**3. Family planning services**

The decision to limit one's family size is wholly personal intimate decision between husband and wife. The practice to limit family size by whatever means has been known since man developed social conscience. In SSA, national family planning programmes were introduced, respectively, in the late 1960s in Kenya and Nigeria [31], in the early 1970s in Ghana and in the mid-1970s in South Africa [32]. Programmes to promote FP in developing countries began in the 1960s in response to improvements in child survival that led to increase in population growth. The number of developing countries with official policies to support FP rose from only 2 in 1960 to 74 by 1975 and 115 by 1996 [30]. Before the 1960s, African countries had no population policies in whatever form; by the mid-1970s, only 25% had; and this rose to 64% in 2009 [9]. Family planning programmes throughout SSA have made use of three approaches to service delivery:

**1.** Health-care facilities

Family planning is a cost-effective public health and development intervention. Generally, planned pregnancies which are safer for the mother produce healthier children than unplanned pregnancy. FP allows individuals and couples to at least plan one aspect of their lives (reproductive life). The cost of averting unwanted birth is quite insignificant compared to the costs to the family and country of unwanted births [9]. Further, fewer public health interventions are as effective as FP programmes in reducing morbidity and mortality of moth-

The health and socio-economic benefits of healthy motherhood including the use of contraception are known. Contraceptive use promotes small family size, improves child survival and reduces sibling competition for scarce family and maternal resources [20, 21]. When used correctly and consistently, contraceptive use in developing countries have been shown to decrease the number of maternal deaths and also prevent more than half of all maternal deaths if full demand of birth control is met [12, 22]. Spacing children can reduce mortality

At macro-level, national population growth is slower which reduces strains on the environment, natural resources, education and health-care systems. FP reduces the risk of maternal mortality per birth (i.e. number of maternal deaths in 100,000 live births per year) [27] as a result of pregnancies too early, too many, too close and too late (4Ts of maternal mortality) [28–30] all of which are prevalent in SSA. The effective use of contraception can help couples achieve the desired number of children they want, prevent the number of unwanted pregnancies and reduce the risks of sexually transmitted infections (STIs) and thus overall improve-

Contraceptive use allows couples to realize their full potentials, and the woman can better fulfill her roles as a wife, mother, wage earner and community member. The man can better expand his roles as husband, father and family caregiver [30]. All these go a long way in curtailing population explosion, reduce dependency ratio (youth), better the health indices for the country and improve socio-economic conditions. This will also assist Africa to make

The decision to limit one's family size is wholly personal intimate decision between husband and wife. The practice to limit family size by whatever means has been known since man developed social conscience. In SSA, national family planning programmes were introduced, respectively, in the late 1960s in Kenya and Nigeria [31], in the early 1970s in Ghana and in the mid-1970s in South Africa [32]. Programmes to promote FP in developing countries began in the 1960s in response to improvements in child survival that led to increase in population growth. The number of developing countries with official policies to support FP rose from only 2 in 1960 to 74 by 1975 and 115 by 1996 [30]. Before the 1960s, African countries had no population policies in whatever form; by the mid-1970s, only 25% had; and this rose to 64% in 2009 [9]. Family planning programmes throughout SSA have made use of three approaches to service delivery:

ers and infants and result in such a huge positive impacts [9, 18, 19].

among under-fives by 10% and among pregnant mothers by 32% [23–26].

progress in achieving all the sustainable development goals (SDGs).

ment in maternal and child health and the nation.

**3. Family planning services**

72 Family Planning


Family planning services and contraceptive commodity supply were started through assistance by the US Agency for International Development (USAID) and other international donors to national governments across Africa. Later on, non-governmental organizations (NGOs) came in to supply and/or donate FP commodities. Initially, the services were provided at health-care facilities in state, district and provincial capitals. During these "infantile" periods, access to family planning methods was under strict control of medical practitioner even in health facilities. During the period clients have to pay a token to access service which also was a huge barrier to many potential users. Firstly, the woman has to meet the eligibility criteria [33], they must be married and husband must give verbal (seen by the doctor) or written consent and be seen by the doctor as soon as she starts her menses. This was a good starting point for FP services delivery, but the burden and disadvantages of this "solo" practice became obviously inconvenient to the clients, long waiting time and other logistics. There was an urgent need to overhaul the system in order to improve access and service utilization. The World Health Organization (WHO) has published international guidelines on medical eligibility criteria that have proven to be invaluable [34].

