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Background: Access to sexual and reproductive health (SRH) services is critical for such outcomes as pregnancy and birth, prenatal and neonatal mortality, maternal morbidity and mortality, and prevention of vertical transmission of infections like HIV. Health facilities are typically set up where they can efficiently serve the nearby targeted population. However, the actual utilization of health care can be complicated as people sometimes bypass the closest or nearby facilities for various reasons such as service quality. A better understanding of how people actually utilize health services can benefit future health resource allocation as well as health program planning.Methods: In this study, we use prenatal care as an example of a basic, widely available service to investigate women's choice and bypassing of SRH facilities as well as potential influencing factors at the geographic, clinic, household, and individual levels. The data come from a population-based survey of women of reproductive age in rural Mozambique. The spatial pattern of utilization of health clinics for prenatal care is explored by geographical information system (GIS)-based spatial analysis. Logistic regression is fitted to test the hypotheses regarding the effect of distance, service quality, and household/individual-level factors on the bypassing of the nearest clinic.Results: The results indicate that most women living near clinics tend to utilize the closest facilities for prenatal care and those who travel farther mainly do so to seek better services. Further, for women who live far from a clinic (> 5.5 km), service quality still plays an important role in the facility bypassing while the effect of distance is no longer significant. The bypassing of nearest facility is also affected by individual characteristics such as age, HIV status, and household economic conditions.Conclusions: The findings help to better understand health facility choice and bypassing in developing settings, in general, and in resource-limited Sub-Saharan settings, in particular. They offer valuable guidance for future health resource allocation and health service planning. [ABSTRACT FROM AUTHOR]

The large and growing denominational diversity of sub-Saharan Christianity has attracted considerable scholarly attention, but its implications for individual experiences and well-being remain poorly understood. I examine women's perceptions, assessments, and practices in everyday construction of church idiosyncrasies, clustering, and hierarchies and women's abilities and propensities to navigate along and across the corresponding organisational boundaries in a predominantly Christian setting in rural Mozambique. The analysis uses a combination of data from a census of religious congregations, a household survey, in-depth interviews, and participant observation conducted over a decade. It demonstrates that women's church involvement is socially indispensable yet also subjectively non-binding. Accordingly, church boundaries, while clearly delineated and recognised, are also seen as highly permeable. This permeability facilitates the crossing of those boundaries but may also disincentivise such crossing. Although rural women are increasingly capable of navigating through the religious space, they are generally precluded from exiting that space altogether, as secular options for non-family social anchoring remain very limited in this and other similar low-income patriarchal contexts.

Migration is commonly seen as a last resort for households impacted by climate shocks, given the costs and risks that migration typically entails. However, pre-existing labor migration channels may facilitate immediate migration decisions in response to climate shocks. This study explores the relationship between migration and droughts in a rural Sub-Saharan setting from which men commonly migrate in search of non-agricultural employment. We use data from the Men's Migrations and Women's Lives project, which includes a longitudinal household panel conducted in rural Mozambique between 2006 and 2017, and combine it with the Standardized Precipitation Evapotranspiration Index, a high-resolution climate measure. The fixed-effect models assess the lagged impact of droughts on the labor migration status of male household heads. We find an immediate increase in migration following a drought, peaking in the first year, then diminishing in the second year, with a slight resurgence in the third year. However, by the sixth-year post-drought, the likelihood of being a migrant turns negative. These findings demonstrate the complex associations of climate shocks with labor migration in low-income rural settings., Competing Interests: Conflict of interest The authors declare no competing interests.

Labor migration is a massive global reality, and its effects on the well-being of nonmigrating household members vary considerably. However, much existing research is limited to cross-sectional or short-term assessments of these effects. This study uses unique longitudinal panel data collected over 12 years in rural Mozambique to examine long-term connections of women's exposure to husband's labor migration with women's material security, their perception of their households' relative economic standing in the community, their overall life satisfaction, and their expectations of future improvements in household conditions. To capture the cumulative quality of such exposure, we use two approaches: one based on migrant remittances ("objective") and the other based on woman's own assessment of migration's impact on the household ("subjective"). The multivariable analyses detect a significant positive association between "objective" migration quality and household assets, regardless of women's current marital status and other characteristics. However, net of household assets, "objective" quality shows a positive association with life satisfaction, but not with perceived relative standing of the household or future expectations. In comparison, "subjective" quality is positively associated with all the outcomes even after controlling for other characteristics. These findings illustrate the gendered complexities of long-term migration impact on nonmigrants' well-being.

