Introduction
While high-income countries have made great strides towards reproductive health, there remains a huge challenge in improving reproductive health in low-and-middle-income countries (LMICs) (World Health Organization, 2017). The WHO estimated that the lifetime risk of a woman dying from maternal-related causes is about 130 times in LMICs compared to a woman in a high-income country (World Health Organization, 2017). Evidence-based interventions capable of improving reproductive health in LMICs include the uptake of modern contraceptives and the utilisation of skilled maternal health services (Stover and Ross, Reference Stover and Ross2010; World Health Organization, 2018, 2019).
In spite of the positive impact of skilled antenatal care (ANC), assisted skilled birth, and modern contraceptive services on reproductive health, the use of these services are low in many LMICs. It was recently reported that the coverage of the 2016 WHO recommended eight plus ANC contacts was 35.6% across LMICs, with some countries recording a coverage below 5% (Apanga and Kumbeni, Reference Apanga and Kumbeni2021). The use of assisted skilled birth and uptake of modern contraception among women were also reported as 66% and 42%, respectively, in LMICs (Adde et al., Reference Adde, Dickson and Amu2020; Ibitoye et al., Reference Ibitoye, Casterline and Zhang2022). In Ghana, while the prevalence of eight plus ANC contacts was 43% (Anaba and Afaya, Reference Anaba and Afaya2022), assisted skilled births and modern contraceptive usage among women of reproductive age were reported as 79% and 25%, respectively (Ghana Statistical Service, 2018).
Several studies have reported the association between sociodemographic factors and use of reproductive health services (Apanga et al., Reference Apanga, Kumbeni, Ayamga, Ulanja and Akparibo2020; Apanga and Kumbeni, Reference Apanga and Kumbeni2021; Kumbeni and Apanga, Reference Kumbeni and Apanga2021). Marital status has been found to be associated with the utilisation of skilled ANC, assisted skilled birth, and modern contraceptive services, with married women more likely to use such services compared to unmarried women (Sakeah et al., Reference Sakeah, Okawa, Rexford Oduro, Shibanuma, Ansah, Kikuchi, Gyapong, Owusu-Agyei, Williams, Debpuur, Yeji, Kukula, Enuameh, Asare, Agyekum, Addai, Sarpong, Adjei, Tawiah, Yasuoka, Nanishi, Jimba and Hodgson2017; Apanga et al., Reference Apanga, Kumbeni, Ayamga, Ulanja and Akparibo2020; Ameyaw et al., Reference Ameyaw, Dickson and Adde2021). Polygyny (i.e., a practice where a man marries more than one wife) may have negative effects on reproductive health of women. For instance, a study in Kenya and an analysis of Demographic and Health Survey (DHS) data in selected West African countries suggest that polygynous marriages were associated with lower utilisation of modern contraceptives when compared to monogamous marriages (Abdi et al., Reference Abdi, Okal, Serour and Temmerman2020; Millogo et al., Reference Millogo, Labité and Greenbaum2022). Furthermore, utilisation of skilled ANC and assisted skilled birth services has also been reported to be lower among women in polygynous marriage compared to monogamous one (Ahinkorah et al., Reference Ahinkorah, Ameyaw, Seidu, Odusina, Keetile and Yaya2021a; Zhang et al., Reference Zhang, Anser, Ahuru, Zhang, Peng, Osabohien and Mirza2022).
The pathways for accessing reproductive health services among women in polygynous marriages remain unclear, but available literature in sub-Saharan Africa (SSA) suggest that there may be competition among cowives to give birth in polygynous marriages, and this may lead to limited usage of contraception among such marriages (Abdi et al., Reference Abdi, Okal, Serour and Temmerman2020). Prior studies also report that women in polygynous marriages may have lower utilisation of assisted skilled birth because of culturally competitive behaviours such as giving birth at home, which is a show of strength and faithfulness to their husband (Yaya et al., Reference Yaya, Bishwajit, Uthman and Amouzou2018; Alatinga et al., Reference Alatinga, Affah and Abiiro2021). Bove and Valeggia (Reference Bove and Valeggia2008) also postulated that sharing of limited resources among women in polygynous marriages may be responsible for their lower utilisation of skilled ANC and assisted skilled birth. Despite the potential consequences of polygynous marriage on the utilisation of reproductive health services, there is little literature to estimate the impact of polygyny on reproductive health of women in SSA, where polygyny is said to be prevalent (Ahinkorah et al., Reference Ahinkorah, Ameyaw, Seidu, Odusina, Keetile and Yaya2021a, Kramer, Reference Kramer2020; Ameyaw et al., Reference Ameyaw, Dickson and Adde2021; Millogo et al., Reference Millogo, Labité and Greenbaum2022; Zhang et al., Reference Zhang, Anser, Ahuru, Zhang, Peng, Osabohien and Mirza2022).
