilizationofTBAsbywell-educated, middleincomewomeninthestudyarea.

Background: Internal migration, a consequence of the demographic transition towards urbanization driven by globalization, represents a particular public health challenge. Change in residence from one sociocultural geographic context to another, with not only economic implications, but also changes in women’s long-established relationships of family interdependence, influences gender relations and can influence Intimate Partner Violence (IPV) against women. Different migratory trajectories may be related to IPV. The aim of this study was to identify the association between internal migration and physical and/or sexual violence against women in the last 12 months. Methods: A secondary analytical cross-sectional analysis of the publicly accessible 2015–2017 Demographic and Family Health Survey (DHS) was performed. The outcome variable was reported physical and/or sexual violence inflicted by the partner (IPV) during the last 12 months. Exposure variable was internal migration, operationalized from three questions: current place of residence, principal place of residence before 12 years of age and number of years of residence in the current place. Migrants were classified as those who reported having lived for 5 years or more in the current location and were categorized as rural-rural migrants, urban-urban migrants, urban–rural migrants and rural–urban migrants, recent migrants and nonmigrants those who resided in the same place all their lives. To identify the association between internal migration and physical violence, a generalized linear model (GLM) of the family and the log Poisson link log option was used, and the results are presented as prevalence ratios (PRs). A crude model and a model adjusted for confounding variables were performed. Results: Rural–urban migrant women had a 15.0% higher probability of experiencing IPV than nonmigrant women (PRa 1.15, 95% CI 1.03–1.29, p = 0.015), while the probability of experiencing IPV in the last 12 months for urban–rural, rural-rural,urban-urban migrantand recent migrant women was not significantly different from that of nonmigrant women. Conclusion: Rural–urban migration among women of childbearing age is a factor associated with a higher probability of IPV in the last 12 months. The identification of women with this rural–urban migration pattern could help prioritize those that may experience a greater probability of physical and/or sexual violence in Peru, it must be studied if this pattern is the same in other countries. / Revisión por pares

Background Under five years of age child mortality rates and the violence against women are prevalent in Rwanda. The violence is known to negatively affect the women’s and their children’s health. This study aimed to examine the association between maternal experience of lifetime intimate partner violence and symptoms of common illnesses (fever, diarrhea, cough, breathing problems) among the children under five years of age in Rwanda. Methods The study was a cross-sectional, based on the data of 2019 –20 Rwanda’s Demographic Health Survey, including 1,290 women and their children. To examine the association between physical, sexual and psychological intimate partner violence and the symptoms of common illnesses, bivariate analysis was performed, followed by logistic regression, where models were adjusted for potential confounders. Results Among the mothers, 36% had experienced physical, 14.7% sexual, and 33.7% psychological intimate partner violence. Around 43% of their children had had symptoms of common illnesses within two weeks before the data collection. In adjusted regression analysis, the experience of physical (OR 1.79, CI 1.41 – 2.27), sexual (OR 1.68, CI 1.22 – 2.30) and psychological intimate partner violence (OR 2.08, CI 1.63 – 2.65) were significantly associated with symptoms of common illnesses among children under five years of age. Conclusion This study showed that maternal experience of lifetime intimate partner violence increases the likelihood of their young children having symptoms of common illnesses in Rwanda. The finding suggests the importance of investing in strategies against intimate partner violence to lower the mortality rates of children within the country.

Background  Both Intimate partner violence and under 5- child mortality are alarmingly high in the world, Nigeria is one of the leading countries. The adverse health outcomes for both women and children as a result of living in a violent environment need to be addressed and combatted. This study aimed to investigate whether there was any association between maternal exposure of lifetime violence (Emotional, physical, sexual, and any violence) and under-5 child mortality.  Method  The study was a cross-sectional study based on secondary data from Nigerian demographic health surveys (DHS) from 2018. The study sample consisted of 8389 married and non-married women, aged 15-49 years who completed the domestic violence module, with a dead or alive first-born child. To assess the associations between maternal experience of lifetime exposure of different types of violence (Emotional, physical, sexual, and any violence) and under-5 child mortality Chi-squared tests were performed, followed by logistic regression. Result In this study, the prevalence of emotional violence was 33,6 %, physical violence 21,3 %, sexual violence 7,7 % and any violence 38,5 %. Moreover, 6,7 % of the children in the sample were dead. The results showed that emotional violence, physical violence, and any violence were not significantly associated with under-5 child mortality. However, sexual violence showed an association with under-5 child mortality (P-value: 0,002). In addition, logistic regression showed that religion was associated with under-5 child mortality (P-value: <0,001). Muslim women had increased odds of child death, compared with Christian women(aOR:0,63, CI:0,50-0,78). The oldest women aged 40-49 years were found to be associated with under-5 child mortality (P-value:< 0,001). High maternal age increased the odds for under-5 child mortality (aOR: 2,08, CI:1,58-2,75). Moreover, maternal working status was associated with under-5 child mortality (P-value: <0,001). Working women had increased odds for experiencing child death, compared with the non-working women (aOR: 7,04, CI: 4,99-9,92). Finally, wealth was negatively associated with the outcome of under-5 child mortality (P-value: 0,007). The richest women had the lower odds of under-5 mortality, compared with the poorest women (aOR: 0,62, CI: 0,44-0,88). Conclusion The study showed an association between sexual violence and under-5 child mortality. Both sexual IPV and under-5 child mortality must be addressed urgently because it has detrimental effects on both women’s and children’s health in Nigeria. The study also found that high maternal age increases the odds for under-5 child mortality, and adequate age for motherhood must be promoted, to save the lives of children. Moreover, belonging to a low wealth quintile increases the risk for child death, and therefore poverty must be relived in Nigeria, so SDG 3.2.1 can be reached: “End all preventable deaths under 5 years and not more than 25 child deaths per 1000 live births by 2030”.