Connections between labour migration and food security of left-behind households are still poorly understood. Using data from two waves of a longitudinal survey conducted among ever-married women in rural Mozambique, we employ multi-level ordered logit and negative binomial regressions to examine over time three possible pathways linking men's migration and its economic success to food security of left-behind households-agricultural investment, household material assets and women's local gainful employment. Our analyses find a significant positive association between migration's success, proxied by remittances, and food security and show that this association is largely mediated by household's possession of material assets., Competing Interests: CONFLICT OF INTEREST STATEMENT No conflict of interest to declare.

The study contributes to the understanding of the societal impact of the coronavirus disease 2019 pandemic in the Global South by examining longer term implications of pandemic-induced disruptions and deprivations for social ties and psychosocial well-being. Using data from a survey of middle-aged women in rural Mozambique, the author finds a negative association between the pandemic-triggered household economic decline and perceived changes in the quality of relations with marital partners, non-coresident children, and relatives, but not with generally more distant actors, such as coreligionists and neighbors. In turn, multivariable analyses detect a positive association of changes in the quality of family and kin ties with participants' life satisfaction, regardless of other factors. Yet women's expectations for changes in their household living conditions in the near future show a significant association only with changes in the quality of relations with marital partners. The author situates these findings within the context of women's enduring vulnerabilities in low-income patriarchal settings., (© The Author(s) 2023.)

As the rest of the developing world, Sub-Saharan Africa has experienced profound transformations in the institution of marriage. Yet, unlike most other regions, polygyny has remained widespread across the subcontinent. There is, however, evidence to suggest that the practice of polygyny is declining and that selection into polygynous unions based on sociodemographic characteristics is increasing assub-Saharan Africa undergoes rapid sociocultural, demographic, and economic change. Using data from 111 Demographic and Health Surveys conducted in 27 countries since the 1990s, we study recent trends in the prevalence of polygyny among currently married women, examine sociodemographic characteristics of women in polygynous unions, and test whether selection on these characteristics into polygynous unions has increased over time. We find that, net of other factors, the likelihood of being in a polygynous union has declined in most countries. We show that women who are less educated, non-Christian, and living in rural areas are more likely to be in a polygynous union and that in many countries, selection into polygynous unions on these characteristics has been growing. These findings contribute to the broader literature on marital and family change by providing new insights into recent trends in and patterns of polygyny across the subcontinent.

Premarital sex is normatively unacceptable in Afghanistan, yet rapid social and cultural transformation in the country may be changing these traditional norms. In dialogue with cross-national scholarship, we examine attitudes toward premarital sex and experience of premarital sexual behaviours among urban Afghan youth. We use data from 1256 never married individuals aged 15-29 surveyed in ten Afghan cities. The results show that respondents, on average, have moderately liberal attitudes toward premarital sex and that almost one quarter of them had engaged in either sexual foreplay or penetrative intercourse. Multivariable results indicate that premarital sexual attitudes and behaviours were significantly associated with several individual-level characteristics, family and intergenerational relationships, and social ties and interactions. At the same time, instructive gender variations emerge. The findings illustrate the dynamics of premarital sexual relations in this and similar contexts where such relations are traditionally stigmatised but multifaceted, societal changes increasingly challenge this stigma.

