The influence of demographic and socioeconomic characteristics on age at first marriage among females in Mozambique

Research Paper Submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in partial completion of the requirements for a Masters Degree (MA) in the field of Demography and Population Studies 2016Context: Various reforms that are approved by the law and are intended to foster gender equality have been established by eleven nations in the Southern African Development Community Region (SADC). However, irrespective of the efforts exercised to eliminate practices that inhibit females from being able to attain their human rights, early marriage remains to be one of the discriminatory traditional practices which occur under harmful customary laws and societal norms in a number of SADC nations. The practice of early marriage violates international human rights laws that are aimed at fostering gender equality, in particular, those of females. In addition, early marriage poses a serious threat to the health and social standing of females which often results in females being politically and financially subordinated in relation to their male counterparts as well as being subjected to sexual abuse and control by males. Despite several strategies that have been established by the Mozambican government that intend to improve education and employment as well as decrease the levels of impoverishment, gender inequality is still a predominant phenomenon that leaves females being the most marginalised in relation to males, in all sociocultural, political and financial domains. This research study sought to explore whether demographic and socioeconomic characteristics including region of residence, current age of the respondent, educational level, religious affiliation, type of place of residence, and wealth status are influential on age at first marriage. Methods: This study utilised secondary statistics acquired from the 2011 Mozambique Demographic and Health Survey. The 2011 Mozambique Demographic and Health Survey is a survey that includes a sample of 13 745 females who are between the ages 15-49 years old. The sample of respondents consisted of females who have been or are in a marital union of childbearing ages 15-49. Due to the event of interest being marriage, only 10893 females were or had been in a marital union while the remaining 2852 had never been in a union. Thus the analytic sample size utilised in this study was 10893 and the remaining 2852 cases were simply right censored. The outcome variable was age at first marriage and the predictors were the respondent’s current age, region of residence, educational level, religious affiliation, type of place of residence and wealth status. A Cox Proportional Hazard Regression model was employed in order to analyse the time of first entry into a marital union, systematically. The data analysis was done in three phases. The first phase included descriptive analyses of the variables utilised in the study through a series of frequency tables and discussions. The second stage included Kaplan-Meier graphs which were used to estimate levels of age at first marriage. The third stage included an unadjusted (bivariate) and adjusted (multivariate) Cox Regression model which was employed to determine characteristics that had an influence on age of first marriage. Results: Hazard ratios shown in the multivariate Cox Proportional Hazard Regression model showed that the respondent’s age, level of education and region of residence are significant predictors of age at first marriage among females in Mozambique. These associations indicated that early marriage is highest in Mozambique’s northern regions with females residing in Manica exhibiting a 19% increased hazard ratio of exposure to early marriage, followed by females residing in Cabo Delgado who exhibit an 11% increased hazard ratio of exposure to early marriage. The lowest rates of early marriage were found in Mozambique’s southern regions with females residing in Maputo exhibiting a 20% lower risk of exposure to early marriage, followed by females residing in Gaza who exhibit a 14% lower risk of exposure to early marriage and this can be attributed to cultural and societal differences. Early age of marriage is highest among females in the 15-19 year age groups and early age of marriage starts to decrease with an in increase in the female’s age. This is evident from the presented hazard ratios which indicated that females aged 45-49 exhibited a 73% lower risk of exposure to early marriage, followed by females aged 40-44 who exhibited a 71% lower risk of exposure to early marriage and females aged 35-39 who exhibited a 70% lower risk, in relation to the younger-aged females. Furthermore, the more education a female attains, the more her age of marriage increases. This is evident from the results as they show that females with a primary education have a 5% higher hazard ratio of exposure to early marriage while females with a secondary education have a 21% reduced hazard ratio of exposure, followed by females with a tertiary education who have a 46% reduced hazard ratio of exposure to early marriage. Conclusion: The overall inference drawn from this study was that early marriage is a pervasive phenomenon that is still carried out in the northern regions of Mozambique and is particularly prevalent among young females aged 15-19 who have a primary or no education. Results demonstrated that a number of inequalities exist in the country and these inequalities are not only exclusive between males and females but also exist among young females themselves, particularly those who reside in the rural regions of Mozambique and this is due to the different lifestyles led in the rural and urban areas. Furthermore, the results showed that customary laws of marriage that have been imposed by traditional authorities specifically among citizens living in the rural areas of Mozambique are not aligned with the main civil laws that have been implemented by the Mozambican government and made rigid in order to foster gender equality and improve the situation of women. This thus suggests that there are inconsistencies in the laws and thus they do not sufficiently protect young females from entry into early marriages. Thus, the Mozambican government needs to scale up strategies that will be beneficial in eradicating the practice of early marriage.MT201