Studies have shown that if given an adequate training, paramedical staff (nurses and midwives) could insert intrauterine devices (IUDs) and provide injectable contraceptives to high clinical standards and even lay staff, after a short training, could also dispense pills, and over-the-counter sale of pills without prescription was justifiable [9, 35–37]. Facility-based service provision is highly restrictive in terms of geographic access; this means that alternative approaches are in dire need in order to make the commodities easily accessible. However, studies have shown that the use of FP methods falls only modestly with increasing distance or travel time to the nearest source of contraception [38]. But in SSA where poverty index is high, physical accessibility becomes predictable and risky especially during raining season, and transport is available only once or twice (during market days) in a week; these are the real challenges to contraceptive use.

The provision of services through government facilities follows the PHC approach: all the three tiers (primary, secondary and tertiary) of health-care systems. The incorporation of contraceptive services into PHC facilities is an approach to boost contraceptive prevalence rates especially in SSA [39] where this has remained persistently low. In order to improve service availability and increase coverage, private health facilities later got involved. This involvement varies widely across the continent, being 40% in Kenya and more than 50% in Uganda but low (<20%) in areas where national government programmes are strong such as Namibia and South Africa. However, majority of these private facilities are Urban-based and thus serve the needs of urban elites.

Commercial outlets such as pharmacies, drug retail shops and patent medicine or street vendors and bazaars also constitute major significant outlets in which contraceptives (e.g. pills, condoms) can be obtained. Social marketing schemes run by NGOs or international organization are popular where advertising, logistics and product prices are highly subsidized in order to promote utilization. It is most effective when pills, condoms or both are fairly common methods; demand for contraception is well established coupled with a well-developed infrastructure (radio and television) and no restriction on promotion of FP methods [9]. In a world that is becoming globalized with rapid urbanization developing across Africa and intense exposure to mass media both formal and informal (WhatsApp, Facebook etc) the role of social marketing of contraceptives will likely rise with time.

to provide FP services [45, 46]. CBD programmes are implemented through various approaches. These include home visits, group education meetings, fixed and mobile CBD posts, etc., while a variety of services are offered—contraceptive commodity distribution, health education and

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According to the WHO [42], different kinds of people can be recruited to work as distributors

In sub-Saharan Africa, Zimbabwe was the first country to initiate CBD programme. On the other hand, Kenya has the greatest diversity in CBD programmes and activities globally. In the 1980s, CBD initiatives proliferated with the encouragement and support of the National Council for Population and Development and financial assistance from Kenyan USAID. Kenya in a sense thus represents a laboratory of CBD diversity in that nearly every type of CBD approach that has been tried elsewhere is present in some way in Kenyan setting [41, 47, 48]. The CBD programme in Tanzania started in 1988, when the International Planned Parenthood Federation (IPPF) launched a programme. By 1996, CBD programmes were fully functionally in 22 of the 104 districts in Tanzania and Zanzibar [43]. In Ghana, CBD programmes started with two experiments: the Danfa Project and Navrongo Community Health and Family Planning Project. The Navrongo Project started in the 1990s to address community explanations for failure of family planning outreach schemes [48]. The Navrongo Health Research Centre (NHRC) is part of a district-wide National Demographic Surveillance System. Mali had its most CBD project in 1986 in the rural district of Katibougou, and by the

• Convenience for clients (in terms of time spent traveling and consultation)

referrals for clinic-based services.

Advantages of CBD programmes:

• Minimal transport costs

• Market traders

• Shopkeepers • Factory workers

• Traditional birth attendants • Community health workers

• Hairdressers and barbers • Traditional healers • Taxi drivers • Mothers • Farmers

• Agricultural extension workers • Waiters and waitresses

**Table 1.** Examples of possible distributors for contraceptive commodities.

in CBD programmes across the world (**Table 1**).