Considerable research in western, low-fertility contexts has examined minority-vs.-majority fertility differentials, typically focusing on minority groups' cultural idiosyncrasies and on socioeconomic disadvantages associated with minority status. However, the formation and functioning of ethnic complexities outside the western world often diverge from the standard western model and so may their impact on fertility preferences, behavior, and outcomes. We expand on the previous research by analyzing ethnic variation in completed and desired fertility in the multiethnic transitional setting of Kyrgyzstan, where ethnic groups and their ethnolinguistic subparts are characterized by both different stages of the demographic transition and different positioning in the socioeconomic and political hierarchies. Using combined data from two rounds of a nationally representative survey, we find that ethnic-specific levels of completed fertility generally align with culturally shaped group-level normative propensities. In contrast, in desires to have a(nother) child, the ranking of the ethnic segments is more reflective of their collective societal positioning, with more disadvantaged segments having lower fertility desires, regardless of actual number of children and various other characteristics. We also find that ethnic homophily of respondents' social milieu and their optimism about the future of their ethnic group are positively associated with fertility desires, even though these associations are more potently present among women, compared to men. We relate our findings to the extant scholarship and reflect on their implications for a better understanding of ethno-racial fertility dynamics and differentials in transitional contexts.

Legal status has shown far-reaching consequences for international migrants' incorporation trajectories and outcomes in Western contexts. In dialogue with the extant research, we examine the implications of legal status for subjective well-being of Central Asian migrant women in the Russian Federation. Using survey data collected through respondent-driven sampling in two large cities, we compare migrants with regularized and irregular legal statuses on several interrelated yet distinct dimensions of subjective well-being. We find that, regardless of other factors, regularized status has a strong positive association with migrants' perception of their rights and freedoms but not with their feeling of being respected in society. Regularized status is positively associated with self-efficacy and negatively with depression. Yet, no net legal status difference is found in migrants' views on their relations with other migrants or on treatment of migrants by native-borns. The findings are situated within the cross-national scholarship on the ramifications of racialized immigrant (il)legality and its implications for membership and belonging.

The Russian Federation is a major immigrant-receiving nation and hosts large immigrant populations from post-Soviet countries including Central Asia. However, there is yet little research on their health needs, and especially on mental health of immigrant women. This study uses qualitative data from 72 interviews with women from Kyrgyzstan, Tajikistan, and Uzbekistan conducted in two large cities in Central Russia, Kazan and Nizhny Novgorod, from April 2014 to February 2017. This study examines psychological distress among immigrant women and applies a gendered socioecological lens to understand its causes. We have identified intersecting factors that operate at different levels and cause distress in Central Asian immigrant women in Russia. Gendered vulnerabilities, persistent worry about their families' well-being, separation from loved ones, and limited sources of social support are key individual and interpersonal level of distress factors. Poor working and housing conditions along with economic hardships and concerns over their ability to reach the goals that guided their decisions to move to Russia reinforce experienced distress among immigrant women. Discrimination against Central Asian nationals and structural racism amplify challenges for immigrants' psychological well-being and mental health in Russia. By investigating underlying factors of psychological distress among an understudied immigrant population, this study defines configurations of Russia's risk environment and contributes to an understanding of migration as an important determinant of mental health., Competing Interests: Declaration of competing interest We have no conflicts of interest to disclose.

Objective: The study examines the association between polygyny and intimate partner violence (IPV) by focusing on the Muslim-vs.-Christian context of polygyny and on co-wives' rank., Background: Although prior research points to a higher incidence of IPV in polygynous unions, the association between polygyny and IPV are not well understood. In particular, the role of broader cultural and religious context of marriage and its connection with intra-marital dynamics have not been examined., Method: The study uses pooled data on over 42,000 women from the 2008, 2013 and 2018 rounds of the Nigeria Demographic and Health Survey to examine the association of polygynous versus monogamous status of marriage, of Muslim versus Christian religious affiliation, and of co-wife rank within polygynous unions in both religions with women's reported experience of physical, emotional, and sexual IPV. Multivariate logit and propensity score models (PSM) are fitted, and the Rosenbaum bounds test is used to gauge the robustness of PSM results., Results: Results show a clear disadvantage of polygynously married women, compared to monogamously married ones; IPV experience is more common among Christians than Muslims. Among women in polygynous marriages, senior wives are more likely to experience IPV than junior wives, but this difference is more pronounced among Christians. Results of a Rosenbaum bounds analysis indicate that unobserved selectivity does not present a challenge to causality between polygyny/wife rank and IPV, particularly when analyses are disaggregated by religion., Conclusion: Findings reflect multi-dimensional gender inequalities embedded in the institution of polygynous marriage and their harmful consequences for women's health and well-being.