Integration of nutrition support using the FIGO nutrition checklist in the Bukhali trial: a dietitian’s perspective

The burden of malnutrition experienced globally, coupled with the increasing rate of micronutrient deficiencies, compromises the health and well-being of women during their reproductive years. Obesity places young South African women at particular risk during pregnancy, and increases obesity risk for their offspring. To address these risks, the Bukhali trial is being implemented in Soweto, South Africa with 18–28-year-old women, as part of the Healthy Lifestyle Trajectory Initiative. A dietitian is part of the Bukhali intervention team (community health workers) to provide nutritional support for overweight/obese trial participants, making use of the International Federation of Gynaecology and Obstetrics (FIGO) Nutrition Checklist. This paper reflects on the experiences and lessons learned by the Bukhali dietitian, including the use of the FIGO Nutrition Checklist and Healthy Conversation Skills to facilitate conversations about making healthy dietary behaviour changes. Identified challenges that influence nutrition and behaviour are discussed, including lack of food affordability, cultural and social influences on healthy food choices, unsupportive environments and food insecurity. Strategies to optimise this nutritional support are also mentioned. The Bukhali trial is showing that introducing additional nutrition support by a dietitian for at-risk participants has the potential to encourage young women to prioritise nutrition and health, even in the midst of contextual challenges to both nutrition and health

A qualitative analysis of community health worker perspectives on the implementation of the preconception and pregnancy phases of the Bukhali randomised controlled trial

Community health workers (CHWs) play an important role in health systems in low- and middle-income countries, including South Africa. Bukhali is a CHW-delivered intervention as part of a randomised controlled trial, to improve the health trajectories of young women in Soweto, South Africa. This study aimed to qualitatively explore factors influencing implementation of the preconception and pregnancy phases of Bukhali, from the perspective of the CHWs (Health Helpers, HHs) delivering the intervention. As part of the Bukhali trial process evaluation, three focus group discussions were conducted with the 13 HHs employed by the trial. A thematic approach was used to analyse the data, drawing on elements of a reflexive thematic and codebook approach. The following six themes were developed, representing factors impacting implementation of the HH roles: interaction with the existing public healthcare sector; participant perceptions of health; health literacy and language barriers; participants’ socioeconomic constraints; family, partner, and community views of trial components; and the HH-participant relationship. HHs reported uses of several trial-based tools to overcome implementation challenges, increasing their ability to implement their roles as planned. The relationship of trust between the HH and participants seemed to function as one important mechanism for impact. The findings supported a number of adaptations to the implementation of Bukhali, such as intensified trial-based follow-up of referrals that do not receive management at clinics, continued HH training and community engagement parallel to trial implementation, with an increased emphasis on health-related stigma and education. HH perspectives on intervention implementation highlighted adaptations across three broad strategic areas: navigating and bridging healthcare systems, adaptability to individual participant needs, and navigating stigma around disease. These findings provide recommendations for the next phases of Bukhali, for other CHW-delivered preconception and pregnancy trials, and for the strengthening of CHW roles in clinical settings with similar implementation challenges

Young women’s social support networks during pregnancy in Soweto, South Africa

Background: Although studies from high-income countries have examined social support during pregnancy, it remains unclear what type of support is received by expectant mothers from low- and middle-income country settings. Aim: To explore young women’s social support networks during pregnancy in Soweto, South Africa. Setting: This study was undertaken in an academic hospital based in the Southwestern Townships (Soweto), Johannesburg, in Gauteng province, South Africa. Methods: An exploratory descriptive qualitative approach was employed. Eighteen (18) young pregnant women were recruited using a purposive sampling approach. In-depth interviews were conducted, and data were analysed using inductive thematic analysis. Results: Analysis of the data resulted in the development of two superordinate themes namely; (1) relationships during pregnancy and (2) network involvement. Involvement of the various social networks contributed greatly to the young women having a greater sense of potential parental efficacy and increased acceptance of their pregnancies. Pregnant women who receive sufficient social support from immediate networks have increased potential to embrace and give attention to pregnancy-related changes. Conclusion: Focusing on less-examined characteristics that could enhance pregnant women’s health could help in the reduction of deaths that arise because of pregnancy complications and contribute in globally accelerating increased accessibility to adequate reproductive health. Contribution: This study’s findings emphasise the necessity for policymakers and healthcare providers to educate the broader community about the importance of partner, family and peer support to minimise risks that may affect pregnancy care and wellbeing of mothers

The role of a community health worker-delivered preconception and pregnancy intervention in achieving a more positive pregnancy experience: the Bukhali trial in Soweto, South Africa

