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This doctoral thesis illustrates how reproduction evolves as a social process profoundly influenced by but also as an instigator of socio-cultural, economic, political, health and personal lived realities and change. Using a mixed methods approach, this study demonstrates how the social-embeddedness of fertility is manifested in practice and lived reality in South Kivu, Democratic Republic of Congo: the introduction of contraceptive technologies has altered and shifted power dynamics and possibilities while also raising new socio-cultural and political questions, concerns and uncertainties. Rather than simplifying reproductive realities in South Kivu this work accomplishes the very opposite: rousing and highlighting the complexities underlying, moving, shaping and influencing fertility, family planning discourse and contraceptive use. Findings form a coherent narrative illustrating where reproduction, fertility and family planning are embedded at the intersection of four conceptual categories: the individual (women and men of reproductive age, individual members of kinship networks who stand to benefit from another’s fertility, health providers and religious leaders); society, community and relationships (conjugal and sexual partners, kinship and social networks); institutions (the State, the health system, religious communities and doctrines); and the broader context (political climate, environment and land, safety and security). This thesis describes how these categories are interconnected and mutually constitutive but also fluid and dynamic – and highly influential. Fertility, reproduction, family planning and contraception sit at the intersection of health, rights and gendered and global power dynamics. The framing of these spaces has far reaching implications for global health discourses, strategies, outcomes and justice movements – the most tangible of which are seen in the shaping of the reproductive choices and realities of women in South Kivu and beyond.

BACKGROUND: Progress in achieving maternal health goals and the rates of reductions in deaths from individual conditions have varied over time and across countries. Assessing whether research priorities in maternal health align with the main causes of mortality, and those factors responsible for inequitable health outcomes, such as health system performance, may help direct future research. The study thus investigated whether the research done in low- and middle-income countries (LMICs) matched the principal causes of maternal deaths in these settings. METHODS: Systematic mapping was done of maternal health interventional research in LMICs from 2000 to 2012. Articles were included on health systems strengthening, health promotion; and on five tracer conditions (haemorrhage, hypertension, malaria, HIV and other sexually transmitted infections (STIs)). Following review of 35,078 titles and abstracts in duplicate, data were extracted from 2292 full-text publications. RESULTS: Over time, the number of publications rose several-fold, especially in 2004-2007, and the range of methods used broadened considerably. More than half the studies were done in sub-Saharan Africa (55.4 %), mostly addressing HIV and malaria. This region had low numbers of publications per hypertension and haemorrhage deaths, though South Asia had even fewer. The proportion of studies set in East Asia Pacific dropped steadily over the period, and in Latin America from 2008 to 2012. By 2008-2012, 39.1 % of articles included health systems components and 30.2 % health promotion. Only 5.4 % of studies assessed maternal STI interventions, diminishing with time. More than a third of haemorrhage research included health systems or health promotion components, double that of HIV research. CONCLUSION: Several mismatches were noted between research publications, and the burden and causes of maternal deaths. This is especially true for South Asia; haemorrhage and hypertension in sub-Saharan Africa; and for STIs worldwide. The large rise in research outputs and range of methods employed indicates a major expansion in the number of researchers and their skills. This bodes well for maternal health if variations in research priorities across settings and topics are corrected.

BACKGROUND: Male involvement in various health practices is recognized as an important factor in improving maternal and child health outcomes. Male involvement interventions involve men in a variety of ways, at varying levels of inclusion and use a range of outcome measures. There is little agreement on how male involvement should be measured and some authors contend that male involvement may actually be detrimental to women's empowerment and autonomy. Few studies explore the realities, perceptions, determinants and efficacy of male involvement in newborn care, especially in African contexts. METHODS: Birth narratives of recent mothers (n = 25), in-depth interviews with recent fathers (n = 12) and two focus group discussions with fathers (n = 22) were conducted during the formative research phase of a community-based newborn care trial. Secondary analysis of this qualitative data identified emergent themes and established overall associations related to male involvement, newborn care and household roles in a rural African setting. RESULTS: Data revealed that gender dictates many of the perceptions and politics surrounding newborn care in this context. The influence of mother-in-laws and generational power dynamics were also identified as significant. Women alone perform almost all tasks related to newborn care whereas men take on the traditional responsibilities of economic providers and decision makers, especially concerning their wives' and children's health. Most men were interested in being more involved in newborn care but identified barriers to increased involvement, many of which related to gendered and generational divisions of labour and space. CONCLUSIONS: Men defined involvement in a variety of ways, even if they were not physically involved in carrying out newborn care tasks. Some participant comments revealed potential risks of increasing male involvement suggesting that male involvement alone should not be an outcome in future interventions. Rather, the effect of male involvement on women's autonomy, the dynamics of senior women's influence and power and the real impact on health outcomes should be considered in intervention design and implementation. Any male involvement intervention should integrate a detailed understanding of context and strategies to include men in maternal and child health should be mutually empowering for both women and men.

Search strategy. (DOCX 25 kb)

Search strategy. (DOCX 25 kb)

Mapping search strategy and protocol. (PDF 1497 kb)

Research topics and quality in countries and regions. (DOCX 38 kb)

Mapping search strategy and protocol. (PDF 1497 kb)

Search strategy for review. (DOCX 25 kb)

Search strategy for review. (DOCX 25 kb)

Research topics and quality in countries and regions. (DOCX 38 kb)