Review of contributions from HDSSs to research in sexual and reproductive health in low- and middle-income countries

Authors


Abstract

Objective

To evaluate the contributions of the INDEPTH Network of health and demographic surveillance system (HDSS) members to research efforts and interventions on reproductive health in low- and middle-income countries (LMICs).

Methods

Review of peer-reviewed published papers on sexual and reproductive health (SRH) that use the HDSS framework through (i) an online search for publications using terminology related to HDSS, HIV, Maternal health, adolescent sexual and reproductive health, family planning/contraceptives and fertility, and (ii) asking INDEPTH member centres for information on their published papers on SRH publications that used the HDSS framework. A paper was included in the review only if it used HDSS data, dealt with SRH issues, and had been published in a peer-reviewed international journal.

Results

Most of the papers in the review focused on HIV, maternal health, family planning and adolescent sexual and reproductive health (ASRH). Generally, people are knowledgeable about HIV. School attendance considerably delays entry into motherhood and reduces the probability of entering into early marriage or sexual union. The general decline in maternal mortality over the last decade is partly due to better access to emergency obstetric services, improved education of women and reduction in fertility.

Conclusion

Sexual and reproductive health is a significant public health need, yet little research has been published in this area to inform policy. The HDSS framework is ideal for SRH research, as it offers the advantage to track and monitor progress of relevant health and demographic indicators, especially in family planning, marriage and fertility studies.

Abstract

Objectif

Evaluer les contributions du Réseau INDEPTH des membres du Système de Surveillance Démographique et de Santé (SSDS) aux efforts de recherche et des interventions en matière de santé reproductive dans les pays à revenus faibles et intermédiaires (PFR-PRI).

Méthodes

Revue d'articles publiés sur la santé sexuelle et reproductive (SSR) qui ont utilisé le cadre SSDS via (a) une recherche en ligne des publications en utilisant la terminologie relative au SSDS, VIH, santé maternelle, santé sexuelle et reproductive des adolescents, planification/contraception familiale et fertilité, et (b) en demandant aux centres des membres de INDEPTH qui ont utilisé le cadre SSDS, leurs articles publiés sur la SSR. Les articles n'ont été inclus dans l'analyse que s'ils ont utilisé les données SSDS, portaient sur des questions de SSR et ont été publiés dans une revue scientifique internationale.

Résultats

La plupart des articles dans la revue étaient axés sur le VIH, la santé maternelle, la planification familiale et la santé sexuelle et reproductive des adolescents (SSRA). En général, les gens sont bien informés au sujet du VIH. La fréquentation scolaire retarde considérablement le début de la maternité et réduit la probabilité de contracter un mariage ou une relation sexuelle précoce. La baisse générale de la mortalité maternelle au cours de la dernière décennie s'explique en partie par un meilleur accès aux services obstétriques d'urgence, l'amélioration de l’éducation des femmes et la réduction de la fertilité.

Conclusion

La SSR est un besoin de santé publique important, mais peu de recherches ont été publiées dans ce domaine pour éclairer les politiques. Le cadre SSDS est idéal pour la recherche sur la SSR, car il offre l'avantage de suivre et de surveiller les progrès des indicateurs pertinents sanitaires et démographiques, en particulier dans la planification familiale, le mariage et les études de fertilité.

Abstract

Objetivo

Evaluar las contribuciones de los miembros de la red de sistemas de vigilancia sanitaria y demográfica (VSyD) de INDEPTH a la investigación en intervenciones en salud reproductiva en países con ingresos medios y bajos (PIMBs).

Métodos

Revisión de las publicaciones con revisión por pares sobre salud sexual y reproductiva (SSR) que utilizaron el marco de VSyD mediante (a) una búsqueda online de publicaciones utilizando terminología relacionada a la VSyD, VIH, salud materna, salud sexual y reproductiva en adolescentes, planeación familiar/anticonceptivos y fertilidad, y (b) preguntando a centros miembros del INDEPTH sobre sus publicaciones de SSR para las que se había utilizado el marco de VSyD. Una publicación se incluía en la revisión solo si había utilizado datos de VSyD, tenía que ver con SSR y se había publicado en una revista internacional con revisión por pares.

Resultados

La mayoría de las publicaciones incluidas en la revisión estaban enfocadas al VIH, la salud materna, la planeación familiar y la salud sexual y reproductiva en adolescentes (SSRA). En general, las personas tenían conocimientos sobre el VIH. El haber ido a la escuela retrasaba considerablemente la entrada en la maternidad y reducía la probabilidad de un matrimonio o unión sexual temprana. La disminución general de la mortalidad materna durante la última década es en parte debida a un mejor acceso a los servicios de emergencia obstétrica, una mejora en el nivel educativo de las mujeres y una reducción de la fertilidad.

Conclusión

La SSR es una importante necesidad de salud pública, y sin embargo se han hecho pocas publicaciones en esta área que puedan guiar las políticas sanitarias. La red de VSyD es ideal para la investigación en SSR, puesto que ofrece la ventaja de seguir y monitorizar el progreso de indicadores sanitarios y demográficos relevantes, especialmente en estudios de planeación familiar y fertilidad.

Introduction

As defined by the United Nations, Sexual and Reproductive Health (SRH) is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to reproductive systems and to its functions and processes’ (United Nations 1994a,b) . Indisputably, SRH is a broad concept. It often refers to subareas such as fertility, marriage, HIV/AIDS, family planning, abortion, and adolescent sexual and reproductive health (ASRH).

One in 26 women of reproductive age dies from a maternal cause in Africa, as opposed to one in 9400 in Europe. In 2012, the total fertility rate (TFR) was 1.6 in more developed countries and 2.6 in less developed countries; in Africa, it was 4.7. In Africa, 31% of married women use contraception (all methods) and 26% of them use modern methods (Population Reference Bureau 2012). A gap persists between the rich and the poor regarding contraceptive use despite the expansion of family planning services and general improvement in socio-economic status (Gakidou & Vayena 2007). Health disparities between the rich and the poor remain a big challenge (Ahmed et al. 2010).

Reaching agreement on the concept of SRH was a milestone of the International Conference on Population and Development, but putting the concept into action is difficult. In the international setting and national development discourse, SRH relates to the health and well-being of individuals, families and society. Advancements in SRH are very important for every country that seeks development. Thus, WHO announced in June 2012 at the Family Planning Summit in London the integration of SRH into basic healthcare and family planning services.

The Millennium Development Goals (MDGs) cannot be achieved without ensuring that the populace have universal access to SRH services and HIV prevention, treatment, care and support (www.un.org/millenniumgoals ). Less attention is given to SRH research and the translation of research evidence to policy issues. SRH becomes controversial within political, religious and ethnic contexts. Continued poor SRH outcomes in low- and middle-income countries (LMICs) highlight the difficulties in reforming policies and laws and implementing effective programmes. One way of getting accurate and up-to-date information on the population is through health and demographic surveillance systems (HDSSs); the majority of these in LMICs are now organised through the INDEPTH Network (www.indepth-network.org).

Our objectives were to (i) identify key contributions made by INDEPTH member HDSSs in SRH research, (ii) identify and discuss any gaps in SRH research, (iii) raise awareness for the need for SRH research using the HDSS platform, and (iv) provide a synthesis of research evidence to guide policy and planning.