• Easy access to contraceptives by rural folk

• Receiving services in one's own environment

#### **3.1. Community-based distribution (CBD) of contraceptives**

Community-based distribution (CBD) of contraceptives can be used to supplement other government and private family planning services to meet the challenges of making the commodity widely available and accessible to those in urban slums, rural areas and hard-to-reach communities. CBD can be an important addendum or alternative to clinic-based services. Usually, it is cheap, easier for many people to reach and available in a wide range of settings. It is a complex concept involving varied operational design to suit local contexts. It is a programme involving non-clinical family planning service approaches that uses community organization, structure and institutions to promote the use of safe and simple contraceptive technologies [40]. It expands acceptability and convenience of contraceptives and resolves the cost of service, thereby extending its use among clientele who seek contraceptives but will not use services that are confined to clinical settings [40, 41].

CBD is thus a good example of the WHO's commitment of PHC by making essential health care available to individuals and families in the community in an acceptable and affordable way with their full participation [42]. CBD is also compatible with the trend in many countries towards the decentralization of health services and the involvement of community in the provision and support of its own health services.

The following factors are used to identify populations in need of CBD programme, all of which are applicable to SSA:


For a successful implementation, the agency (government, NGOs or international donors) usually worked with its own staff and the communities to identity local leaders and influential community members (gatekeepers). Regular meetings are held in the community centers, and assistance is sought to identify local volunteers (women and men) who will act as distributors of contraceptive methods.

CBD programmes originated in Asia in the 1960s and spread throughout Asia and Latin America in the 1970s and 1980s. It was introduced into sub-Saharan Africa in the late 1980s and 1990s; by 1996 more than half of the population of SSA lived in countries with some kind of CBD programme [41, 43]. At inception CBD programmes were integrated into existing health-care services with health-care providers involved in delivering FP services. But with time, community needs exceeded the abilities of national governments' health programmes [44]. So, lay health workers became a good asset to drive CBD programmes, and selected community members were trained to provide FP services [45, 46]. CBD programmes are implemented through various approaches. These include home visits, group education meetings, fixed and mobile CBD posts, etc., while a variety of services are offered—contraceptive commodity distribution, health education and referrals for clinic-based services.

According to the WHO [42], different kinds of people can be recruited to work as distributors in CBD programmes across the world (**Table 1**).

Advantages of CBD programmes:

infrastructure (radio and television) and no restriction on promotion of FP methods [9]. In a world that is becoming globalized with rapid urbanization developing across Africa and intense exposure to mass media both formal and informal (WhatsApp, Facebook etc) the role

Community-based distribution (CBD) of contraceptives can be used to supplement other government and private family planning services to meet the challenges of making the commodity widely available and accessible to those in urban slums, rural areas and hard-to-reach communities. CBD can be an important addendum or alternative to clinic-based services. Usually, it is cheap, easier for many people to reach and available in a wide range of settings. It is a complex concept involving varied operational design to suit local contexts. It is a programme involving non-clinical family planning service approaches that uses community organization, structure and institutions to promote the use of safe and simple contraceptive technologies [40]. It expands acceptability and convenience of contraceptives and resolves the cost of service, thereby extending its use among clientele who seek contraceptives but will not use services that are confined to clinical settings [40, 41]. CBD is thus a good example of the WHO's commitment of PHC by making essential health care available to individuals and families in the community in an acceptable and affordable way with their full participation [42]. CBD is also compatible with the trend in many countries towards the decentralization of health services and the involvement of community in the

The following factors are used to identify populations in need of CBD programme, all of

For a successful implementation, the agency (government, NGOs or international donors) usually worked with its own staff and the communities to identity local leaders and influential community members (gatekeepers). Regular meetings are held in the community centers, and assistance is sought to identify local volunteers (women and men) who will act as dis-

CBD programmes originated in Asia in the 1960s and spread throughout Asia and Latin America in the 1970s and 1980s. It was introduced into sub-Saharan Africa in the late 1980s and 1990s; by 1996 more than half of the population of SSA lived in countries with some kind of CBD programme [41, 43]. At inception CBD programmes were integrated into existing health-care services with health-care providers involved in delivering FP services. But with time, community needs exceeded the abilities of national governments' health programmes [44]. So, lay health workers became a good asset to drive CBD programmes, and selected community members were trained

of social marketing of contraceptives will likely rise with time.

**3.1. Community-based distribution (CBD) of contraceptives**

provision and support of its own health services.