Objective: This study examines trends over several decades in bridewealth marriage and analyzes the association of bridewealth with women's experiences in marriage in a rural sub-Saharan setting., Background: Bridewealth - payments from the groom's to the bride's family as part of the marriage process - has long been a central element of kinship and marriage systems in patrilineal sub-Saharan Africa. This payment, which symbolizes the transfer of sexual and reproductive rights from the wife's to the husband's family, is grounded in a collectivist-oriented family system that closely ties women's status and value to their reproductive capacity., Method: The study draws on population-based longitudinal survey data collected in 2006, 2009, and 2011 from 1,552 women in rural Mozambique. We use multivariable regression to investigate whether year of marriage predicts being in a bridewealth marriage and whether bridewealth status predicts marital dissolution, women's decision-making autonomy, women's work outside of subsistence agriculture, or modern contraceptive use., Results: The proportion of marriages involving bridewealth payment has declined over time. While no difference by bridewealth status exists in women's autonomy levels or modern contraceptive use, women in bridewealth marriages are less likely to divorce over a five-year period and less likely to work outside of subsistence agriculture, net of other factors., Conclusion: These findings reflect the complexity of a modernizing marriage system. With the decline of bridewealth marriage, its meaning has evolved, becoming increasingly indicative of individual wealth and status rather than family control.

Objective: This study contributes to a better understanding of the role of Christianity in the persistence of polygyny in sub-Saharan Africa., Background: Marital systems and practices are closely connected to religious norms, but these connections are often complex and contradictory. Polygynous marriage remains widespread in sub-Saharan Africa, including its heavily Christianized parts, where public opposition to it should be strongest., Methods: The study analyzes a rich combination of quantitative and qualitative data from a predominantly Christian district in Mozambique. The data include a household-based survey, a census of the district's religious congregations, and focus group discussions and individual interviews with leaders and rank-and-file members of various churches., Results: The multivariate statistical tests point to instructive denominational differences in the prevalence and acceptance of polygyny, with the starkest contrast being between two types of African Initiated Churches - one that is more lenient on pre-Christian practices and the other that is vehemently opposed to them. These tests also show a contrast between church leaders and rank-and-file members, the latter being generally more accepting of polygyny, and illustrate variations in acceptability of polygyny across different church membership scenarios. The analysis of the qualitative data complements the statistical tests by highlighting ideological and social mechanisms through which polygynous marriage is both rejected and legitimized in Christian communities., Conclusion: Both condemnation and toleration of polygyny by Christian churches reflect the complexities of the transformation of sub-Saharan marital systems and of the role that religion plays in that process.

Polygyny has shown a positive association with intimate partner violence (IPV), yet the nature and mechanisms of this association are not well understood. This study uses data from rural Mozambique to distinguish women in polygynous unions by rank and co-residence. Findings show that senior wives report higher rates of violence than their junior-wife and monogamously married counterparts. At the same time, no difference is detected between junior wives and women in monogamous marriages. Additionally, the analysis finds that polygynously married women living away from their co-wives report higher rates of violence than both women co-residing with co-wives and women in monogamous unions, while the difference between the latter two categories is not statistically significant. However, the results also indicate that senior wives living away from their co-wives face particularly high risks of violence. These findings illustrate the social complexity of polygynous marriages and resulting differential vulnerabilities of women in them.

Context: Research on institutional child delivery in Sub-Saharan Africa typically focuses on availability and accessibility of health facilities. Cultural factors, including religion, that may facilitate or hinder the use of such services have not been well examined and remain poorly understood., Methods: The relationship between religious affiliation and delivery in a health facility was explored using data from a household survey of 1,297 women aged 18-50 and a census of 825 religious congregations, both conducted in a predominantly Christian district in Mozambique in 2008. Multilevel logistic regression analyses were conducted to predict the likelihood of recent institutional delivery according to both individual religious affiliation and the concentration of religious congregations of certain denominations in the community of residence., Results: Approximately 63% of deliveries occurred in a health facility. The odds of such deliveries were lower among women who belonged to Apostolic churches or had no religious affiliation than among members of Catholic or mainline Protestant churches, net of other factors (odds ratios, 0.5 and 0.6, respectively). In addition, regardless of a woman's religion, the odds that she had an institutional delivery increased by 9% for each additional Catholic or mainline Protestant congregation in her community of residence (1.1)., Conclusions: Organized religion is associated with critical health outcomes in Mozambique and, potentially, in other Sub-Saharan African contexts. Policymakers should consider designing programs and interventions that promote the use of institutional delivery services among members of religious groups characterized by low use of these services and in areas where such religious groups have a strong presence.