Overview of indepth network and HDSSs

INDEPTH is a network of member health research centres, which operate HDSSs in LMICs. As of March 2013, INDEPTH had 41 member research centres operating 48 HDSSs in 20 countries in Africa, Asia and Oceania. A total of 36 HDSSs are in Africa, 10 in Asia and 2 in Oceania with more than 3 200 000 people under surveillance. Most of the HDSSs are located in rural areas, with few urban and peri-urban ones (Sankoh & Byass 2012). HDSSs are established to collect epidemiological data (risks, exposures and outcomes) within a defined population on a longitudinal basis. In terms of Pearce's classification scheme for epidemiological study designs (Pearce 2012), the HDSS approach is very comprehensive because all available information on the source population over the risk period is used. Unlike many epidemiological study designs, in which study participants are somehow selected to represent particular population subgroups, HDSSs generally set out to cover a real-life population and observe what happens epidemiologically over a period of years and even decades (Figure 1 here).

Review process

The study considered peer-reviewed published papers on SRH using the HDSS framework, which makes longitudinal evaluation of the data possible. The reason for limiting ourselves to studies carried out at HDSS field sites was to evaluate their contribution to research efforts and interventions on SRH in LMICs.

Two search methods were used: an online search and a specific call to all 48 INDEPTH member HDSSs. The inclusion criteria for a paper to be considered in the study (i) were published in a peer-reviewed journal in English, (ii) were covering at least one of the following SRH areas: HIV/STIs, maternal health, contraceptives, abortion, fertility, adolescents, or family planning and must substantially address an SRH issue, (iii) must have used the HDSS framework, and (iv) must be carried out in an LMIC.

PubMed and Google Scholar were used for the online search between June and July 2012, which was updated after reviewers’ comments. The specific call to INDEPTH HDSSs was sent in the same period with a deadline for submission. The call asked centres to indicate any published papers in the areas mentioned earlier.

Fifteen HDSSs submitted publications (not all INDEPTH member HDSSs focus on SRH issues). After the revised search, 97 papers were identified, 44 of which used cross-sectional surveys using the HDSS platform, six were cohort studies within the HDSS, four used mixed methods and two were nested surveys with the HDSS (Table 1 here).

Table 1. Showing research methods used for the various studies
Research methods used for the papersNumber of papers
Cross sectional survey44
Cohort studies6
Mixed methods4
Nested Survey2
Qualitative method (FGD)7
Baseline survey1
Experimental method (Randomised control trials)1
Unknown32

Results

Dedicated SRH research projects in LMICs

We reviewed 97 studies. Thirty-nine were on HIV followed by maternal health (29), and 11 papers each were published on family planning and ASRH. Relatively little attention has been paid to research areas such as marriage and fertility. (See Appendix List of papers with authors reviewed under this study for list of paper and authors). These studies span the period from the 1970s to 2010, and projects on SRH that used the HDSSs platform with publications (Figure 2 here).

Geographical distribution of SRH publications

Geographically, 18 of the SRH publications reviewed were published by HDSSs in Kenya, 20 by South Africa and 12 by Tanzania. Indeed, most of the SRH publications by countries were from East Africa followed by South Africa and then West Africa. Cross-country publications accounted for 4 of the papers reviewed. Four papers were reviewed from Bangladesh, five from Vietnam and one from Thailand of the total publications, which probably highlights the fact that the review did not capture papers in languages other than English (Figure 3 here).

The regional disparity in SRH publications can also be attributed to other factors including the research focus of the HDSSs. Some HDSSs were established to research on specific areas such as HIV/AIDS, malaria and child mortality, hence SRH research is not prominent in many HDSSs.

Figure 1.

The concept of a longitudinal HDSS (source: Sankoh & Byass 2012).

Figure 2.

A bar chart showing results of the 97 papers on SRH reviewed.

Source: From the review of INDEPTH HDSSs published papers on SRH.

Figure 3.

Showing Geographical distribution of SRH Publications by HDSSs.

Source: From the review of INDEPTH HDSSs published papers on SRH.

Findings of the four SRH-focused areas by HDSSs

The studies on HIV focused on sexual behaviour, knowledge and attitudes, marital partnership, mobility and separation of couples. The studies were conducted mostly in East Africa and South Africa; the majority used cross-sectional surveys or cohort studies. Prevalence of HIV was investigated, and sexual behaviour was considered very important in almost all papers on HIV reviewed (Urassa et al. 2006 ; González et al. 2012 ; Amornkul et al. 2009 ; Da Silva et al. 2008 ; Bärnighausen et al. 2008 ; Madise et al. 2012) . Women mostly have a significantly higher HIV prevalence than men. The HIV incidence rate was significantly higher for both men and women. On knowledge, attitude and behaviour, nearly all respondents in the studies had knowledge about HIV/AIDS and sexual transmission of HIV. The reported number of sexual partners among sexually active men and women did not change over the past years; half of the men had more than one partner. Generally, most individuals continued to feel that they were not at risk of HIV, but two studies (Achan et al. 2009, 2010) found that young womens’ childbearing obligations make protective sex less feasible for them; more assertive women insist their husbands use condoms, or employ protective strategies such as masturbation of their partner when they perceive themselves at risk.

Sociocultural changes are affecting marriage (Boerma et al. 1999, 2002, 2003). Sex outside marriage and having more than one sexual partner was common, as was infrequent condom usage. Prevalence of HIV in adolescents is slower in men than women and peaks during their thirties. Migration is a significant factor for HIV infection. Among women who were mobile, sex with partners outside marriage was common (Todd et al. 2007; Coffee et al. 2007; Camlin et al. 2010). This mobility, coupled with risky sexual behaviour, increases their risk of contracting HIV compared with women who are not mobile. The sexual behaviour of men whose wives are mobile is as risky as that of men who are mobile themselves (Kishamawe et al. 2006). Nevertheless, the impact of migration depends upon the epidemic's stage of HIV infection and the pattern of migration (Boerma et al. 2002). Frequent migration between populations with different HIV prevalence rates accelerated HIV spread in the early epidemic stage, but local sexual risk behaviour determined the eventual scale of the epidemic (Gregson et al. 2009).

The survival rate of HIV-infected individuals in developing and developed countries was the same before antiretroviral therapy was introduced (Isingo et al. 2007; Todd et al. 2007). Jahn et al. (2008) found that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy. Gargano et al. (2012) found an increase in HIV resident enrolment when ART facilities increased in the study area. Cooke et al. (2010) found that an individual's likelihood of accessing ART was not associated with level of education, household assets or urban/rural locale. ART uptake was strongly negatively associated with distance from the nearest primary healthcare facility. Chihana et al. (2012) found that 4 years after the introduction of ART into HIV care in Karonga district, all-cause mortality had fallen dramatically, with no evidence of an increase in deaths owing to NCD.

