Modern contraceptive use among adolescent girls and young women in Benin: a mixed-methods study

Objectives: The study aimed to assess the determinants of modern contraceptive method use among young women in Benin.Design: A mixed-methods design.Setting and participants: We used the Benin 2017–2018 Demographic and Health Survey datasets for quantitative analysis. Data collection was conducted using multiple-cluster sampling method and through household survey. Qualitative part was conducted in the city of Allada, one of the Fon cultural capitals in Benin. The participants were purposively selected.Outcomes: Contraceptive prevalence rate, unmet need for modern method and percentage of demand satisfied by a modern method for currently married and sexually active unmarried women were measured in the quantitative part. Access barriers and utilisation of modern methods were assessed in the qualitative part.Results: Overall, 8.5% (95% CI 7.7% to 9.5%) among young women ages 15–24 were using modern contraceptives and 13% (12.1% to 14.0%) among women ages 25 or more. Women 15–24 had a higher unmet need, and a lower demand satisfied by modern contraceptive methods compared with women ages 25 or more. 60.8% (56.9% to 64.7%) of all unmarried young women had unmet need for modern contraceptives. Young women were more likely to use male condoms which they obtain mainly from for-profit outlets, pharmacies and relatives. The factors associated with demand satisfied by a modern method were literacy, being unmarried, knowing a greater number of modern contraceptive methods and experiencing barriers in access to health services. On the other hand, the qualitative study found that barriers to using modern methods include community norms about pre-marital sexual intercourse, perceptions about young women’s fertility, spousal consent and the use of non-modern contraceptives.Conclusion: Contraceptive use is low among young women in Benin. The use of modern contraceptives is influenced by sociodemographic factors and social norms. Appropriate interventions might promote comprehensive sexuality education, increase community engagement, provide youth-friendly services and address gender inequalities

'Rowing against the current': The policy process and effects of removing user fees for caesarean sections in Benin

Background In 2009, the Benin government introduced a user fee exemption policy for caesarean sections. We analyse this policy with regard to how the existing ideas and institutions related to user fees influenced key steps of the policy cycle and draw lessons that could inform the policy dialogue for universal health coverage in the West African region. Methods Following the policy stages model, we analyse the agenda setting, policy formulation and legitimation phase, and assess the implementation fidelity and policy results. We adopted an embedded case study design, using quantitative and qualitative data collected with 13 tools at the national level and in seven hospitals implementing the policy. Results We found that the initial political goal of the policy was not to reduce maternal mortality but to eliminate the detention in hospitals of mothers and newborns who cannot pay the user fees by exempting a comprehensive package of maternal health services. We found that the policy development process suffered from inadequate uptake of evidence and that the policy content and process were not completely in harmony with political and public health goals. The initial policy intention clashed with the neoliberal orientation of the political system, the fee recovery principles institutionalised since the Bamako Initiative and the prevailing ideas in favour of user fees. The policymakers did not take these entrenched factors into account. The resulting tension contributed to a benefit package covering only caesarean sections and to the variable implementation and effectiveness of the policy. Conclusion The influence of organisational culture in the decision-making processes in the health sector is often ignored but must be considered in the design and implementation of any policy aimed at achieving universal health coverage in West African countries.sch_iih3pub5185pub1 [e000537

Exploring the sustainability of obstetric near-miss case reviews: a qualitative study in the South of Benin.

INTRODUCTION: near-miss case reviews are one of a number of audit approaches currently being used and evaluated by those with an interest in reducing high rates of maternal mortality in developing countries. Researchers are beginning to take an interest in issues relating to the sustainability of audits. OBJECTIVE: to develop an understanding of the barriers and facilitators to the sustainability of obstetric near-miss case reviews in five hospitals in southern Benin. DESIGN AND METHODS: semi-structured interviews were designed to explore health workers' and policy makers' views and experiences of the sustainability of near-miss case reviews aimed to improve quality of care and reduce maternal mortality. SETTING: five hospitals in three regions in the south of Benin. PARTICIPANTS: two Ministry of Health officials and eight health-care workers involved in a feasibility study conducted in 1998-2001 that introduced near-miss case reviews. ANALYSIS: framework analysis to identify themes. FINDINGS: while all participants believed in the importance and value of audit, all hospitals had stopped performing near-miss case reviews within two years of completing the feasibility study. Ten qualitative interviews identified six themes relating to the sustainability of case reviews: clear advantages in ensuring quality of care, fear of blame and punishment, availability of resources, training, supportive hospital work environment, and broader policy issues. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: implementing and sustaining audit is a complex intervention that requires careful planning and consideration. It is important to consider both the content and the context in which audit takes place when developing strategies for sustainability

Validity and reliability of postpartum morbidity questionnaires in Benin.

