摘要：Objectives. We examined the role of community-level factors in explaining geographic variations in modern contraceptive use in 6 African countries. Methods. We analyzed Demographic and Health Survey and contextual data sources with multilevel modeling techniques to identify factors contributing to geographic variations in women’s use of modern contraceptives. Results. We found significant associations between several community-level factors and reported use of modern contraceptive methods. We also identified several pathways of influence between the community and the individual. Conclusions. Aspects of a community’s sociocultural and economic environment appear to influence a woman’s use of modern contraceptive methods. Many developing countries have substantial geographic variations in contraceptive use, 1 , 2 although the factors shaping these variations are little understood. Previous studies suggested that variations in contraceptive use typically remain after accounting for individual and household factors. 1 , 3 Contextual factors such as community-level cultural beliefs, the presence and quality of reproductive health services, the physical characteristics of the area, macroeconomic factors, and the presence of transport routes have been suggested as causes of geographic variations in contraceptive use. 2 – 8 Studies of the determinants of contraceptive use, however, have focused on individual- and household-level factors. The use of modern contraceptive methods (oral pills, condoms, intrauterine devices, sterilization, implants, and injectables) has traditionally been low in sub-Saharan Africa, but there is evidence of an increase during the past decade. During the 1990s, the self-reported use of modern contraceptives among married women increased in East Africa by 1% each year to 17% by 1999; in West Africa, it increased by 0.5% each year to 8% by 1999. 9 Previous research concentrated on individual and household demographic and socioeconomic factors as determinants of the uptake of contraception. For example, associations between modern contraceptive use and parity, 3 , 10 , 11 education, 3 , 10 , 12 and household socioeconomic status 11 , 13 , 14 are well established. However, evidence as to how community-level contextual factors influence variations in the use of contraceptive methods is limited. 8 , 15 At the community level, studies of contraceptive use have focused on the influence of health service characteristics (for example, the influence of quality of care on contraceptive adoption). 3 – 5 , 12 We examined geographic variations in modern contraceptive use in 6 countries from East (Kenya, Malawi, and Tanzania) and West (Burkina Faso, Ghana, and Ivory Coast) Africa, focusing on contextual factors that may influence contraceptive use. A greater understanding of the contextual factors associated with modern contraceptive use has the potential to inform the development of community-level programs aimed at increasing contraceptive use and to allow the targeting of programs to communities in need. It is unlikely that characteristics of the health services in a community alone account for all geographic variation in contraceptive use. For example, contraceptive use may be indirectly influenced by economic development, through a relationship with access to health services 7 or through its relationship with female autonomy and positive attitudes toward health service use. 16 Some studies have examined the effects of other characteristics of the community, including the influence of levels of community economic development, 2 , 6 , 7 , 17 levels of school participation, 18 , 19 economic roles of children, 20 , 21 and community fertility norms, 4 , 6 , 22 on contraceptive use. We took a holistic view of contextual influences on modern contraceptive use, to provide insight into the role of the community in individual contraceptive behavior and contrast this across the 6 African countries.