Two studies on HIV counselling (Baiden et al. 2005, 2007) found that most people desire to know their HIV status but prefer locations outside of the health facility for VCT. The majority of respondents accepted lay counsellors. Stigmatisation of people living with HIV/AIDS (PLWHA) was evident (Baiden et al. 2005). More than half of the respondents believed that they could get HIV by sharing a drinking cup or by buying food items, such as vegetables, from infected people. People with formal education were less likely to stigmatise people living with HIV/AIDS. Ndinda et al. (2007) found negative attitudes towards those living with HIV by the general community. Willingness to get tested for HIV by pregnant women does not equate with the perception of the test's usefulness, and spouses were likely to exert strong influence on the attitude towards VCT (Baiden et al. 2007). HIV testing participation was related to discussing HIV screening with the partner and the number of antenatal care (ANC) visits already accomplished (Sarker et al. 2007). Ziraba et al. (2010) found that more men than women were willing to be tested for HIV when they are contacted for the test. Perceived risk of HIV infection may drive HIV testing among youth (Kabiru et al. 2011).

The studies of Lan et al. (2008) on reproductive tract infections (RTI) and perception and attitudes to RTI in Vietnam found that RTI/STI were prevalent among married women in a rural population of Vietnam. Health-seeking patterns for reproductive tract infections including sexually transmitted infections (RTI/STI) differed between men and women in rural areas; self-medication was more common among women, while men were more likely to seek health care from private providers. Lan et al. (2009a,b) found that of 1805 respondents, 78% (73% married vs. 93% unmarried, P < 0.001) did not know any symptoms of STI, 50% could not identify any cause of STI and 59% (54% married vs. 76% unmarried, P < 0.001) did not know that STI can be prevented. Only 31% of the respondents (36% married vs. 14% unmarried, P < 0.001) knew condom use could protect against STI, and 56% considered partner treatment necessary. Of the 465 healthcare providers interviewed, 80% considered gonorrhoea and syphilis as STI. Sharing clothes/food or kissing were commonly mentioned as transmission routes (60%).

Hunter et al. (2002) found a substantial reduction in fertility among HIV-infected women compared with HIV-uninfected women. Mwaluko et al. (2003) and Bloom et al. (2002) found that men who lived in trading centres or subvillages with the highest level of social and economic activity have a higher probability of being HIV positive than those in places with low levels of activity. Nnko et al. (2004) found that under-reporting of non-marital partnerships was much more common among single woman than among married women and men. Women who reported multiple partners were at high risk of contracting HIV.

Bärnighausen et al. (2007) found that one additional year of education reduced the hazard of acquiring HIV by net of sex, age, wealth, household expenditure, rural vs. urban/peri-urban residence, migration status and partnership status. In Bärnighausen et al. (2009), the study showed for the first time that high levels of HIV incidence have been maintained without any sign of decline over the past 5 years in both women and men in a rural South African community with high HIV prevalence.

Maternal health

Twenty-nine research and intervention studies were reviewed on maternal health: 12 from East Africa, 12 from West Africa, two from South Africa and three from Asia. The studies show that there has been a decline of maternal death over the years 1976–2010 attributable to better access to emergency obstetric services, improved education of women and reduction in fertility.

The major causes of maternal death were complications from abortions, haemorrhage, sepsis, eclampsia, hypertension disorders, sepsis, obstructed labour and ruptured uterus (Hoj et al. 1999; Baiden et al. 2006 ; Mills et al. 2008a,2008b). Hoj et al. (2003) found that more maternal deaths occur during the first 42 days after delivery/miscarriage.

The slum population in Nairobi City had a high maternal mortality ratio, high rates of unwanted pregnancies and abortions (Ziraba et al. 2009). Abortion complications were one cause of maternal deaths in the study. Abortion-related deaths were better captured by verbal autopsy than healthcare facility records. Pregnant women may decide by themselves to visit ANC, but they were more likely to do so after advice by mothers or mothers-in-law. Women learn about a proper diet, the benefits of regular ANC visits and delivery in hospital, about newborn care, family planning, HIV and malaria prevention.

Ba et al. (2003) carried out a study in three rural sites (Niakhar, Bandafassi and Mlomp) and found that among the 471 female deaths using verbal autopsy, 97 were in Niakhar, 36 in Bandafassi and 10 in Mlomp. The risk of maternal death was 1 woman in 21 in Niakhar, 1 in 16 in Bandafassi and 1 in 41 in Mlomp. Maternal mortality rate was 13.3/10 000 reproductive age women in Niakhar, 17/10 000 in Bandafassi and 6.9/10 000 in Mlomp. Kodio et al. (2002) and Pison et al. (2000) found that the maternal mortality ratio was similar in Mlomp and Niakhar, but significantly higher in the more remote area of Bandafassi.

Factors significantly associated with women giving birth outside hospital were age ≥30 years, pregnancy ‘wantedness’, parity ≥5, low socio-economic status of the household, <8 years of education and >1-h walking distance from a health facility (Van Eijk et al. 2006 ; Hoj et al. 2002) . De Allegri et al. (2011) found that living within 5 km from a health facility, and having attended at least three ANC visits were positively associated with delivering in a health facility. In De Allegri et al. (2012) again assessed the impact of targeted subsidies for facility-based delivery on access to care and equity found that the amount received for all services associated with births decreased by 67% (P < 0.001), but women continued to pay on average 1423 CFA ([euro] 1 = 655 CFA), about 500 CFA more than the set tariff of 900 CFA. Mills et al. (2008a,2008b) found that physical access factors such as availability of public transport, travel distance to the district hospital as well as community perception of access to the nearest health facility are statistically significantly associated with use of health professionals at last delivery. Fotso et al. (2009a,2009b) found that household wealth, education and demographic and health covariates had strong relationships with place of delivery; the effects of women's overall autonomy, decision-making and freedom of movement were rather weak. Apart from education and wealth, main predictors of place of delivery included being advised during antenatal care to deliver at a health facility, pregnancy ‘wantedness’ and parity (Fotso et al. 2009a,2009b) .

In a study on reproductive health issues in rural western Kenya, Van Eijk et al. (2008) found that of 673 participants, 41% had started antenatal clinic visits at the time of interview and 69% reported ITN use; 19% reported using a contraceptive method to delay or prevent pregnancy before the current pregnancy (injection 10%, pill 8%, condom 0.4%). Ouma et al. (2010) found no difference in attendance with regard to antenatal care (ANC) in the two areas they studied.

Essendi et al. (2011) indicated that utilisation formal emergency obstetric care services are inhibited by various factors, including ineffective health decision-making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. Kruk et al. (2010) found that women are persuaded to utilise a health facility for delivery when there is receptive provider attitude and availability of drugs and equipment.

In their study on population and antenatal-based HIV prevalence estimates in a female population in rural South Africa with a high rate of contraceptive use, Rice et al. (2007) found that population-based HIV prevalence estimates for all women (25.2%) and pregnant women (23.7%) were significantly lower than that for ANC attendees (37.7%).

Doctor et al. (2012) found that, of 38 761 maternal sisters of whom 3592 had died and of whom 1261 were maternal-related deaths, the LTR of maternal death was 8% (referring to a period of about 10.5 years prior to the survey) with a maternal mortality rate of 1049 deaths per 100 000 live births (95% confidence interval, 1021–1136).

