Socioeconomic and residence-based inequalities in adolescent fertility in 39 African countries.

Despite the advancement in sexual and reproductive healthcare services and several public health measures aimed at controlling fertility rates, countries in sub-Saharan Africa (SSA) still experience higher adolescent fertility rates than other low-and middle-income countries. This study examined the disparities in adolescent fertility in 39 countries in SSA, focusing on socioeconomic and residence-based dimensions. This study involved a secondary analysis of data obtained from 39 recent Demographic and Health Surveys conducted in SSA. The measures of difference (D), ratio (R), population attributable fraction (PAF), and population attributable risk (PAR) were estimated using the Health Equity Assessment Tool (HEAT) software version 3.1 developed by the World Health Organization. The measures: D, R, PAF, and PAR were used to examine the inequalities in adolescent fertility across the socioeconomic and residence-based dimensions. Out of the 39 countries included in the study, Guinea (D=27.70), Niger (D=27.50), Nigeria (D=23.90), and Côte d'Ivoire (D=23.60) exhibited the most significant residence-based inequalities in the rate of adolescent fertility, with the higher rate observed among adolescents in rural areas. Rwanda was the sole country that showed a slight inclination towards rural inequality in terms of the rate of adolescent fertility, with a value of D = -0.80. The burden of adolescent fertility was disproportionately higher among young women with low economic status across all the countries, exacerbating wealth-based inequities. The countries with the largest absolute discrepancies were Nigeria (D=44.70), Madagascar (D=41.10), Guinea (D=41.00), and Cameroon (D=40.20). We found significant disparities in educational attainment contributing to unequal inequalities in adolescent fertility, particularly among young women who lack access to formal education. Countries such as Madagascar (D=59.50), Chad (D=55.30), Cameroon (D=54.60), and Zimbabwe (D=50.30) had the most significant absolute disparities. This study revealed that young women residing in rural areas, those in households with low economic status and those with limited educational opportunities experience a disproportionately high burden of adolescent fertility across the 39 countries in SSA. The current findings offer valuable information to governmental entities at all levels regarding the need to ensure the provision of equitable, accessible, and dependable sexual and reproductive health services to the populace, particularly for young women. Therefore, the various stakeholders need to enhance the effectiveness of health policies and legislation pertaining to adolescent women living in rural areas, those from economically disadvantaged households, and those with limited or no access to formal education. Such interventions could potentially reduce adolescent fertility rates and mitigate the adverse maternal and child outcomes associated with high adolescent fertility in SSA.

Ahinkorah BO ，Aboagye RG ，Mohammed A ，Duodu PA ，Adnani QES ，Seidu AA ... -  《Reproductive Health》

Socioeconomic and geographical inequalities in adolescent fertility rates in Sierra Leone, 2008-2019.

Sierra Leone, like many other sub-Saharan African countries, grapples with the challenge of high adolescent fertility rates. This study examines the socio-economic and geographical inequalities in adolescent fertility rates in Sierra Leone between 2008 and 2019. Three rounds of the Sierra Leone Demographic and Health Surveys (2008, 2013, and 2019) were analysed to examine inequalities in adolescent fertility rates. Descriptive analyses were performed using the online version of the World Health Organization's Health Equity Assessment Toolkit software. Adolescent fertility rate was stratified using four dimensions: economic status, education, place of residence, and province. Difference (D), ratio (R), population attributable risk (PAR) and population attributable fraction (PAF) were calculated as measures of inequality. The adolescent fertility rates in Sierra Leone declined from 142.5 births per 1,000 women aged 15-19 years in 2008 to 103.5 births per 1,000 women aged 15-19 years in 2019. For economic status, inequality in adolescent fertility rates decreased from 117.3 births per 1,000 adolescent girls in 2008 to 110.6 in 2019. The PAF indicated that the national adolescent fertility rate could have been 46.8% lower in 2008, 42.5% lower in 2013, and 53.5% lower in 2019 if all wealth quintiles had the same fertility rates as the wealthiest quintile (quintile 5). Educational inequality in adolescent fertility rates decreased significantly, from 135.3 births per 1,000 adolescent girls in 2008 to 75.8 in 2019. The PAF showed that the setting average of adolescent fertility rate could have been 57.9% lower in 2008, 33.1% lower in 2013, and 23.9% lower in 2019 without education-related disparities. For place of residence, inequality between urban and rural areas decreased from 82.3 births per 1,000 adolescent girls in 2008 to 74.5 in 2019. The PAF indicated that the national adolescent fertility rate could have been 32.9% lower in 2008, 30.7% lower in 2013, and 33.9% lower in 2019 if rural girls had the same fertility rates as urban girls. Our results further showed that inequality based on province decreased from 77.9 births per 1,000 adolescent girls in 2008 to 64.0 in 2019. The PAF showed that the national average of adolescent fertility rates could have been 34.6% lower in 2008, 37.6% lower in 2013, and 35.8% lower in 2019 without provincial disparities. Our study found a positive decline in AFR across socioeconomic and geographic groups in Sierra Leone, but significant inequalities remain. Economic status and education are key drivers, with the poorest quintile consistently showing higher AFR. Although AFR declined among girls across all levels of education over time, it increased between 2008 and 2019 for those with primary and higher education. Rural areas had a higher AFR than urban ones, though with less national impact. Policymakers should focus on improving economic opportunities, enhancing quality education, and expanding access to family planning services to reduce adolescent pregnancy and address socioeconomic and educational inequalities.