A growing body of research has argued that the traditional categories of stopping and spacing are insufficient to understand why individuals want to control fertility. In a series of articles, Timæus, Moultrie, and colleagues defined a third type of fertility motivation-postponement-that reflects a desire to avoid childbearing in the short term without clear goals for long-term fertility. Although postponement is fundamentally a description of fertility desires, existing quantitative research has primarily studied fertility behavior in an effort to find evidence for the model. In this study, we use longitudinal survey data to consider whether postponement can be identified in standard measures of fertility desires among reproductive-age women in rural Mozambique. Findings show strong evidence for a postponement mindset in this population, but postponement coexists with stopping and spacing goals. We reflect on the difference between birth spacing and postponement and consider whether and how postponement is a distinctive sub-Saharan phenomenon.

In sub-Saharan settings, parental religion may have important implications for children's health and well-being. Using survey data from rural Mozambique, we examine the relationship between women's religion and the likelihood of their children being chronically malnourished (stunted). Multivariate analyses show that children of religiously affiliated women are significantly less likely to be stunted than children of non-affiliated women. We also find a strong advantage of mainline Protestants, especially compared to members of Pentecostal-type denominations, net of other factors. We relate this advantage to two historically rooted characteristics of mainline Protestantism: its connections to the public health sector and higher levels of women's autonomy that it fosters.

In dialogue with mainly western literature on determinants of religious mobility and the evidence on the transformative role of mass education in developing settings, we examine the relationship of educational attainment with religious reaffiliation and disaffiliation in the context of rural and small-town sub-Saharan Africa. Adapting western scholarship to the realities of that context, where most people do not complete primary school, we conceptualize both basic education and religious belonging as parts and expressions of profound societal transformations in the sub-continent. We use data from a survey of women aged 18-50 conducted in a predominantly Christian area in Mozambique to test this relationship from both the lifetime and dynamic perspectives. We find a strong positive association between educational level and the probability of church switching, with modest variations by denominational destination of and main reasons for reaffiliation. Disaffiliation is negatively related to schooling level. These findings are situated within a broader discourse on religion, development, and social change in the sub-Sahara.

Classic demographic theories conceptualize desired family size as a fixed goal that guides fertility intentions over the childbearing years. However, a growing body of research shows that fertility plans, even nominally long-term plans for completed childbearing, change in response to short-term conditions. Because of data limitations, much of this research has focused on low-fertility contexts, but short-term conditions are likely to be even more important in high-fertility contexts. This paper uses three waves of survey data collected in rural Mozambique to study predictors of the desire to stop childbearing in a context of relatively high fertility and high individual and social instability. We use fixed effects models to assess how women's desires to stop childbearing are shaped by demographic factors, household economic conditions, and health status, controlling for constant individual characteristics. Results provide evidence that fertility desires both reflect stable underlying goals and evolve in response to individual and social circumstances.

In many high-fertility countries, and especially in sub-Saharan Africa, substantial proportions of women give non-numeric responses when asked about desired family size. Demographic transition theory has interpreted responses of "don't know" or "up to God" as evidence of fatalistic attitudes toward childbearing. Alternatively, these responses can be understood as meaningful reactions to uncertainty about the future. Following this latter approach, we use data from rural Mozambique to test the hypothesis that non-numeric responses are more common when uncertainty about the future is greater. We expand on previous research linking child mortality and non-numeric fertility preferences by testing the predictive power of economic conditions, marital instability, and adult mortality. Results show that uncertainty related to adult and child mortality and to economic conditions predicts non-numeric responses, while marital stability is less strongly related.