Men were willing to pay more than women, while women were willing to pay a greater proportion of their income for improvement in maternal health (Ternent et al. 2010) . HIV-infected women experienced more morbidity and mortality than HIV-uninfected women (Coutsoudis et al. 2010) ; this was predicted by maternal immune status and socio-economic factors. A study by Assefa et al. (2012) found that out of a total of 1438 pregnancies, 143 (9.9%) did not end in live births (116 ended due to bleeding and 27 were stillbirths). Pregnancy loss was low among women with pregnancy interval of two or more years and high among women having unplanned pregnancy. In women in Nairobi poverty generates adverse maternal outcomes by exposing women to exceedingly hard and heavy workloads during pregnancy and postpartum (Izugbara & Ngilangwa 2010). It also exposes women to inhospitable and unpleasant treatment by service providers.

One intervention study on a maternal health voucher programme (Bellows et al. 2013) found a statistically significant increase in attended deliveries after the voucher programme was implemented. The significant increase in deliveries with skilled birth attendants (SBAs) indicates that the vouchers did not merely shift women who would deliver at home with a SBA to a facility. Although claiming causality is difficult with the lack of comparable control areas that did not receive the voucher intervention, the finding shows a positive association between programme launch and increase in facility deliveries. Another notable finding was that the voucher was more likely to be used by women in their first pregnancy than by women with higher parity, which may reflect preferences formed in previous deliveries.

A study by Koenig et al. (1988) revealed a significant reduction in maternal mortality rates and was attributed to introduction of a family planning programme in half of the Matlab study area. Rahman et al. (2010) found that the difference in maternal mortality rates between the two areas was mainly a result of the MCH-FP area's lower pregnancy rate and its lower case-fatality rates for induced abortions, miscarriages and stillbirths. However, Chowdhury et al. (2009) revealed education of women as a strong predictor of the maternal mortality decline in both areas studied.

Adolescent sexual and reproductive health

Ten of the 11 papers on adolescent sexual and reproductive health (ASRH) were surveys; one (De Walque et al. 2012) was a randomised control trial, which was an intervention study. The studies focused on adolescent transition, adolescent sexuality and risky behaviour, first sex experience, first birth, first independent housing, marriage and parenthood. Two papers (Beguy et al. 2011; Kabiru et al. 2010) revealed that education of adolescents may significantly delay childbearing. School attendance considerably delays adolescents’ entry into motherhood and reduces the probability of entering into early marriage. Sexual experience for adolescent boys and girls happens outside marriage or another union (cohabiting). Beguy et al. (2011) found that marriage, being out of school and having negative models in peer, family and school contexts are associated with early childbearing among females aged 15–17 years. In a study on adolescent resilience, a significant proportion of 1722 never-married, aged 12–19 adolescents growing up in urban slums managed to stay in and do well in school and avoid engagement in risk behaviours (Kabiru et al. 2012). Beguy et al. (2009) study on inconsistency on self reporting of sexual activity among adolescents found that adolescents males who are in school and are slum residents were more likely to give inconsistent on their sexual activity.

Haque and Soonthorndhada (2009) found that the majority of adolescents engage in sexual activity before the age of 20 years. Unmarried adolescents are more likely to use condoms when having sex with temporary partners than with their regular partners because of perceived risk of contracting STI from temporary partners. Education plays a critical role in risk perception of STIs: perception of risk increases with level of education. Age group and first sexual experience are significantly associated. School enrolment and higher educational level were associated with delay of sexual debut and delay of childbearing.

An analysis of age at first sex (AFS) by McGrath et al. (2009) revealed that factors associated with earlier AFS across gender were peri-urban residence (vs rural), ever use of alcohol and knowing at least one person who had HIV; in contrast, school attendance had a significantly delay on early sexual activity. Maternal death was significantly associated with earlier AFS for women.

A study on abortion by Ganatra and Hirve (2002) revealed that of the married women interviewed on induced abortion, most young adolescents reported that they have a lesser role in the decision-making process on abortion than older women. Most abortions were obtained in the private sector, and birth spacing was the main reason for adolescents seeking abortion, but prior contraceptive use among them was rare. Sex selection accounted for more than one-fifth of abortions among adolescents, and most adolescents were less likely than older women to receive post-abortion contraceptive counselling or to adopt contraception. A qualitative analysis on never-married and separated adolescents seeking abortion revealed that many unwanted pregnancies were from non-consensual sex. Due to cost, stigmatisation and lack of partner/family support, many prefer to go to unqualified practitioners to have abortion.

A randomised control trial on a strategy of preventing HIV and sexually transmitted infection (STI) and of sensitising people to safe sex through the use of conditional cash transfers (De Walque et al. 2012) found a significant reduction in combined point prevalence of the four curable STIs for the group, which received quarterly payments of $20. Such a reduction was not found among the group that received quarterly payments of $10. The impact of the conditional cash transfer did not differ between males and females.

Maharaj (2006) found that of 2067 sexually active men and women aged 15–24, 64% of condom users cited protection against both pregnancy and HIV infection as the main reason for condom use. Among HIV-infected adolescents aged 14–17 (n = 983), males were significantly more likely than girls to report lifetime sexual activity (37.7% vs. 13.8%, P < 0.01) (Harrison et al. 2012) . Perceptions of male peer behaviour were associated with both ever having participated in sexual activity. Discussion of condom use with a partner was found to be the strongest predictor of condom use.

Family planning

Eleven papers were reviewed on family planning. Five from West Africa, two from East Africa, two from South Africa and two from Asia. Main issues investigated were knowledge about contraception, available and preferable methods of contraception, abortion and spousal communication on risky sexual behaviours.

A study on exploring the condom gap (Papo et al. 2011) found that almost half of among sexually active respondents had ever used a condom and that condom use was less common among rural than urban respondents (< 0.05). A study by Hall et al. (2008) on social and logistical barriers to the use of reversible contraception among women in a rural India found that married women obtain information on contraceptives from other village women. Most married women in rural India believe that modern reversible and irreversible methods carry high physical and social risks and that a woman can achieve fertility goals without their use. To them, reversible contraception is undesirable, socially unacceptable and usually unnecessary.

In a study on project exposure on contraceptive knowledge, awareness of supply sources, reproductive preferences, contraceptive use and fertility, Debpuur et al. (2002) found an increase in knowledge of methods and supply sources as a result of exposure to project activities. There was an emergence of preferences to limit childbearing, which was associated with the deployment of nurses to the communities. Ndiaye et al. (2003) study found that married men and women were more likely to know about methods such as the pill, intra-uterine device (IUD) and injections due to family planning campaigns, which mostly focus on these methods with married women as the target. Subramanian et al. (2008) found significantly higher odds of current contraceptive use among married vs. engaged/unmarried women and age, marital status, education level and parity were found to be associated with different contraceptive method choices.

Bawah (2002) showed that spousal communication does predict contraceptive behaviour, even when other factors are controlled. In a society where payment of bride wealth denotes a woman's requirement to bear children, there are deeply ingrained expectations about women's reproductive obligations, and therefore, contraception becomes a problem (Bawah et al. 1999). Women who mostly use injectables as contraceptive method are regarded by men as ‘wet’, ‘cold’ and/or ‘tasteless’ (Smit et al. 2002).