Background: A patient-centered, human-rights based approach to maternal care moves past merely reducing maternal mortality and morbidity, towards achieving a positive pregnancy experience. When evaluating an intervention, particularly in the context of the complex challenges facing maternal care in South Africa, it is therefore important to understand how intervention components are experienced by women. We aimed to qualitatively explore (i) factors influencing the pregnancy and postpartum experience amongst young women in Soweto, South Africa, and (ii) the influence of Bukhali, a preconception, pregnancy, and early childhood intervention delivered by community health workers (CHWs), on these experiences. Methods: Semi-structured, in-depth interviews were conducted with 15 purposively sampled participants. Participants were 18–28-year-old women who (i) were enrolled in the intervention arm of the Bukhali randomized controlled trial; (ii) were pregnant and delivered a child while being enrolled in the trial; and (iii) had at least one previous pregnancy prior to participation in the trial. Thematic analysis, informed by the positive pregnancy experiences framework and drawing on a codebook analysis approach, was used. Results: The themes influencing participants’ pregnancy experiences (aim 1) were participants’ feelings about being pregnant, the responsibilities of motherhood, physical and mental health challenges, unstable social support and traumatic experiences, and the pressures of socioeconomic circumstances. In terms of how support, information, and care practices influenced these factors (aim 2), four themes were generated: acceptance and mother/child bonding, growing and adapting in their role as mothers, receiving tools for their health, and having ways to cope in difficult circumstances. These processes were found to be complementary and closely linked to participant context and needs. Conclusion: Our findings suggest that, among women aged 18–28, a CHW-delivered intervention combining support, information, and care practices has the potential to positively influence women’s pregnancy experience in South Africa. In particular, emotional support and relevant information were key to better meeting participant needs. These findings can help define critical elements of CHW roles in maternal care and highlight the importance of patient-centred solutions to challenges within antenatal care. Trial registration: Pan African Clinical Trials Registry PACTR201903750173871, 27/03/2019

School attendance among refugee children with disabilities residing in South Africa: A cross-sectional, descriptive study.

Refugee children with disabilities are entitled to an education under South African law. These children face the challenges of living in a different country and having to manage their disabilities. However, without providing a quality education to refugee children with disabilities, they face lifelong challenges including poverty and exploitation. This nationally representative cross-sectional study, examines the prevalence of school attendance of refugee children with disabilities in South Africa. Using the Community Survey of 2016, 5,205 refugee children with disabilities are identified and studied. Descriptive statistics are used and results show that less than 5% of refugee children with disabilities are in school. Further there are differences across province of residence, sex and other sociodemographic characteristics. This study is a starting point for more quantitative analysis and further qualitative analysis on the barriers to education for refugee children with disabilities in the country

Integration of nutrition support using the FIGO nutrition checklist in the Bukhali trial: a dietitian’s perspective

The burden of malnutrition experienced globally, coupled with the increasing rate of micronutrient deficiencies, compromises the health and well-being of women during their reproductive years. Obesity places young South African women at particular risk during pregnancy, and increases obesity risk for their offspring. To address these risks, the Bukhali trial is being implemented in Soweto, South Africa with 18–28-year-old women, as part of the Healthy Lifestyle Trajectory Initiative. A dietitian is part of the Bukhali intervention team (community health workers) to provide nutritional support for overweight/obese trial participants, making use of the International Federation of Gynaecology and Obstetrics (FIGO) Nutrition Checklist. This paper reflects on the experiences and lessons learned by the Bukhali dietitian, including the use of the FIGO Nutrition Checklist and Healthy Conversation Skills to facilitate conversations about making healthy dietary behaviour changes. Identified challenges that influence nutrition and behaviour are discussed, including lack of food affordability, cultural and social influences on healthy food choices, unsupportive environments and food insecurity. Strategies to optimise this nutritional support are also mentioned. The Bukhali trial is showing that introducing additional nutrition support by a dietitian for at-risk participants has the potential to encourage young women to prioritise nutrition and health, even in the midst of contextual challenges to both nutrition and health

A qualitative exploration of the reasons and influencing factors for pregnancy termination among young women in Soweto, South Africa: a Socio-ecological perspective