• Low usage of existing family planning services

• Cultural barriers that impede attendance at clinics [42]

• Are far away from family planning clinics

which are applicable to SSA:

74 Family Planning

• Low prevalence of contraceptive use • Lack of awareness of family planning

tributors of contraceptive methods.


In sub-Saharan Africa, Zimbabwe was the first country to initiate CBD programme. On the other hand, Kenya has the greatest diversity in CBD programmes and activities globally. In the 1980s, CBD initiatives proliferated with the encouragement and support of the National Council for Population and Development and financial assistance from Kenyan USAID. Kenya in a sense thus represents a laboratory of CBD diversity in that nearly every type of CBD approach that has been tried elsewhere is present in some way in Kenyan setting [41, 47, 48]. The CBD programme in Tanzania started in 1988, when the International Planned Parenthood Federation (IPPF) launched a programme. By 1996, CBD programmes were fully functionally in 22 of the 104 districts in Tanzania and Zanzibar [43]. In Ghana, CBD programmes started with two experiments: the Danfa Project and Navrongo Community Health and Family Planning Project. The Navrongo Project started in the 1990s to address community explanations for failure of family planning outreach schemes [48]. The Navrongo Health Research Centre (NHRC) is part of a district-wide National Demographic Surveillance System. Mali had its most CBD project in 1986 in the rural district of Katibougou, and by the


**Table 1.** Examples of possible distributors for contraceptive commodities.

early 1990s, the second project was funded by USAID to expand FP service delivery in nine rural districts in two regions using village-level family planning promoters [45, 49].

accommodated over the years despite initial challenges. Family planning service has also been well integrated into other reproductive health services. It is important to note that contraceptive use relies on the principle of demand and supply. Generating demand is critical in the uptake of contraceptives, but this will not happen if supply system cannot guaranty consistent availability

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Pregnancies too early, too frequent, too many and too late are always associated with adverse outcomes [27, 29]. The health of mothers and that of her baby are inextricably bound, and the survival and wellbeing of even the older children are also compromised by their mother's death. To avoid these adverse outcomes, medical guidelines recommend the uptake of family planning method by 6 weeks postpartum [50]. Contraceptive methods are by definition, preventive methods to assist women avoid unwanted pregnancies. The last few decades have witnessed a contraceptive revolution, and advances in medical science have shown us how to

The production of an "ideal contraceptive" has continued to be elusive (contraceptive that is safe, inexpensive, acceptable, effective, reversible and long-lasting enough to obviate frequent administration which requires little or no medical attention) [51]. It is also difficult to assume that "one jacket" fits all, as a method that may be suitable to an individual may be unsuitable to another for a number of reasons—medical eligibility [34], religious beliefs and socio-economic situations. The current approach in family planning programmes is to provide a "cafeteria choice" where couples or individuals are offered all the available methods for which a choice can be made based on the need. Each method is unique in its mode of action,

In every human society, there are traditions that are passed down from generation to generation through the teaching of certain beliefs, cultural norms, attitudes, customs and habits. These traditional beliefs and practices cover all aspects of life including reproduction. Throughout human history, traditional family planning practices to space children have been rich and varied [52]. Traditional methods of contraception are those methods which do not involve the use of orthodox medicine. Some of these methods have existed dating back to prehistoric times. Today, traditional family planning is practiced worldwide for a number of reasons: being natural does not involve a third party (health-care provider) and does not fall under any religious ban [53]. Natural family planning (fertility awareness) is a method of family planning and preventing or spacing pregnancy by observing naturally (physiological) occurring signs and symptoms of the menstrual cycle. The couples avoid intercourse in the days (fertile period) during the

of acceptable and affordable commodities.

The methods can be categorized into:

**b.** Modern (temporary and permanent)

effectiveness, advantages and disadvantages.

*3.2.1. Traditional (natural) family planning methods*

**a.** Natural

**3.2. Family planning methods: Natural and modern**

interfere with physiology of reproduction-ovulation cycle.

Nigeria has had some form of CBD programmes since the 1990s; but in 2007, the country reviewed the results of pilot programme in the use of Community Health Extension Workers (CHEWS). CHEWS are the lowest cadre of trained medical personnel, who had at least 2–3 years of training in basic curative and preventive health services. The country also undertook a study tour to Uganda in 2008 to assess its community-based distribution of injectable contraceptives. By 2012, the National Council on Health approved the recommendation that allows CHEWS to provide injectable contraceptives across the country.