Switching from traditional religion to Christianity or Islam is associated with increased contraceptive use and decreased fertility. The more rapid change in religious affiliation among women than men may have social consequences for the status of women, signalling a trend towards greater autonomy in the family and new aspirations, values and behaviour as evidenced by the proportion of people adopting contraceptives (Doctor et al. 2009). Fertility declined in the intervention area from 4.8 in 1979 to 2.9 in 2000 after maternal and child health and family planning programme which was implemented in 1977, while contraceptive prevalence rose from 30% to 70% and from 16% to 50% in intervention and the comparison areas, respectively (Saha & Bairagi 2007).

Menstrual resumption acts as a start for initiating contraceptive use with a peak of contraceptive initiation occurring shortly after the first month when menses are reported (Ndugwa et al. 2011). No variation was found in contraceptive method between women who initiate contraceptive use before and after menstrual resumption. In marginalised areas such as slums, poor post-partum women experience an appreciable risk of unintended pregnancy. Adolescents who have temporary partners were more likely to perceive the risks associated with STIs in relation to condom use.

Discussion

Our findings reveal a significant association between adolescent age and sexual debut. Education reduces the likelihood of entering into early marriage, consistent with the findings of Dodoo et al. (2003). Higher education level and school enrolment were associated with delayed childbearing (Beguy et al. 2011; Kabiru et al. 2010). Prevalence of HIV, knowledge of HIV/AIDS, STIs and sexual behaviour were considered very important in almost most HIV studies. This is because this indicators help to inform policy with evident based information.

Sociocultural changes are affecting marriage systems through premarital sex and multiple partners, which has increased vulnerability to HIV and other infectious diseases (Boerma et al. 1999, 2002). The voucher intervention study for pregnant women (De Walque et al. 2012), which increased antenatal and delivery at health facilities, clearly shows that there is need for more intervention studies in LMICs for result-oriented outcomes and better health-seeking behaviour. Interventions, especially those involving cash transfers, have greater impact on people's behaviour.

The INDEPTH HDSSs platform provides opportunities for researchers to test hypotheses, clinical trials interventions among others. HDSS's longitudinal data contribute to understanding of trends and patterns analysis. The platform gives year-by-year trends and reveals patterns of events in the population. The longitudinal platform also allows for impact assessment when an intervention is introduced in a defined population.

Why is so little research carried out in some areas of SRH?

Most studies have been on HIV/AIDS and maternal health, with some focus on adolescent sexual and reproductive health and family planning, with a considerable number of papers on HIV from East Africa. Rather less attention has been paid by HDSSs to fertility and marriage, where no comparative cross-centre paper has been published on SRH by HDSSs. Abortion, male involvement in family planning, ASRH communication between parents and adolescents and sources of reproductive health information available to adolescents need to be the subjects of studies.

Inadequate data collection on needed variables might explain this. All INDEPTH member HDSSs are required to collect data on fertility (and monitoring of pregnancies). However, more variables are not taken into consideration, and therefore, data are not collected on them. This makes it difficult to compute some important indicators at analysis stage, rendering HDSSs unable to publish much on fertility. INDEPTH as a network is working to improve HDSSs data to have quality and plausible data for the network.

Most centres were established with a vision or a particular research agenda in mind, perhaps informed by the prevailing issues at the time and by the funding institution. Most HDSSs were established to do research on malaria, neonatal mortality, under-5 mortality among others, which does not enable them to conduct other research unless there is available funding for that purpose. Studies are largely determined by funders.

Cultural barriers present other problems. Some HDSSs have difficulties getting ethical clearance or implementing some research. For example, research on abortion or family planning cannot be implemented in some parts of LMICs. It may be difficult to collect data from respondents even when ethical clearance has been granted.

The year of establishment of HDSSs and their priority research areas (Appendix List of papers with authors reviewed under this study) also play a role in this discussion. Table 2 below shows that 20 HDSSs were established in the 1990s, concentrating on HIV and maternal health. Between 2000 and 2004, research focused on maternal health, HIV and fertility. In the years 2005–2009, priority was given to research on HIV, maternal health, marriage, ASRH and family planning. Between 2010 and 2012, ASRH became the priority.

Table 2. Showing the date of establishment of HDSSs and the number of publications during that period
YearNumber of HDSSs in existenceNumber of publications
  1. Source: SRH papers reviewed from HDSSs centers.

1980s–1990s205
2000–20043115
2005–20093744
2010–20124833

Conclusion

This review has shown that the HDSS platform can be effectively used to carry out SRH research. Specifically, research on family planning, marriage and fertility is needed to inform interventions and policies to reduce other reproductive health-related problems such as unsafe abortion, pregnancy complications and transmission of HIV/AIDS. Much attention on SRH needs to focus on family planning. There should be more emphasis on contraception, which helps reduce fertility and also prevents HIV/AIDS and other STIs. Marriage patterns, especially how these patterns are likely to affect mobility and vulnerability to infection in young women and men, need to be studied. In conclusion, SRH is a significant public health need in all communities. It is crucial in the development of any country; yet, research in these areas is scarce.

Appendix: List of papers with authors reviewed under this study

Name of the study/projectAuthors, sponsors, collaborating agencies, year of publicationSampleStudy designYear of studyCountry, geo-coverageGeneral scope covered
Fertility
 Determinants of fertility in rural Ethiopia: the case of Butajira Demographic Surveillance System (DSS)Mekonnen & Worku (2011)9996Survey Butajira, EthiopiaMarriage, fertility, Education
 Measurement of trends in unintended birth in Bangladesh, 1983–2000Gipson et al. (2011) Cross-sectional data from five KAP surveys1983–2000BangladeshUninteneded birth, fertility preferences
 Fertility trends and net reproduction in Agincourt, rural South Africa, 1992–2004Garenne et al. (2007)Female population AGE:15-49 1992–Agincourt, South AfricaFertility
 Fertility Trend and Pattern in a Rural Area of South Africa in the Context of HIV/AIDSCamlin et al. (2004)21 847 women  KwaZulu-Natal (KZN), South Africancontraceptive use, HIV prevalence, fertility
 Refining the Criteria for Stalled Fertility Declines: An Application to Rural KwaZulu-Natal, South AfricaMoultrie et al. (2008)  1990–2005KwaZulu-Natal, South AfricaFertility, stalled fertility, contraceptive methods
HIV/AIDS
 Trends in HIV and sexual behaviour in a longitudinal study in a rural population in TanzaniaMwaluko et al. 20037438 males and femalesOpen community cohort study with all consenting adults. Age 15–441994–2000Tanzania, Mwanza- Kisesa wardHIV/AIDS
 Determinants for HIV testing and counseling in Nairobi urban informal settlementsZiraba et al. (2011)3162Cross sectional survey2006–2007Viwandani and Korogocho in NairobiHIV testing status
 Time from HIV seroconversion to death: a collaborative analysis of eight studies in six low and middle-income countries before highly active antiretroviral therapyTodd et al. (2007)41103 population based, 2 occupational, 3 clinic cohorts 

Kisesa, Tanzania

Masaka, Uganda

Rakai, Uganda

South African miners

Thailand blood donors

HIV
 The impact of HIV/AIDS on mortality and household mobility in rural TanzaniaUrassa et al. (2001)20 000 males and femalesOpen community cohort study with a demographic surveillance system andtwo sero-epidemiological surveys. aged 15 ± 44 years1994–1998 Kisesaward in Mwanza, TanzaniaHIV-specific mortality
 Survival after HIV infection in the pre-antiretroviral therapy era in a rural Tanzanian cohortIsingo et al. (2007)369Open cohort study1994 and 2006Kisesa in Mwanza, TanzaniaHIV/AIDS
 Socio demographic context of the AIDS epidemic in a rural area in Tanzania with a focus on people's mobility and marriageBoerma et al. (2002)12 233 males and females

