Introduction Sub-Saharan Africa still bears the heaviest burden of maternal mortality among the regions of the world, with an estimated 201,000 (66%) women dying annually due to pregnancy and childbirth related complications. Utilisation of maternal healthcare services including antenatal care, skilled delivery and postnatal care contribute to a reduction of maternal and child mortality and morbidity. Factors influencing use of maternal healthcare occur at both the individual and contextual levels. The objective of this study was to systematically examine the evidence regarding the influence of contextual factors on uptake of maternal health care in sub-Saharan Africa. Materials and Methods The process of scoping review involved searching several electronic databases, identifying articles corresponding to the inclusion criteria and selecting them for extraction and analysis. Peer reviewed multilevel studies on maternal healthcare utilisation in sub-Saharan Africa published between 2007 and 2019 were selected. Two reviewers independently evaluated each study for inclusion and conflicts were resolved by consensus. Results We synthesised 34 studies that met the criteria of inclusion out of a total of 1,654 initial records. Most of the studies were single-country, cross-sectional in nature and involved two-level multilevel logistic regression models. The findings confirm the important role played by contextual factors in determining use of available maternal health care services in sub-Saharan Africa. The level of educational status, poverty, media exposure, autonomy, empowerment and access to health facilities within communities are some of the major drivers of use of maternal health services. Conclusions This review highlights the potential of addressing high-level factors in bolstering maternal health care utilisation in sub-Saharan Africa. Societies that prioritise the betterment of social conditions in communities and deal with the problematic gender norms will have a good chance of improving maternal health care utilisation and reducing maternal and child mortality. Better multilevel explanatory mechanisms that incorporates social theories are recommended in understanding use of maternal health care services in sub-Saharan Africa.

Background Teenage pregnancy remains a major social and public health challenge in developing countries especially sub-Saharan Africa (SSA) where prevalence rates are still increasing. Even if considerable effort has been made over the years to study determining factors of teenage pregnancy in SSA, few studies have looked at the trends and associated factors over a longer period. Furthermore, no known study has focussed on both individual and contextual factors influencing teenage pregnancy in Zambia. This study, thus sought to fill this gap in knowledge by simultaneously investigating trends of teenage pregnancy as well as its individual and contextual determining factors. Methods A total pooled weighted sample of 10,010 teenagers (in the age group 15–19) from four waves of the Zambia Demographic and Health Surveys were extracted. Using bivariate analysis, we investigated the trends of teenage pregnancy between 2001 and 2018. Separate multilevel logistic regression models were fitted on pooled teenage pregnancy data in relation to several individual and contextual level factors. Both fixed and random effects were produced. Bayesian parameter estimates were produced using lme4 package in R statistical programming environment. Results Results of the trends of teenage pregnancy in Zambia have shown an overall decrease of 2% between 2001 and 2018. Almost all the socioeconomic and demographic variables were consistently associated with teenage pregnancy (p < 0.001) in a bivariate analysis across the four survey. In multilevel analysis, the odds of being pregnant were higher for teenagers who were employed (aOR = 1.21, 95% CI: 1.02–1.42), married (aOR = 7.71, 95% CI: 6.31–9.52) and those with knowledge of ovulation period (aOR = 1.58, 95% CI: 1.34–1.90). On the other hand, belonging to households in high wealth quintiles, being literate, exposure to mass-media family planning messages and delayed sexual debut were associated with decreased odds of teenage pregnancy. Conclusion The study shows that teenage pregnancy remains a social and public health challenge in Zambia as the country has seen little decrease in the prevalence over the years under consideration. Factors associated with teenage pregnancy include marital status, and employment, knowledge of ovulation period, wealth quintile, sexual debut and exposure to mass-media family planning messaging. Concerted effort must be made to improve literacy levels, reduce poverty and enhance sexual health promotion through the mass media in view of cultural norms, which may prevent parents and children from discussion sexual education topics thus exacerbate the vice.

BackgroundEven though evidence shows that fertility transition has begun almost everywhere in sub–Saharan Africa, the decline has been slower than in other parts of the world. Researchshows that there is a positive relationship between fertility levels and desired family size. Therefore, many countries in the region are implementing family planning education campaigns targeting at influencing reproductive behaviour of women. Thus,this studyaimed at examiningthe extent to which exposure to family planning communication is associated withdesired family size in adolescencein sub-Saharan Africa.MethodsThis study used data extracted fromthe most recent Demographic and Health Survey datasets for 28 countries in sub-Saharan Africa. Analyses were conducted on a pooled weighted sample of 87,950female adolescents’ aged 15-19 yearscaptured in respective country surveys. Multivariate logistic regression models were fitted in Stata version 16 software to examine the effects of exposure to family planning communication on adolescents desired family size.ResultsFindings show that regardless of the country,exposure to family planning communication among adolescentshad a significant effect on desire for fewer children. Average ideal family size among adolescents who had exposure to family planning communication was (3.8 children compared to 4.5 children;p<0.001) among those with no exposure.Marital status, wealth status, education level,contraceptive use and employment status were also significantly associated with adolescents’desiredfamily size.Country level differences were observed regarding desired family size among adolescents. Adolescents from West Africa Countries had higher desired family size.ConclusionExposure to family planning communication has shown the potential to influence adolescents’ fertility behavior in the region. Desire for large family size is predominantly high among adolescents from West and Central African countries. Suggesting that high fertility remains a social concern in these regions. Furthermore, the study found sub-regional variations in determinants ofdesired family size among adolescents. Calling for the need to scale-up family planning education programmes especially in West and Central Africa countries.