We describe the validity and reliability of midwife-administered postpartum questionnaires in home and clinic settings. Women identified prospectively before or following hospital delivery (n = 476), September 2004-January 2005, were re-contacted at 6 months postpartum for home interview and medical examination. Reliability was measured by comparing women's responses to the same questions at home and in clinic interviews. Validity was measured by comparing questionnaire responses with results of medical examination. Reliability of responses to questions comparing home and clinic interview was very good (κ > 0.6) for resumption of menstruation and occurrence of hemorrhoids, moderate (0.4 < κ ≤ 0.6) for weight loss and incontinence, and poor (κ ≤ 0.4) for burning sensation or pain on urination and exhaustion or fatigue. The home and clinic interviews had poor validity for detecting common postpartum morbidities: anaemia (sensitivity 33.7%, specificity 65.7%), urinary incontinence (5.1, 98.1%), urinary tract infection (2.1, 94.5%), prolapse (18.2, 91.2%); but good validity for hemorrhoids (71.4, 86.9%). In this setting, questionnaire-based interviews were neither reliable nor valid tools for measuring morbidity at 6 months postpartum. A medical examination is required to identify and measure the levels of morbidity up to 6 months postpartum

Risk of psychological distress following severe obstetric complications in Benin: the role of economics, physical health and spousal abuse.

BACKGROUND: Little is known about the impact of life-threatening obstetric complications ('near miss') on women's mental health in low- and middle-income countries. AIMS: To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin. METHOD: One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities. RESULTS: In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth. CONCLUSIONS: A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms

“To give life is a journey through the unknown”: an ethnographic account of childbirth experiences and practices in Southern Benin

AbstractIn Benin maternal mortality remains high at 397 deaths per 100,000 live births, despite 80% of births being attended by skilled birth attendants in health facilities. To identify childbirth practices that potentially contribute to this trend, an ethnographic study was conducted on the use of biomedical and alternative health services along the continuum of maternal care in Allada, Benin. Data collection techniques included in-depth interviews (N = 83), informal interviews (N = 86), observations (N = 32) and group discussions (N = 3). Informants included biomedical, spiritual and alternative care providers and community members with a variety of socioeconomic and religious profiles. In Southern Benin alternative and spiritual care, inspired by the Vodoun, Christian or Muslim religions, is commonly used in addition to biomedical care. As childbirth is perceived as a “risky journey to the unknown”, these care modalities aim to protect the mother and child from malevolent spirits, facilitate the birth and limit postpartum complications using herbal decoctions and spiritual rites and rituals. These practices are based on mystical interpretations of childbirth that result in the need for additional care during facility-based childbirth. Because such complementary care is not foreseen in health facilities, facility-based childbirth is initiated only at an advanced stage of labour or at the onset of a perceived immediate life-threatening complication for the mother or baby. Programmes and policies to reduce maternal mortality in Benin must seek synergies with alternative providers and practices and consider the complementary and integrated use of alternative and spiritual care practices that are not harmful

Effects of severe obstetric complications on women's health and infant mortality in Benin.

OBJECTIVE: To document the impact of severe obstetric complications on post-partum health in mothers and mortality in babies over 12 months in Benin and to assess whether severe complications associated with perinatal death are particularly likely to lead to adverse health consequences. METHODS: Cohort study which followed women and their babies after a severe complication or an uncomplicated childbirth. Women were selected in hospitals and interviewed at home at discharge, and at 6 and 12 months post-partum. Women were invited for a medical check-up at 6 months and 12 months. RESULTS: The cohort includes 205 women with severe complications and a live birth, 64 women with severe complications and perinatal death and 440 women with uncomplicated delivery. Women with severe complications and a live birth were not dissimilar to women with a normal delivery in terms of post-partum health, except for hypertension [adjusted OR = 5.8 (1.9-17.0)], fever [adjusted OR = 1.71 (1.1-2.8)] and infant mortality [adjusted OR = 11.0 (0.8-158.2)]. Women with complications and perinatal death were at increased risk of depression [adjusted OR = 3.4 (1.3-9.0)], urine leakages [adjusted OR = 2.7 (1.2-5.8)], and to report poor health [adjusted OR = 5.27 (2.2-12.4)] and pregnancy's negative effects on their life [adjusted OR = 4.11 (1.9-9.0)]. Uptake of post-natal services was poor in all groups. CONCLUSION: Women in developing countries face a high risk of severe complications during pregnancy and delivery. These can lead to adverse consequences for their own health and that of their offspring. Resources are needed to ensure that pregnant women receive adequate care before, during and after discharge from hospital. Near-miss women with a perinatal death appear a particularly high-risk group

Can hospital audit teams identify case management problems, analyse their causes, identify and implement improvements? A cross-sectional process evaluation of obstetric near-miss case reviews in Benin.

