Understanding trends, transitions & perceptions of fertility and family planning in a fragile context: South Kivu, Democratic Republic of Congo Inauguraldissertation zur Erlangung der Würde eines Doktors der Philosophie vorgelegt der Philosophisch-Naturwissenschaftlichen Fakultät der Universität Basel Von Mari Dumbaugh Pittsburgh, Pennsylvania, Vereinigte Staaten Basel, 2020 Originaldokument gespeichert auf dem Dokumentenserver der Universität Basel https://edoc.unibas.ch Genehmigt von der Philosophisch-Naturwissenschaftlichen Fakultät auf Antrag von Prof. Dr. Marcel Tanner, Dr. Sonja Merten, und Dr. Lenore Manderson Basel, 12. Dezember 2017 Prof. Dr. Martin Spiess Dekan der Philosophisch-Naturwissenschaftlichen Fakultät ii Contents List of Tables ......................................................................................................................... ix List of Figures ......................................................................................................................... x Abbreviations ........................................................................................................................ xi Acknowledgements .............................................................................................................. xii Funding ............................................................................................................................... xvi Summary ............................................................................................................................ xvii 1. Introduction ...................................................................................................................21 1.1 Locating fertility & reproduction in sub-Saharan Africa ................................................23 1.2 Global fertility transitions in numbers: the ‘conundrum’ of sub-Saharan Africa ............24 1.3 Demographic transition theory ....................................................................................26 1.3.1 Malthusian theory of population growth & the advent of classic demographic transition theory ................................................................................................................31 1.3.1.1 Critiques of classic demographic transition theory .................................................32 1.4 Post-classic fertility transition theories .........................................................................35 1.4.1 Economic & utilitarian determinants of fertility transition ...........................................35 1.4.2 Socio-cultural determinants of fertility transition .......................................................36 1.4.3 Culture & political economy of reproduction .............................................................37 1.5 Sub-Saharan Africa: a different fertility transition? .......................................................38 1.5.1 Common threads of ‘African exceptionalism’ theories ..............................................41 2. Situating contemporary sexual & reproductive realities in the evolution of discourse .....43 2.1 Colonial histories of sexual & reproductive health .......................................................43 2.2 ‘Politics of population’: racial panics & population control ............................................46 2.3 Sexual & reproductive health as human rights ............................................................48 2.4 Facilitators of & barriers to contraceptive uptake .........................................................50 2.5 Family planning & contraceptive interventions post-Cairo ...........................................52 2.5.1 Family planning & contraceptive interventions in sub-Saharan Africa .......................52 2.5.2.1 Performance-based financing for sexual and reproductive health .........................54 2.5.2.1.1 Ethical considerations & debates surrounding performance-based financing .....55 2.5.2.2 Conditional cash transfers for maternal health service use, family planning and birth spacing .....................................................................................................................56 2.5.2.2.1 Ethical considerations and debates surrounding cash transfers .........................57 3. Research context: The Democratic Republic of the Congo ............................................60 3.1 Geography, governance and administration ................................................................61 3.2 History and politics of an exceptional country ..............................................................63 3.3 South Kivu province: particularities of the study areas ................................................65 3.3.1 Gender constructs & gendered power relations ........................................................69 3 3.4 Health system and health indicators: South Kivu in the context of a nation ................72 3.4.1 Health System: structure and challenges ................................................................72 3.4.2 General health and development indicators .............................................................74 3.4.3 Sexual, reproductive and contraceptive health indicators .........................................75 3.5 Government commitment to sexual, reproductive and maternal health .......................79 4. Research aim & objectives ...............................................................................................81 4.1 Research aim ..............................................................................................................81 4.2 Research objectives ....................................................................................................81 5. Guiding theoretical frameworks ........................................................................................82 5.1 Gender analysis & reproduction as a socially embedded process ...............................82 5.2 Shortcomings of contemporary measures of gender in health research ......................84 6. Quantitative methods: longitudinal, community-based survey ...........................................87 6.1 Study design ...............................................................................................................87 6.2 Study sites ..................................................................................................................87 6.2.1 Maternal health interventions by study sites .............................................................88 6.3 Study population .........................................................................................................89 6.3.1 Sample size and sampling strategy ..........................................................................89 6.4 Data collection ............................................................................................................90 6.5 Data management & analysis .....................................................................................91 7. Qualitative methods: in-depth interviews, focus group discussions & participant observation ...........................................................................................................................92 7.1 Participant selection ....................................................................................................92 7.2 Informed consent and data collection ..........................................................................93 7.2.1 Informed consent, confidentiality and participant compensation ...............................93 7.3 Data collection ............................................................................................................94 7.4 Data transcription and analysis ...................................................................................95 7.4.1 Data transcription .....................................................................................................95 7.4.2 Data analysis ...........................................................................................................95 8. Ethics, limitations & critical appraisal of research methods ...............................................97 8.1 Ethical approval ..........................................................................................................97 8.2 Ethical considerations & risks to research participants ................................................97 8.3 Limitations of the research setting ...............................................................................98 8.4 Researcher positionality & reflexivity ...........................................................................99 9. Evaluating the comparative effectiveness of different demand side interventions to increase maternal health service utilization and practice of birth spacing in South Kivu, Democratic Republic of Congo: An innovative, mixed method approach* ........................... 103 9.1 Background ............................................................................................................... 105 iv 9.1.1 Context .................................................................................................................. 106 9.1.2 Study settings ........................................................................................................ 107 9.2 Intervention ............................................................................................................... 108 9.2.1 Conditional user fee subsidization