Objectives: To analyze data from recent Demographic and Health Surveys (DHS) conducted in 21 low-and middle-income countries (LMICs) to examine patterns of interpregnancy intervals, unmet need, pregnancy risk and family planning method use and method mix among women 0-23 months postpartum. Study design: Secondary analysis of postpartum women aged 15-49 years in 22 DHS surveys from 21 LMICs conducted between 2005 and 2012. We applied an adapted unmet need definition for postpartum women to look at prospective fertility preferences. We also constructed a new composite pregnancy risk indicator for postpartum women who have been sexually active since their last birth. Results: In 9 of 22 surveys, 50% or more of nonfirst births occur at interpregnancy intervals that are too short. Overall prospective unmet need for family planning by postpartum women has not changed demonstrably since a 2001 analysis and is universally high: 61% of all postpartum women across the 21 countries have an unmet need for family planning. In 10 of 22 surveys, pregnancy risk rises steadily throughout the 2 years after birth. In the remaining 12 surveys, the risk of pregnancy peaks at 6-11 months after birth. Even when postpartum women are using family planning, they rely overwhelmingly on short-acting methods (51-96% in 21 of 22 surveys). Conclusion: Our approach of estimating pregnancy risk by postpartum timing confirms a high probability for pregnancies to be less than optimally spaced within 2 years of a prior birth and suggests that special consideration is needed to effectively reach this population with the right messages and services. Implications: Using recent, multicountry data for women within 2 years postpartum in LMICs, this paper updates existing estimates of high prospective unmet need for family planning and presents a new composite pregnancy risk analysis based on postpartum women's actual practices to demonstrate the magnitude of missed opportunities for programmatic intervention for the postpartum population.

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Abstract.Concerted efforts from national and international partners have scaled up malaria control interventions, including insecticide-treated nets, indoor residual spraying, diagnostics, prompt and effective treatment of malaria cases, and intermittent preventive treatment during pregnancy in sub-Saharan Africa (SSA). This scale-up warrants an assessment of its health impact to guide future efforts and investments; however, measuring malaria-specific mortality and the overall impact of malaria control interventions remains challenging. In 2007, Roll Back Malaria's Monitoring and Evaluation Reference Group proposed a theoretical framework for evaluating the impact of full-coverage malaria control interventions on morbidity and mortality in high-burden SSA countries. Recently, several evaluations have contributed new ideas and lessons to strengthen this plausibility design. This paper harnesses that new evaluation experience to expand the framework, with additional features, such as stratification, to examine subgroups most likely to experience improvement if control programs are working; the use of a national platform framework; and analysis of complete birth histories from national household surveys. The refined framework has shown that, despite persisting data challenges, combining multiple sources of data, considering potential contributions from both fundamental and proximate contextual factors, and conducting subnational analyses allows identification of the plausible contributions of malaria control interventions on malaria morbidity and mortality.

Female genital mutilation/cutting (FGM/C), also known as female circumcision, is a global public health and human rights problem affecting women and girls. Several concerted efforts to eliminate the practice are underway in several sub-Saharan African countries where the practice is most prevalent. Studies have reported variations in the practice with some countries experiencing relatively slow decline in prevalence. This study investigates the roles of normative influences and related risk factors (e.g., geographic location) on the persistence of FGM/C among 0–14 years old girls in Kenya. The key objective is to identify and map hotspots (high risk regions). We fitted spatial and spatio-temporal models in a Bayesian hierarchical regression framework on two datasets extracted from successive Kenya Demographic and Health Surveys (KDHS) from 1998 to 2014. The models were implemented in R statistical software using Markov Chain Monte Carlo (MCMC) techniques for parameters estimation, while model fit and assessment employed deviance information criterion (DIC) and effective sample size (ESS). Results showed that daughters of cut women were highly likely to be cut. Also, the likelihood of a girl being cut increased with the proportion of women in the community (1) who were cut (2) who supported FGM/C continuation, and (3) who believed FGM/C was a religious obligation. Other key risk factors included living in the northeastern region; belonging to the Kisii or Somali ethnic groups and being of Muslim background. These findings offered a clearer picture of the dynamics of FGM/C in Kenya and will aid targeted interventions through bespoke policymaking and implementations.

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