Osborne A ，Bangura C ，Ahinkorah BO 《PLoS One》

Care-seeking for difficulties conceiving in sub-Saharan Africa: findings from population-based surveys in eight geographies.

What is the nature of women's care-seeking for difficulties conceiving in sub-Saharan Africa (SSA), including the correlates of seeking biomedical infertility care at a health facility? Care-seeking for difficulties getting pregnant was low, much of which involved traditional or religious sources of care, with evidence of sociodemographic disparities in receipt of biomedical care. Nearly all research on infertility care-seeking patterns in SSA is limited to clinic-based studies among the minority of people in these settings who obtain facility-based services. In the absence of population-based data on infertility care-seeking, we are unable to determine the demand for services and disparities in the use of more effective biomedical sources of care. We used cross-sectional, population-based data from the Performance Monitoring for Action (PMA) female survey in eight geographies in SSA, including nationally representative data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda and regionally representative data from two provinces in the Democratic Republic of the Congo (DRC) (Kinshasa and Kongo Central) and two states in Nigeria (Kano and Lagos). We employed a multi-stage cluster random sampling design with probability proportional to size selection of clusters within each geography to produce representative samples of women aged 15-49. Samples ranged from 1144 in Kano, Nigeria, to 9489 in Kenya. PMA collected these data between November 2021 and December 2022. We restricted the sample to women who had ever had sex, with analytic samples ranging from 854 in Kano to 8,059 in Kenya, then conducted descriptive and bivariable analyses to examine characteristics of those who sought care for difficulties getting pregnant. Among those who reported seeking care, we conducted bivariable and multivariable logistic regression analyses to determine factors associated with receipt of biomedical services from a health facility. All analyses were conducted separately by geography. Our study found low levels of care-seeking for difficulties getting pregnant among sexually active women in eight geographies in SSA, ranging from 3.7% (Kenya) to 15.3% (Côte d'Ivoire). Of this, 51.8% (Burkina Faso) to 86.7% (Kinshasa) involved receipt of biomedical services in health facilities. While many factors were consistently associated with infertility care-seeking from any source across geographies, factors associated with receipt of biomedical care specifically were less pronounced. This may be a result of the highly limited sources of infertility services in SSA; thus, even privileged groups may struggle to obtain effective treatment for difficulties getting pregnant. However, we did observe disparities in biomedical care-seeking in our bivariable results in several geographies, with the wealthiest women, those with more education, and those residing in urban areas generally more likely to have sought biomedical care for difficulties getting pregnant. Our data lacked details on the nature of the services received and outcomes, and we do not have information on reasons why women chose the sources they did. Small samples of women who sought care limited our power to detect significant differences in care-seeking by women's characteristics in several geographies. Infertility and access to appropriate treatment are issues of reproductive health and human rights. While our results do not indicate to what extent use of non-biomedical sources of care is driven by preferences, cost, or lack of accessible services, it is clear from our results and existing literature that more needs to be done to ensure access to affordable, quality, cost-effective infertility services in SSA. This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare. N/A.

Bell SO ，Larson E ，Bittle D ，Moreau C ，Omoluabi E ，OlaOlorun FM ，Akilimali P ，Kibira SPS ，Makumbi F ，Guiella G ，Mosso R ，Gichangi P ，Anglewicz P ... -  《-》

Global fertility in 204 countries and territories, 1950-2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021.

GBD 2021 Fertility and Forecasting Collaborators 《-》

Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling.

Elwenspoek MM ，Thom H ，Sheppard AL ，Keeney E ，O'Donnell R ，Jackson J ，Roadevin C ，Dawson S ，Lane D ，Stubbs J ，Everitt H ，Watson JC ，Hay AD ，Gillett P ，Robins G ，Jones HE ，Mallett S ，Whiting PF ... -  《-》