Abstract Background Pregnancy termination is an essential component of reproductive healthcare. In Southern Africa, an estimated 23% of all pregnancies end in termination of pregnancy, against a backdrop of high rates of unintended pregnancies and unsafe pregnancy terminations, which contributes to maternal morbidity and mortality. Understanding the reasons for pregnancy termination may remain incomplete if seen in isolation of interpersonal (including family, peer, and partner), community, institutional, and public policy factors. This study therefore aimed to use a socio-ecological framework to qualitatively explore, in Soweto, South Africa, i) reasons for pregnancy termination amongst women aged 18–28 years, and ii) factors characterising the decision to terminate. Methods In-depth interviews were conducted between February to March 2022 with ten participants of varying parity, who underwent a termination of pregnancy since being enrolled in the Bukhali trial, set in Soweto, South Africa. A semi-structured, in-depth interview guide, based on the socioecological domains, was used. The data was analysed using reflexive thematic analysis, and a deductive approach. Results An application of the socio-ecological framework indicated that the direct reasons to terminate a pregnancy fell into the individual and interpersonal domains of the socioecological framework. Key reasons included financial dependence and insecurity, feeling unready to have a child (again), and a lack of support from family and partners for the participant and their pregnancy. In addition to these reasons, Factors that characterised the participants’ decision experience were identified across all socio-ecological domains and included the availability of social support and (lack of) accessibility to termination services. The COVID-19 pandemic and resultant lockdown policies also indirectly impacted participants’ decisions through detrimental changes in interpersonal support and financial situation. Conclusions Amongst the South African women included in this study, the decision to terminate a pregnancy was made within a complex structural and social context. Insight into the reasons why women choose to terminate helps to better align legal termination services with women’s needs across multiple sectors, for example by reducing judgement within healthcare settings and improving access to social and mental health support

Exploring health perceptions and priorities of South African youth: understanding what matters for health literacy interventions.

Introduction: health literacy is a key factor underpinning health behaviours and effective use of health information. Optimising health literacy in adolescents and young adults (AYA) is critical as they transition from childhood to adulthood, changing health-related behaviours alongside physical, emotional, and cognitive change. In South African AYA, with unplanned pregnancy common, poor health literacy may impact multiple generations. However, to create culturally and contextually appropriate health literacy interventions, co-development with AYA is essential.Aim: our aim was to explore health perceptions and priorities of South African AYA as the first stage in the co-development of contextually relevant health literacy intervention design.Methods: through purposive sampling of youth registered at a youth development centre in Soweto, South Africa, AYA (n=39, 18-25y) were recruited to form an advisory Youth Health Council (YHC). Focus group discussions were recorded for inductive thematic analysis to inform AYA health literacy needs. Health literacy was assessed with the Health Literacy Test for Limited Literacy populations (HELT-LL).Findings: most AYA (85%) had suboptimal health literacy. Analysis showed that AYA perceived ‘health’ as a complex mix of indicators (physical, emotional, mental, spiritual) that formed a holistic view of health. However, lack of funds and factors inherent in their local environment (food systems, family hierarchy, crime, vandalism, limited healthcare services) frequently challenged beneficial health behaviours. Stress was a common feature in the lives of AYA associated with multiple health domains.Conclusion: stress-focused health literacy interventions are needed for youth in challenging environments. Understanding the complex constructions and the core tenets of health that young people hold can inform contextually relevant intervention co-creation for improved health literacy as youth transition into adulthood.<br/

The role of a community health worker-delivered preconception and pregnancy intervention in achieving a more positive pregnancy experience: the Bukhali trial in Soweto, South Africa

Abstract Background A patient-centered, human-rights based approach to maternal care moves past merely reducing maternal mortality and morbidity, towards achieving a positive pregnancy experience. When evaluating an intervention, particularly in the context of the complex challenges facing maternal care in South Africa, it is therefore important to understand how intervention components are experienced by women. We aimed to qualitatively explore (i) factors influencing the pregnancy and postpartum experience amongst young women in Soweto, South Africa, and (ii) the influence of Bukhali, a preconception, pregnancy, and early childhood intervention delivered by community health workers (CHWs), on these experiences. Methods Semi-structured, in-depth interviews were conducted with 15 purposively sampled participants. Participants were 18–28-year-old women who (i) were enrolled in the intervention arm of the Bukhali randomized controlled trial; (ii) were pregnant and delivered a child while being enrolled in the trial; and (iii) had at least one previous pregnancy prior to participation in the trial. Thematic analysis, informed by the positive pregnancy experiences framework and drawing on a codebook analysis approach, was used. Results The themes influencing participants’ pregnancy experiences (aim 1) were participants’ feelings about being pregnant, the responsibilities of motherhood, physical and mental health challenges, unstable social support and traumatic experiences, and the pressures of socioeconomic circumstances. In terms of how support, information, and care practices influenced these factors (aim 2), four themes were generated: acceptance and mother/child bonding, growing and adapting in their role as mothers, receiving tools for their health, and having ways to cope in difficult circumstances. These processes were found to be complementary and closely linked to participant context and needs. Conclusion Our findings suggest that, among women aged 18–28, a CHW-delivered intervention combining support, information, and care practices has the potential to positively influence women’s pregnancy experience in South Africa. In particular, emotional support and relevant information were key to better meeting participant needs. These findings can help define critical elements of CHW roles in maternal care and highlight the importance of patient-centred solutions to challenges within antenatal care. Trial registration Pan African Clinical Trials Registry PACTR201903750173871, 27/03/2019