BACKGROUND: Obstetric near-miss case reviews are being promoted as a quality assurance intervention suitable for hospitals in low income countries. We introduced such reviews in five district, regional and national hospitals in Benin, West Africa. In a cross-sectional study we analysed the extent to which the hospital audit teams were able to identify case management problems (CMPs), analyse their causes, agree on solutions and put these solutions into practice. METHODS: We analysed case summaries, women's interview transcripts and audit minutes produced by the audit teams for 67 meetings concerning one woman with near-miss complications each. We compared the proportion of CMPs identified by an external assessment team to the number found by the audit teams. For the latter, we described the CMP causes identified, solutions proposed and implemented by the audit teams. RESULTS: Audit meetings were conducted regularly and were well attended. Audit teams identified half of the 714 CMPs; they were more likely to find managerial ones (71%) than the ones relating to treatment (30%). Most identified CMPs were valid. Almost all causes of CMPs were plausible, but often too superficial to be of great value for directing remedial action. Audit teams suggested solutions, most of them promising ones, for 38% of the CMPs they had identified, but recorded their implementation only for a minority (8.5%). CONCLUSIONS: The importance of following-up and documenting the implementation of solutions should be stressed in future audit interventions. Tools facilitating the follow-up should be made available. Near-miss case reviews hold promise, but their effectiveness to improve the quality of care sustainably and on a large scale still needs to be established

Modern contraceptive use among adolescent girls and young women in Benin: a mixed-methods study

OBJECTIVES: The study aimed to assess the determinants of modern contraceptive method use among young women in Benin. DESIGN: A mixed-methods design. SETTING AND PARTICIPANTS: We used the Benin 2017–2018 Demographic and Health Survey datasets for quantitative analysis. Data collection was conducted using multiple-cluster sampling method and through household survey. Qualitative part was conducted in the city of Allada, one of the Fon cultural capitals in Benin. The participants were purposively selected. OUTCOMES: Contraceptive prevalence rate, unmet need for modern method and percentage of demand satisfied by a modern method for currently married and sexually active unmarried women were measured in the quantitative part. Access barriers and utilisation of modern methods were assessed in the qualitative part. RESULTS: Overall, 8.5% (95% CI 7.7% to 9.5%) among young women ages 15–24 were using modern contraceptives and 13% (12.1% to 14.0%) among women ages 25 or more. Women 15–24 had a higher unmet need, and a lower demand satisfied by modern contraceptive methods compared with women ages 25 or more. 60.8% (56.9% to 64.7%) of all unmarried young women had unmet need for modern contraceptives. Young women were more likely to use male condoms which they obtain mainly from for-profit outlets, pharmacies and relatives. The factors associated with demand satisfied by a modern method were literacy, being unmarried, knowing a greater number of modern contraceptive methods and experiencing barriers in access to health services. On the other hand, the qualitative study found that barriers to using modern methods include community norms about pre-marital sexual intercourse, perceptions about young women’s fertility, spousal consent and the use of non-modern contraceptives. CONCLUSION: Contraceptive use is low among young women in Benin. The use of modern contraceptives is influenced by sociodemographic factors and social norms. Appropriate interventions might promote comprehensive sexuality education, increase community engagement, provide youth-friendly services and address gender inequalities

Giving birth in maternity hospitals in Benin: testimonies of women.

In Benin, a Francophone country in West Africa, maternity mortality has been estimated at between 473 and 990 deaths per 100,000 live births. Yet 92 per cent of women gave birth in either a public or private health centre, and almost all of them received antenatal care. This paper reports on an exploratory, qualitative study in 1995, among 19 women aged 20-40 who had recently given birth in a referral hospital, of their experiences of antenatal and emergency obstetric care, as part of a larger study on measuring the prevalence of severe maternal morbidity in the community. Thirteen of the women had had obstetric complications and 11 had had a caesarean section. Pregnancy was described as a period of great vulnerability, and feelings of insecurity and fear of death were omnipresent in the women's accounts. Their primary motivation for seeking antenatal care was the appearance of symptoms or events they perceived as abnormal. Although a minority were lucky enough to have a kind midwife, many complained about not being able to ask questions or get any explanations, being mistreated and humiliated by health personnel and described the anguish they felt in the face of medical procedures they did not understand, especially caesarean section, which they were told were necessary to save their lives. Access to emergency obstetric care is a priority in the battle against maternal mortality, but it cannot be at the expense of improvements in the quality of the interaction between women and health personnel. The inclusion of women's voices in the objectives of safe motherhood programmes is necessary to better serve women's needs