Background: Globalization is considered a major structural determinant of health and health care outcomes across the world. This study examines the influence of globalisation on maternal healthcare utilisation in sub-Saharan Africa. Methods: Cross-sectional pooled survey data from 34 Demographic and Health Surveys (DHS) with 22559 randomly selected women of reproductive age group with a recent birth were combined with country-level globalisation indices from the KOF Swiss Economic Institute. Bayesian multilevel models were applied on maternal health care utilisation indicators (antenatal care visits, institutional delivery, and postnatal care check-ups) in relation to three dimensions of globalisation indices (economic, social, and political) and selected covariates. Results: The results from the study demonstrate that the influence of globalisation on maternal healthcare depends on the dimension of globalisation. After controlling for selected individual and community-level factors, social globalisation is significantly associated with all the indicators of maternal healthcare utilisation while economic globalisation is significantly associated with antenatal care and postnatal check-ups for mothers and new-born babies. Conclusion: More consideration in terms of public policy and further research, should be given to dimensions of globalisation which are more likely to influence maternal healthcare utilisation in sub-Saharan Africa. Keywords: globalisation, maternal healthcare, multilevel modelling, Bayesian analysis, sub-Saharan Africa

Background: The rights-based and capability approaches have received increased attention relative to maternal health in the aftermath of the 2015 Millenium Development Goals (MDGs). This is in view of the sub-optimal progress gained in reducing maternal and child mortality, especially in developing countries. Despite the combined potential of these models, limited empirical studies testing their viability in maternal health exist. This is what this study sought to accomplish. Method: We combined several datasets for this study, including the Demographic Health Survey (DHS), World Development Indicators, the World Governance Indicators and Freedom House. Using the R programming environment and the R2MLwiN package, Bayesian multilevel logistic regression models were applied on three indicators of maternal healthcare (antenatal care visits, institutional delivery, and postnatal check-ups) in relation to selected individual, community and country-level factors representing right-based and capability approaches. All the models report posterior odd ratios (POR).Results: The results support the potence of the rights-based and capability approaches in bolstering maternal healthcare utilization in sub-Saharan Africa. Living in countries which have high freedom status (POR = 1.19) and higher female secondary school enrolments (POR = 1.54) increases the odds of adequate antenatal care. Living in countries with high freedom status (POR =1.33) and higher voice and accountability (POR = 1.72) also increases the odds of institutional delivery. Similar results are reported for postnatal care where country freedom status (POR = 1.89), voice and accountability (POR = 1.25) and female school enrolment (POR = 1.41) are significant predictors. Conclusion: The results imply that the rights-based and capability approaches have the potential to enhance maternal healthcare utilization in sub-Saharan Africa. Therefore, policy strategies emphasizing on freedoms, accountability and individual capability functionings should be encouraged in the pursuit of achieving Sustainable Development Goals number 3.

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Maternal health care utilization still remains crucial in ensuring good pregnancy outcomes and a reduction in maternal and child mortality especially in developing countries. Although several studies have been conducted to investigate determinants of maternal health care utilization, the innfluence of gender relations and women empowerment on maternal healthcare in cross-national context has received little attention. This paper sought out to examine the influence of gender relations and women empowerment on maternal healthcare utilization in sub-Saharan Africa. The analysis pools sample data of 245,955 respondents from the most recent Demographic and Health Surveys (DHS) and World Development Indicators of 35 sub-Saharan African countries. Separate Bayesian multilevel logistic regression models are fitted for adequate antenatal care and institutional delivery in relation to several factors indicating gender relations and women empowerment at three levels. Several components of gender relations and women empowerment were significantly associated with maternal health care after adjusting for covariates. In addition, significant between country and between community variations in the odds of maternal health care utilisation were observed. These results underscore the importance of prioritising contextual gender equity and women empowerment to achieve better utilisation of maternal healthcare services and subsequently, a reduction in maternal mortality in sub-Saharan Africa.

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