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Abstract Background Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. Methods We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. Results The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. Conclusions Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

# Background Modern contraceptives are effective interventions for preventing unwanted pregnancies, but their use remain low among adolescent girls in sub-Saharan Africa. First, we aimed to assess the trends of modern contraceptive use among adolescent girls aged 15-19 years in Sierra Leone in the period 2008-2019. Second, we explored how individual and contextual determinants of their use changed during this period. # Methods We used a combined sample of 8,774 adolescent girls aged 15-19 years from the 2008, 2013, and 2019 Sierra Leone Demographic and Health Surveys (SLDHS), respectively, to estimate the modern contraceptive prevalence rate (MCPR) and unmet need for family planning. We described the method mix and sources of contraceptives among modern method users. We then conducted a multivariable logistic regression to examine the determinants of modern contraceptive use among sexually active adolescent girls, separately for 2008 and 2019. # Results MCPR increased from 5.9% (95% CI=4.5-7.8) in 2008 to 21.0% (95% CI=19.2-22.9) in 2019. Most of the increase had occurred by 2013. Norplant (48.8%) and injectables (39%) were the common methods in 2019. Unmet need for family planning declined from 15.4% (95% CI=13.2-17.9) in 2008 to 11.3% (95% CI=9.9-12.7) in 2019, while the prevalence of modern contraceptive use among sexually active adolescent girls increased from 13.1% (95% CI=10-17.0) in 2008 to 43.5% (95% CI=40.2-46.9) in 2019. In both the 2008 and 2019 surveys, the adjusted odds of using modern contraceptives among sexually active adolescent girls were higher among those with more than one sexual partner in the past 12 months, and with secondary or tertiary education. In 2019, the adjusted odds of using a modern contraceptive were also lower among adolescent girls who were married or living with a partner, had more than one child, and lived in the Western province. # Conclusions The increase in contraceptive use among adolescent girls in Sierra Leone had stalled since 2013. Interventions, including increasing awareness and accessibility to modern contraceptives, are urgently needed, particularly for adolescents without formal education. Comprehensive and affordable community and school-based interventions, including adolescent-friendly services, would be helpful.

IntroductionThe objective of this study was to analyze providers' knowledge, attitudes, and practices regarding access to and use of contraception by urban adolescents and youth.MethodsThis is a cross-sectional study of 1,707 health care providers in 173 selected private and public health facilities in the capital city of Conakry and the seven administrative regions of Guinea. Factors associated with health care providers' attitudes and practices were then analyzed using logistic regression.ResultsAmong the 1,707 health providers, 71% had a good level of Knowledge about modern contraceptive use among adolescents and youth. In addition, 62% had positive attitudes, and 41% had good prescribing practices toward using modern contraceptive methods by adolescents and youth. Being a midwife (aOR: 1.39, 95%CI: 1.02–1.89), Being aged 25–34 years (aOR: 1.7, 95%CI: 1.2–2.3), 35–44 years (aOR: 2.1, 95%CI: 1.4–3.0), and 45 years, and older (aOR: 2.4, 95%CI: 1.3–4.2), an increase of years in professional experience (aOR:1.05; 95%CI: 1.02–1.08) were factors significantly associated with provider positive attitudes. However, being a medical doctor (aOR: 2.37, 95%CI: 1.04–4.42), an increase of years in professional experience (aOR: 1.07; 95%CI: 1.04–1.10) and a positive attitude (aOR: 3.16. 95%CI: 2.48–4.01) were factors associated with good practice in delivering modern contraceptive methods to adolescents and youth.ConclusionPositive attitudes and good practices toward the use of contraceptive services by adolescents and youth were found among providers. However, many health care providers still have unfavorable attitudes and practices toward delivering FP services to urban adolescents and youth. Therefore, future intervention programs should focus on training health care providers in youth- and adolescent-friendly reproductive health services and promoting contraception among adolescents.

IntroductionMaternal mortality remains very high in Sub-Saharan African countries and the risk is higher among adolescent girls. Maternal mortality occurs in these settings mainly around the time of childbirth and the first 24 hours after birth. Therefore, skilled attendance in an enabling environment is essential to reduce the occurrence of adverse outcomes for both women and their children. This study aims to analyze the determinants of facility childbirth among adolescents and young women in Guinea.MethodsWe used the Guinea Demographic and Health Survey (DHS) conducted in 2018. All females who were adolescents (15-19) or young women (20-24 years) at the time of their most recent live birth in the five years before the survey were included. We examined the use of health facilities for childbirth and its determinants selected through the Andersen health-seeking model using descriptive analysis and multilevel multivariable logistic regression. All descriptive and analytical estimated were produced by adjusting for the survey sampling using the svy option, including adjustment for clustering, stratification and unequal probability of selection and non-response (individual sample weights). The subpopulation option was also used to account for the variance of estimations.ResultsOverall, 58% of adolescents and 57% of young women gave birth in a health facility. Young women were more likely to have used private sector facilities compared to adolescents (pConclusionThe percentage of births in health facilities among adolescents and young women in Guinea was 58%. This remains suboptimal regarding the challenges associated maternal mortality and morbidity issues in Guinea. Socio-economic characteristics, region of residence and antenatal care use were the main determinants of its use. Efforts to improve maternal health among this group should target care discontinuation between antenatal care and childbirth (primarily by removing financial barriers) and increasing the demand for facility-based childbirth services in communities, while paying attention to the quality and respectful nature of healthcare services provided there.

IntroductionFebrile illnesses constitute a major clinical challenge in tropical settings. We aimed to assess the frequency, presentation and management of febrile illness at two health facilities in Forécariah, Guinea, with a focus on appropriateness of antibiotic prescription.Materials and methodsThis was a retrospective study conducted in patient files in a health center and a district hospital. Proportions of antibiotic prescription were determined by age group and syndromes as well as appropriateness of antibiotic prescription using the WHO model list (2019).ResultsFrom 2014 to 2020, 23,583 of 62,185 (38.0%) visits were related to febrile illness. Most patients with fever were female (56.1%) and evaluated at the health center (81.0%). Gastrointestinal (40.6%) and respiratory syndromes (36.8%), and undifferentiated fever (30.0%) were the most common presentations. Malaria was confirmed in 61.3% of the cohort. Overall, the rate of antibiotic prescription was high (14,834/23,583, 62.9%), mostly among patients aged ConclusionsFebrile illness is a major cause of consultation in rural Guinea. Rate of antibiotic prescription was high, even in confirmed malaria and was often considered inappropriate. There is a pressing need to investigate the etiological spectrum and improve the diagnostic approach of febrile illness in Guinea.