Thus, it can be said that CBD programmes has expanded in SSA over the past 20 years. A review of 93 developing countries in 1984 revealed that CBD programmes were functioning in 34 countries across the world with 7 programmes operating in SSA [40]. Between the 1980s and 1990s, the programme has expanded considerably. Countries with coverage <21% were designed as weak effort, while those with ≥21% coverage in all areas are strong [40]. Even though coverage within countries is variable and actual rates of exposure to CBD activities are unknown, more than half of populations of SSA lived in countries where CBD activity is operating by 1996 (**Figure 1**). So, it can be said that CBD programmes are well grounded in Africa, and considerable experience has

**Figure 1.** Sub-Saharan countries with CBD programmes, pilot projects or research (1994–1998) [40].

accommodated over the years despite initial challenges. Family planning service has also been well integrated into other reproductive health services. It is important to note that contraceptive use relies on the principle of demand and supply. Generating demand is critical in the uptake of contraceptives, but this will not happen if supply system cannot guaranty consistent availability of acceptable and affordable commodities.

#### **3.2. Family planning methods: Natural and modern**

Pregnancies too early, too frequent, too many and too late are always associated with adverse outcomes [27, 29]. The health of mothers and that of her baby are inextricably bound, and the survival and wellbeing of even the older children are also compromised by their mother's death. To avoid these adverse outcomes, medical guidelines recommend the uptake of family planning method by 6 weeks postpartum [50]. Contraceptive methods are by definition, preventive methods to assist women avoid unwanted pregnancies. The last few decades have witnessed a contraceptive revolution, and advances in medical science have shown us how to interfere with physiology of reproduction-ovulation cycle.

The methods can be categorized into:

**a.** Natural

early 1990s, the second project was funded by USAID to expand FP service delivery in nine

Nigeria has had some form of CBD programmes since the 1990s; but in 2007, the country reviewed the results of pilot programme in the use of Community Health Extension Workers (CHEWS). CHEWS are the lowest cadre of trained medical personnel, who had at least 2–3 years of training in basic curative and preventive health services. The country also undertook a study tour to Uganda in 2008 to assess its community-based distribution of injectable contraceptives. By 2012, the National Council on Health approved the recommendation that

Thus, it can be said that CBD programmes has expanded in SSA over the past 20 years. A review of 93 developing countries in 1984 revealed that CBD programmes were functioning in 34 countries across the world with 7 programmes operating in SSA [40]. Between the 1980s and 1990s, the programme has expanded considerably. Countries with coverage <21% were designed as weak effort, while those with ≥21% coverage in all areas are strong [40]. Even though coverage within countries is variable and actual rates of exposure to CBD activities are unknown, more than half of populations of SSA lived in countries where CBD activity is operating by 1996 (**Figure 1**). So, it can be said that CBD programmes are well grounded in Africa, and considerable experience has

rural districts in two regions using village-level family planning promoters [45, 49].

allows CHEWS to provide injectable contraceptives across the country.

76 Family Planning

**Figure 1.** Sub-Saharan countries with CBD programmes, pilot projects or research (1994–1998) [40].

**b.** Modern (temporary and permanent)

The production of an "ideal contraceptive" has continued to be elusive (contraceptive that is safe, inexpensive, acceptable, effective, reversible and long-lasting enough to obviate frequent administration which requires little or no medical attention) [51]. It is also difficult to assume that "one jacket" fits all, as a method that may be suitable to an individual may be unsuitable to another for a number of reasons—medical eligibility [34], religious beliefs and socio-economic situations. The current approach in family planning programmes is to provide a "cafeteria choice" where couples or individuals are offered all the available methods for which a choice can be made based on the need. Each method is unique in its mode of action, effectiveness, advantages and disadvantages.

#### *3.2.1. Traditional (natural) family planning methods*

In every human society, there are traditions that are passed down from generation to generation through the teaching of certain beliefs, cultural norms, attitudes, customs and habits. These traditional beliefs and practices cover all aspects of life including reproduction. Throughout human history, traditional family planning practices to space children have been rich and varied [52]. Traditional methods of contraception are those methods which do not involve the use of orthodox medicine. Some of these methods have existed dating back to prehistoric times. Today, traditional family planning is practiced worldwide for a number of reasons: being natural does not involve a third party (health-care provider) and does not fall under any religious ban [53].