In Ghana, an estimated 16% of married couples are in polygynous marriages (Millogo et al., Reference Millogo, Labité and Greenbaum2022); however, it is unclear if polygyny is associated with the utilisation of skilled ANC, assisted skilled birth, and modern contraceptive services. We hypothesised that polygyny might negatively influence the uptake of skilled ANC, assisted skilled birth, and modern contraceptive services among women in Ghana. Therefore, the aim of this study was to assess the relationship between polygynous marriage and the use of skilled ANC, assisted skilled birth, and modern contraceptive services among married women of reproductive age in Ghana.
Materials and methods
Study setting
Ghana is located in West Africa on the Gulf of Guinea. It shares boundaries with Côte d’Ivoire, to the west, Burkina Faso, to the north, and Togo lies on the east. Ghana has a total population of 30.8 million people, of which about seven million of these people are women in their reproductive age (Ghana Statistical Service, 2022). Ghana has 16 administrative regions, 5 teaching hospitals, 10 regional hospitals, and several district hospitals and clinics/health centres across the country. Ghana runs a national health insurance scheme which provides free maternal health care for all women living in the country (Blanchet et al., Reference Blanchet, Fink and Osei-Akoto2012). Recent analysis suggest that an estimated 16% of married couples in Ghana are in polygynous marriages (Millogo et al., Reference Millogo, Labité and Greenbaum2022).
Data sources, study design, and study population
Data were extracted from the 2017 Ghana Maternal Health Survey (GMHS). The 2017 GMHS was a cross-sectional survey conducted for only women in their reproduction age (i.e., 15–49 years) who had a live or stillbirth in the last 5 years prior to the survey. Multiple-stage sampling was employed in the survey with the first stage centred on the selection of enumeration areas, while the second stage involved systematic random sampling of households from the enumeration areas. The survey had a response rate of 99% representing 25,062 women. However, our analysis was restricted to a weighted sample of 9,098 married women aged 15–49 years. Therefore, we excluded women who were single, cohabiting, divorced, separated, or widowed from our analysis. Women who were pregnant at the time of the GMHS survey were also excluded from the contraception analysis.
The 2017 GMHS is a national representative data specially designed by DHS to assess maternal and child health indicators in Ghana. Hence, these data were well suited for our study given the study objectives.
Outcome variables
We assessed three outcome variables as indicators of reproductive health services. These variables were number of ANC contacts, assisted skilled birth, and modern contraceptive use. The number of ANC contacts was estimated as the number of times a pregnant women had contacts with a skilled health provider from conception to birth, and was categorised into 0–7 and ≥ 8 contacts. We categorised this variable based on the 2016 WHO recommendation of at least eight ANC contacts required for a positive pregnancy experience (World Health Organization, 2018). Assisted skilled birth was categorised into skilled birth provider and unskilled birth provider. Skilled birth provider referred to delivery services rendered by a nurse/midwife/doctor, while such services were considered unskilled if they were provided by a traditional birth attendant/relative. Our categorisation of assisted skilled birth was based on the WHO definition (World Health Organization, 2023). The ANC contacts and assisted birth provider measures were assessed for the recent pregnancy and childbirth, respectively, prior to the 2017 GMHS survey. Modern contraceptive use was defined as women who used any of the following methods: sterilisation, intrauterine devices, implants, injectables, pills, condoms, foam/jelly, diaphragm, and emergency contraception. The variable was dichotomised as ‘yes’ for women who were using any of the above methods at the time of the survey and ‘no’ for those who were not using any of these methods.
Predictor variable
The predictor of interest was marriage type. Marriage type was categorised into monogamous and polygynous. Monogamous marriage referred to a marriage where the husband had only one wife, whereas polygynous marriage was when the husband had two or more wives (i.e., one or more wives besides the index woman in the study).
Covariates
The covariates in our study included; age category, parity, place of residence, education, wealth index, health insurance coverage, and access to media. The covariates were categorised as follows: age category (15–19, 20–34, and 35–49 years); parity (nulliparous, primiparous, and multiparous); place of residence (urban and rural); education (no formal education, primary education, secondary education, and higher education); health insurance coverage (yes and no); and access to media (yes and no). Women who had access to either newspapers or radio or television at least once a week were considered as having access to media. Wealth index was generated using the principal component analysis on household ownership of selected assets, such as television and bicycles, and materials used for housing construction and types of water access and sanitation facilities (Poirier et al., Reference Poirier, Grépin and Grignon2020). The DHS wealth index categorises household wealth into quintiles (poorest, poor, middle, rich, and richest). We recoded the wealth index into three categories (poor = poorest and poor; middle = middle; rich = rich and richest). This categorisation has been reported in prior literature (Kumbeni et al., Reference Kumbeni, Afaya and Apanga2023).