First and second survey: 5820 and 6413 respondents

Age 15–44

1994–1998Kisesa in Mwanza, TanzaniaHIV/AIDS knowledge and attitude,sexual behaviour, STI treatment, marital partnerships, Poverty, Marriage, migration
 Understanding the Uneven Spread of HIV Within Africa Comparative Study of Biologic, Behavioural, and Contextual Factors in Rural Populations in Tanzania and ZimbabweBoerma et al. (2003) Cross-sectional population-based HIV surveys1998–2000Kisesa,Tanzania and Manicaland, ZimbabweHIV, STI, Marriage, spatial mobility, sexual partners, education
 Sexual behaviour change in countries with generalized HIV epidemics? Evidence from population-based cohort studies in sub-Saharan AfricaGregson et al. (2009) longitudinal studies1998–2007Uganda, Tanzania, Malawi, Zimbabwe and South AfricaSexualbehaviour, HIV
 Modelling the impact of migration on the HIV epidemic in South AfricaCoffe et al. (2007)488 adultsSurvey KwaZulu/Natal, South AfricaMobility, HIV, sexual behaviour
 Mobility and HIV in Tanzanian couples: both mobile persons and their partners show increased riskKishamawe et al. (2006)2800 couplesSurvey from Longitudinal cohort study1996 and again in 2002Kisesaward in Mwanza, Tanzaniasexual behaviour, HIV, mobility
 HIV prevalence and sexual behaviour changes measured in an antenatal clinic setting in northern TanzaniaUrassa et al. (2006)11 ANC clinics- two in Mwanza city, 1 in the district hospital in Magu town, 4 in rural roadside settlements, 4 in remote rural areas of Magu districtSurvey2000 and 2002.North west TanzaniaHIV prevalence and sexual behaviour
 Spread of HIV infection in a rural area of TanzaniaBoerma et al. (1999) Twosero-surveys of all resident adults aged 15–44 and 15–46 years1994–1995 and 1996–1997 respectivelyKisesaward in MwanzaRegion, TanzaniaHIV prevalence, mobility, sexual behavior, commercial sex workers
 Community effects on the risk of HIV infection in rural TanzaniaBloom et al. (2002)Men = 2271 and women = 2752Survey1994–1997Kisesaward in Mwanza Region, TanzaniaHIV
 High HIV prevalence in Southern semi-rural area of Mozambique: a community –based surveyGonzález et al. (2012)722 age 18–47Cross- sectional community study Manhica, MozambiqueHIV, Ante Antenatal clinic
 The effect of non response on HIV prevalence estimates in a population-based survey in two informal settlements in Nairobi cityZiraba et al. (2010)

4767 age 15–54 men

Age 15–49 females

Cross sectional serosurvey2006–2007Viwandani, Nairobi-KenyaHIV
 The association between HIV and fertility in rural TanzaniaHunter et al. (2003) Survey1994–1998Kisesa, TanzaniaHIV, fertility, contraception
 Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in MalawiJahn et al. (2008)32 000Survey2002–2006Northern MalawiHIV, adult mortality, Antiretroviral therapy
 HIV prevalence and associated risk factors among individuals aged 13–34 years in Rural Western KenyaAmornkul et al. (2009)1822Survey2003–2004West KenyaHIV/STI
 Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in KenyaMadise et al. (2012)3000 men and women (compared with 6500 from DHS)Cross sectional serosurvey2006–2007Viwandani, Nairobi-KenyaHIV and social determinants
 The adult population impact of HIV care and antiretroviral therapy (ART)- Nyanza province, Kenya, 2003–2008Gargano et al. (2012)5421 adults 2003–2008Nyanza, KenyaHIV, antiretroviral therapy
 HIV/AIDS among youth in urban informal (slum) settlements in Kenya: what are the correlates of and motivations for HIV testing? Kabiru et al. (2011)4028 (51% male and 49% females) youth (12–22 years) Survey2007Korogocho and Viwandani slum settlements in Nairobi (Kenya)HIV testing
 Determinants of HIV Counselling and Testing Participation in a Prevention of Mother-to-child Transmission Programme in Rural Burkina FasoSarker et al. (2007)435 pregnant womenCross sectionalJuly to December 2004Burkina FasoHIV counselling and testing, antenatal visit, mother –to-child transmission
 Community Attitudes Towards Individuals Living with HIV in Rural KwaZulu-Natal, South AfricaNdinda et al. (2007) Qualitative study South AfricaAIDS, cummunity attitudes
 Coping Strategies of Young Mothers at Risk of HIV/AIDS in the Kassena-Nankana District of Northern GhanaAchan et al. (2009)Young mothers in their mid-twenties to early thirties and their male partnersQualitative study GhanaMothers’ vulnerability to HIV/AIDS
 Postpartum Abstinence and Risk of HIV among Young Mothers in the Kassena-Nankana District of Northern GhanaAchan et al. (2010) Qualitative study Ghanayoung mothers’ sexual conduct, vulnerability to HIV infection, postpartum abstinence, STIs
 Using Lay Counselors to Promote Community-based Voluntary Counselling and HIV Testing in Rural Northern Ghana: a Baseline Survey on Community Acceptance and StigmaBaiden et al. (2007)403 respondentsA cross-sectional questionnaire survey and Qualitative (Focus group discussions) Kassena-Nankana, GhanaVoluntary counseling and HIV testing, HIV/AIDS
 Voluntary Counseling and HIV Testing for Pregnant Women in the Kassena-Nankana District of Northern Ghana: Is Couple Counseling the Way Forward?Baidenet al. (2007)270 antenatal clinic attendants  Kassena-Nankana, Ghanavoluntary counseling and HIV testing, Pregnant Women
 Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural TanzaniaNnko et al., (2004)All men and woemn of reproductive age in the study area  TanzaniaHIV, sexual behaviour
 Lack of a Decline in HIV Incidence in a Rural Community with High HIV Prevalence in South Africa, 2003–2007Bärnighausen et al. (2009)8095 individuals 2003–2007KwaZulu-Natal, South AfricaHIV incidence
 High HIV Incidence in a Community with High HIV Prevalence in Rural South Africa: Findings from a Prospective Population-based StudyBärnighausen et al. (2008)5253 individualsPopulation-based HIV survey2003–2005KwaZulu-Natal, South AfricaHIV incidence
 The Socioeconomic Determinants of HIV Incidence: Evidence from a Longitudinal, Population-based Study in Rural South AfricaBärnighausen et al. (2007)3325 individuals  KwaZulu-Natal, South Africasocioeconomic status, HIV incidence
 Gender, Migration and HIV in Rural KwaZulu-Natal, South AfricaCamlin et al. (2010)11 677 women aged 15–49 and men aged 15–54 2003–2004KwaZulu-Natal, South AfricaMigration, HIV infection, gender
 Adult Mortality and Probable Cause of Death in Rural Northern Malawi in the Era of HIV TreatmentChihana et al (2012)905 deaths 2004 to August 2009Karonga, MalawiART, HIV/AIDS
 Population Uptake of Antiretroviral Treatment Through Primary Care in Rural South AfricaCooke et al. (2010)   KwaZulu-Natal, South AfricaHIV, ART
 Changes in Prevalence and Incidence of HIV-1, HIV-2 and Dual Infections in Urban Areas of Bissau, Guinea-Bissau: Is HIV-2 Disappearing?Da Silva et al. (2008)2548 individualsA cross-sectional survey1996 and 2006Guinea-BissauHIV prevalence and incidence, HIV-1 and HIV-2
 Reproductive Tract Infections Including Sexually Transmitted Infections: a Population-based Study of Women of Reproductive Age in a Rural District of VietnamLan et al. (2008)1012 Married women aged 18–49 years Community-based cross-sectional study VietnamReproductive tract infections, sexually transmitted infections,, HIV, and syphilis
 Lack of Knowledge About Sexually Transmitted Infections Among Women in North Rural Vietnam.Lan et al. (2009a,b)1805 women aged 15–49 yearsCross-sectional population-based study VietnamSexually transmitted infections, STI knowledge
 Perceptions and Attitudes in Relation to Reproductive Tract Infections Including Sexually Transmitted Infections in Rural Vietnam: a Qualitative StudyLan et al. (2008)With 46 women and 27 men aged 15-49Qualitative study VietnamPerceptions, attitudes and health-seeking patterns, RTI/STI
 Knowledge and Practice Among Healthcare Providers in Rural Vietnam Regarding Sexually Transmitted InfectionsLan et al. (2009a,b)465 healthcare providersA cross-sectional study2006 VietnamSTI knowledge, practices
Marriage
 Trends in marriage and time spent single in sub-Saharan Africa: a comparative analysis of six population-based cohort studies and nine Demographic and Health SurveysMarston et al. (2009) 