Natural family planning (fertility awareness) is a method of family planning and preventing or spacing pregnancy by observing naturally (physiological) occurring signs and symptoms of the menstrual cycle. The couples avoid intercourse in the days (fertile period) during the menstrual cycle when the woman is most likely to become pregnant. Fertility awareness is based on a scientific knowledge of the female and male reproductive systems and on the understanding of the signs and symptoms that occur physiologically in women's menstrual cycle to indicate when she is fertile or infertile. This is often referred to as safe period.

**4. Hormonal contraceptives**

**a.** Combined oral contraceptives (COCs)

**b.** Progestogen-only pill (POP)

**c.** Emergency contraception **2.** Slow-release (depot) formulations

**b.** Subcutaneous implants

can be classified into:

**a.** Injectable

**c.** Vaginal rings

than 4% use the pill.

successful use of OCs.

**5. Injectable contraceptives**

**1.** Oral pills

Since the 1960s when oral contraceptives (OCs) were first marketed, they have symbolized modern contraception and have remained the most widely used hormonal method globally. OCs provide millions of women with effective, convenient and safe protection from pregnancy. Currently, more than 100 million women use OCs. Data on both ever use and current use of contraceptive revealed the continuing popularity of OCs [63]. Hormonal contraceptives

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Worldwide, an estimated 8% of all married women currently use the pill and rank third among all family planning methods currently used by married women. The use of pills accounts for about one-quarter of all contraceptive use among both married and unmarried women in sub-Saharan Africa [62]. Overall, about 15% of married women use family planning, and less

In some countries in Africa, OC usage is among the highest in the world: 33% of married women in Zimbabwe, 21% in Mauritius, 1.8% in Nigeria, 18% each in Botswana and Cape Verde respectively [62]. The use of COCs has been associated with health benefits. It reduces menstrual blood flow and dysmenorrhoea and lowers the prevalence of iron deficiency anaemia [63–65]. Generally, when taken correctly, OCs offer highly effective contraceptive. Among perfect users (women who do not miss pills and follow the instructions correctly), only 1 in every 1000 women becomes pregnant in the first year [62]. Among typical users, about 60–80 women in every 1000 will become pregnant during the first year [66]. Appropriate health education and counseling of clients are the key ingredients to the

When oral contraceptives were introduced in family planning programmes, they were hailed as a major breakthrough. However, overtime, it became obvious that not many women are good in remembering to take their pills on a daily basis and follow the schedule

Natural family planning provides women with alternatives for those who do not wish to use modern (artificial) methods. In low-income countries, women tend to adopt postpartum family planning methods only after resumption of sexual intercourse or menses [54–56]. In sub-Saharan Africa, both events can be delayed as typically women practice prolonged breastfeeding (up to 2 years) which lengthens their period of amenorrhea, and in Middle and West Africa, women abstain from sexual intercourse for extended periods of time after a birth [57]. Indeed, many African cultures discourage sex during breast-feeding because of misconception that semen pollutes the breast milk. However, recent report has shown that the mean duration of postpartum insusceptibility to pregnancy (combined period of amenorrhea and abstinence) is between 15 and 20 months in most SSA countries [58, 59]. The safety of these methods despite their use cannot be guaranteed. For instance, withdrawal method (coitus interruptus), one of the oldest methods of fertility control, the slightest mistake in timing of withdrawal may result in deposition of some amount of semen. Thus, the failure rate may be as high as 25% [51]. Many women erroneously believed that they were protected completely when amenorrhoeic. At the population level, amenorrhoea is related to low risk of pregnancy; the absence of menses does not guarantee protection from pregnancy for individual women (except during the time frame of lactational amenorrhoea). Despite these problems, till date they continue to be used alongside modern contraceptives as evidenced by Demographic and Health Surveys (DHS) conducted across Africa.


**Table 2** shows the percentage of women who use modern and traditional methods of contraception in 1992 and most recent DHS reports of some selected countries in SSA.

**Table 2.** Family planning methods currently used (percentages) by married women (15–49 years) [60, 61].

(1) Robey et al.; (2) data from recent DHS of various countries.