A comparative analysis of six population-based cohort studies and nine Demographic and Health Surveys

Age 15–49

 Uganda, Tanzania, South Africa, Zimbabwe and Malawi and Demographic and Health Survey (DHS) data from Uganda, Tanzania and Zimbabwe wereAge at first sex, age at first marriage, HIV/AIDS
 Separation of Spouses due to Travel and Living Apart Raises HIV Risk in Tanzanian CouplesVissers et al. (2008)95 men and 85 women living apart with 283 men and 331 women living togetherHIV cohort study1994–2003Kisesa, TanzaniaSexual behavior, HIV, Mobility, marital partners
Maternal health
 Reproductive health issues in rural Western KenyaVan Eijk et al. (2008)403 womenCommunity-based cross-sectional survey2003Wagai and Yala, KenyaInsecticide treated nets (ITNs), pregnant women, HIV
 Use of antenatal services and delivery care among women in rural western Kenya: a community based surveyVan Eijk et al. (2006)730 womenPopulation-based cross-sectional survey Asembo (Rarieda Division) and Gem (Wagai and Yala Divisions) in western KenyaAntenatal care,delivery care
 Antenatal and delivery care in rural western Kenya: the effect of training health care workers to provide ‘focused antenatal care’Ouma et al. (2010) Cross-sectional survey2002–2005Asembo (Rarieda Division) and Gem (Wagai and Yala Divisions) in western KenyaAntenatal care
 Increase in facility-based deliveries associated with maternal health voucher programme in informal settlements in Nairobi, KenyaBellows et al. (2013) Two cross-sectional household survey2004–2008Nairobi, KenyaMaternal health Voucher, facility based delivery, skilled birth attendant
 Causes of maternal mortality decline in Matlab, BangladeshChowdhury et al. (2009)769 maternal deaths and 215 779 pregnancy records 1976–2005Matlab, Bangladesh 
 The role of pregnancy outcomes in the maternal mortality rates of two areas in Matlab, BangladeshRahman et al. (2010)165 894 1982–2005Matlab, BangladeshPregnancy outcome
 Verbal Autopsy to Measure Maternal Mortality in Rural SenegalBa et al. (2003)471 female deathsSurvey Niakhar, SenegalVerbal autopsy, maternal mortality
 Maternal Mortality decline in the Kassena-Nankana district of Northern GhanaMills et al. (2008a,2008b)516Survey2002–2004Kassena-Nankana, Navrongo, GhanaMaternal death, abortion
 Use of health professionals for delivery following the availability of free obstetric care in Northern GhanaMills et al. (2008a,2008b)3433 2004Kassena-Nankana, Navrongo, GhanaAntenatal care, obstetric care
 Maternal mortality in Matlab, Bangladesh:1976–1985Koenig et al. (1988)387 1976–1985BangladeshMaternal mortality
 Maternal mortality in the informal settlements of Nairobi city: what do we knowZiraba et al. (2009)

nearly all female deaths

Age 15–49

 2003–2005Two slum communities in NairobiMaternal Mortality
 Maternal health in resource-poor urban settings: how does women's autonomy influence the utilization of obstetric care services? Fotso et al. (2009a,b)1927 womenSurvey2004–2005Nairobi, KenyaMaternal health, pregnancy outcome., women's autonomy
 What does access to maternal care mean among the urban poor? Factors associated with use of appropriate maternal health services in the slum settlements of Nairobi, KenyaFotso et al. (2009a,b)1927 womenSurvey NairobiMaternal care, access, place of delivery
 Barriers to Formal Emergency Obstetric Care Services’ UtilizationEssendi et al. (2011)16 focus group discussions (FGDs) were held with each of the groups. Women ageQualitative:focus group discussions (FGDs)2006Two slums Nairobi, KenyaEmergency obstetric, care utilization
 Women's Preferences for Obstetric Care in Rural Ethiopia: a Population-based Discrete Choice Experiment in a Region with Low Rates of Facility DeliveryKruk et al. (2010)1006 womenSurvey Gilgel Gibe, EthiopiaObstetric care, delivery
 Population and Antenatal-based HIV Prevalence Estimates in a High Contracepting Female Population in Rural South AfricaRice et al. (2007) Population-based serological survey2005South Africaantenatal-care, family planning, fertility
 Maternal Mortality: Only 42 Days?Hoj et al. (2003)15 844 women of childbearing ageCohort study Guinea-BissauMaternal mortality
 Unmet Need for Essential Obstetric Services in a Rural District in Northern Ghana: Complications of Unsafe Abortions Remain a Major Cause of Mortality VLBaiden et al. (2006)  January 2001 to December 2003Kassena-Nankana, GhanaCaesarean, antenatal services, obstetric services
 Maternal Mortality in Guinea-Bissau: The Use of Verbal Autopsy in a Multi-ethnic PopulationHoj et al. (1999)10 000 womencohort study Guinea-Bissauverbal autopsies, Maternal deaths
 Maternal Mortality in Northern Nigeria: Findings of a Health and Demographic Surveillance System in Zamfara State, NigeriaDoctor et al. (2012)17 087 women reported 38 761 maternal deathsCohort study NigeriaMaternal death
 Factors Associated with Maternal Mortality in Rural Guinea-Bissau. A Longitudinal Population-based StudyHoj et al. (2002)10 931 pregnanciesPopulation-based Study Guinea-BissauMaternal death, Multiple pregnancy
 Levels and Causes of Maternal Mortality in SenegalKodio et al. (2002)15–49Community-based SenegalMaternal death
 Maternal Mortality in Rural SenegalPison et al. (2000)   Bandafassi Niakhar, and Mlomp in SenegalMaternal death, hospital delivery, caesareans
 The impact of targeted subsidies for facility-based delivery on access to care and equity – evidence from a population-based study in rural Burkina FasoDe Allegri et al. (2012)Sample of 1050 households Cross-sectional surveys2006–2010Nouna, Burkina FasoDelivery
 Determinants of utilization of maternal care services after the reduction of user fees: a case study from rural Burkina FasoDe Allegri et al. (2011)Sample of 435 women 2009Nouna, Burkina FasoANC utilization, delivering in a facility, user fee
 Willingness to pay for maternal health outcomes: are women willing to pay more than men?Ternent et al. (2010)409 male heads of households and their spousescontingent valuation survey2005Nouna, Burkina FasoMaternal health, monetary values
 Women's Morbidity and Mortality in the First 2 Years After Delivery According to HIV StatusCoutsoudis et al. (2010)2624 women  South AfricaKnowledge of the impact of HIV status, morbidity, mortality
 The Hazard of Pregnancy Loss and Stillbirth Among Women in Kersa, East Ethiopia: a Follow up StudyAssefa et al. (2012)1438 terminated pregnanciesSurvey Kersa, EthiopiaTerminated pregnancies, still birth,Pregnancy Loss
 Women, Poverty and Adverse Maternal Outcomes in Nairobi, KenyaIzugbara & Ngilangwa (2010) Qualitative study Nairobi, KenyaPoverty, maternal outcomes
Adolescent Sexual and Reproductive Health (ASRH)
 Transition into first sex among adolescents in slum and non-slumcommunities in Nairobi, KenyaKabiru et al. (2010)2134 adolescentsSurvey-two waves of the Education Research Program (ERP)Since 2005Two slum and two non slum settlements in Nairobi, KenyaAdolescent sexuality, transition, first sex
 Timing and Sequencing of Events Marking the Transition to Adulthood in Two Informal Settlements in Nairobi, KenyaBeguy et al. (2011)3944 (12–22)Survey2007–2010Two slum settlements in NairobiTransition to Adulthood, First intercourse, First union, First birth, marriage, parenthood
 Incentivizing safe sex: a randomized trial of conditional cash transfer for HIV and sexually transmitted infection prevention in rural TanzaniaDe Walque et al. (2012)2399 aged 18–30 including adult spouseRandomised and control trial TanzaniaHIV, STIs
 Risk Perception and condom-use among Thai Youths: Findings from Kanchanaburi Demographic surveillance system site in ThailandHaque et al. (2009)195 males age 15–24Survey2003–2004 (Round 5)Kanchanaburi, ThailandSexual partners, Youth Risk perception, Education condom use, health risk behaviour
 Induced Abortions Among Adolescent Women in Rural Maharashtra, IndiaGanatra et al. (2002)197 adolescents 1996–1998IndiaSex selection, abortion, contraceptive counseling, Family planning
 Gender, Peer and Partner Influences on Adolescent HIV Risk in Rural South AfricaHarrison et al. (2012)983 youth aged 14–17 A cross-sectional survey KwaZulu-Natal, South AfricaHIV
 Reasons for Condom Use Among Young People in KwaZulu-Natal: Prevention of HIV, Pregnancy or BothMaharaj (2006)2067 sexually active men and women aged 15–24 2001KwaZulu-Natal, South AfricaHIV infection, condom use
 Age at First Sex in Rural South AfricaMcGrath et al. (2009)The 4724 women and 4029 men 2003–2007KwaZulu-Natal, South AfricaAge at first sex, prevalence and incidence of HIV
 ‘Making It’: Understanding Adolescent Resilience in Two Informal Settlements (Slums) in Nairobi, KenyaKabiru et al. (2012)

1722

never-married 12–19 year

Survey2007–2008Korogocho and Viwandani-Nairobi, KenyaAdolescent, Resilience- sexual behavior
 Entry into motherhood among adolescent girls in two informal settlements in Nairobi, KenyaBeguy et al. (2011)897 female adolescents aged 15–19 yearsNested Survey2007–2008Nairobi, KenyaAdolescent transition, age at first birth
 Inconsistencies in Self-reporting of Sexual Activity Among Young People in Nairobi, KenyaBeguy et al. (2011)2324 adolescentsBaseline survey2007–2008Nairobi, KenyaFirst sexual intercourse, sexual debut, virginity
Family planning/contraceptive use
 Inconsistencies in the relationship between contraceptive use and fertility in BangladeshSaha & Bairagi (2007)  

BHDS:1999–2000

DSS:1978–2001

BangladeshContraceptive prevalence, fertility,abortion
 Menstrual Pattern, Sexual Behaviors, and Contraceptive Use among Postpartum Women in Nairobi Urban SlumsNdugwa et al. (2011)2994Nested survey2007–2008Korogocho and Viwandani, NairobiMenstrual pattern, sexual behavior, postpartum, contraceptive use
 Knowledge and Utilisation of Contraceptive Methods in the Rural Serer of SenegalNdiaye et al. (2003)804 20-to-69-year-old men and 1039 15-to-54-year-old women  SenegalContraceptive knowledge, Contraceptive prevalence, marital contraception
 Social and Logistical Barriers to the Use of Reversible Contraception Among Women in a Rural Indian VillageHall et al. (2008)Married women aged 19+ years were interviewed in six focus groups (n = 60) and individually (n = 15)  IndiaContraceptive information, contraceptive methods, reversible methods, vasectomy, sterilization, abortion
 Family Planning Methods Among Women in a Vaginal Microbicide Feasibility Study in Rural KwaZulu-Natal, South AfricaSubramanian et al. (2008)Of 866 sexually active women  KwaZulu-Natal, South AfricaModern contraceptives
 Spousal Communication and Family Planning Behavior in Navrongo: a Longitudinal AssessmentBawah (2002)   GhanaFamily planning, spousal Communication, contraceptive use
 Women's Fears and Men's Anxieties: The Impact of Family Planning on Gender Relations in Northern GhanaBawah et al. (1999) Qualitative Study: (focus-group discussions) GhanaFamily planning
 The Impact of the Navrongo Project on Contraceptive Knowledge and Use, Reproductive Preferences, and FertilityDebpuur et al. (2002)   GhanaFamily Planning, contraceptive, knowledge of methods, fertility
 Vaginal Wetness: An Underestimated Problem Experienced by Progestogen Injectable Contraceptive Users in South AfricaSmit et al. (2002)848 women aged 15–49Community-based cross-sectional household survey South AfricaVaginal wetness, contraceptive
 The Influence of Changes in Women's Religious Affiliation on Contraceptive Use and Fertility Among the Kassena-Nankana of Northern GhanaDoctor et al. (2009)  1995 and 2003Nankana, GhanaReligion, contraceptive use, fertility
 Condom Access and Use in an Urban and a Rural Setting in Kilifi District, KenyaPapo et al. (2011)630 men and women aged 15–49  Kilifi, KenyaCondom gap

Ancillary