Statistical analysis
Descriptive statistics of the study population are presented below using frequencies and percentages (Table 1). We used three separate multivariable logistic regression models to assess the association between our predictor and each of the outcome variables, while adjusting for covariates in each model.
Table 1. Characteristics of study participants
Note: N = sample size; ANC = antenatal care; % = percent.
In the first model (model I), we assessed the association between marriage type and number of ANC contacts. In the second model (model II), we assessed the relationship between marriage type and assisted skilled birth. In the third model (model III), we assessed the association between marriage type and modern contraceptive use. We controlled for age category, parity, place of residence, education, wealth index, health insurance coverage, and access to media in models I and II, while adding number of ANC contacts and assisted birth provider in addition to these covariates in model III. Variable selection was based on prior literature and their availability in the GMHS dataset (Mugo et al., Reference Mugo, Dibley and Agho2015; Ahinkorah et al., Reference Ahinkorah, Budu, Aboagye, Agbaglo, Arthur-Holmes, Adu, Archer, Aderoju and Seidu2021b; Kumbeni and Apanga, Reference Kumbeni and Apanga2021). A p-value < 0.05 was considered as the cut-off point for statistical significance.
We conducted sensitivity analysis to assess the relationship between the number of wives in marriage (i.e., a wife, two wives, and three or more wives) and each of our outcome variables to see if there was a dose–response relationship. We compared the prevalence of eight plus ANC contacts among women in two wives marriage type (i.e., one additional wife besides the index woman) and women in three or more wives marriage type (i.e., two or more additional wives besides the index woman) to women who were in one wife marriage type (i.e., monogamous marriage) as the reference category. We also compared the prevalence of assisted skilled birth and the prevalence of modern contraceptive use with the same categorisation as above. To understand the relative magnitude of the effect of polygynous marriages on the outcomes of interest, we calculated the average marginal effects following each of the three multivariable models.
We also tested for multicollinearity using variance inflation factor (VIF) in each of the models to ensure that they were no issues of collinearity. We accounted for clustering, stratification, and sampling weights in all our analyses. Stata/MP 17.0 (College Station, Texas) was used for the analyses.
Results
Characteristics of study participants
The results included a total weighted sample of 9,098 married women. The prevalence of eight plus ANC contacts was 47.0%, assisted skilled birth 81.4%, and modern contraceptive use 25.4%. Of the women sampled, 15.3% were in polygamous marriage, while 84.7% reported being in monogamous marriages. Majority of the women were aged 35–49 years (52.2%) and multiparous (81.5%). Appropriately, 47% of women were in the rich wealth index and 55% had valid health insurance coverage (Table 1).
The association between polygynous marriage and ANC contacts, assisted skilled birth, and modern contraceptive use
In model I, we found that polygynous marriage was associated with 19% (adjusted odds ratio [aOR] 0.81, 95% CI: 0.69, 0.96) lower odds of having eight plus ANC contacts compared to monogamous marriage. Also, women aged 20–34 or 35–49 years, had secondary or tertiary education, were in the middle or rich wealth index, had higher odds of attaining eight plus ANC contacts compared to women aged 15–19 years, had no formal education, and were in the poor wealth index (Table 2).
Table 2. The association between polygynous marriage and ANC contacts, assisted skilled birth, and modern contraceptive use
ANC = antenatal care; aOR = adjusted odds ratio; CI = confidence interval; Ref. = reference category.
* p-Value < 0.05.
In the second model, women in polygynous marriage had 25% (aOR 0.75, 95% CI: 0.63, 0.89) lower odds of having assisted skilled birth compared to those in monogamous marriages. Women in rural area also had lower odds of having assisted skilled birth compared to those in urban areas. Primary, secondary, and tertiary education were associated with higher use of assisted skilled birth compared to no formal education, while women in the middle and rich wealth index had higher odds of using assisted skilled birth compared to those in the poor wealth index. Having a valid health insurance was also associated with the use of assisted skilled birth (Table 2).
Our third model also found that polygynous marriage was associated with 19% (aOR 0.81, 95% CI: 0.66, 0.99) lower odds of using modern contraception compared to monogamous marriage. Multiparous and primiparous women had higher odds of using modern contraception compared to nulliparous women, and women in rural area also had higher odds of using modern contraption compared those in urban area. Women with secondary and tertiary education were more likely to use modern contraception compared to those with no formal education, whereas those with a valid health insurance were less likely to use modern contraception (Table 2).
Our sensitivity analysis showed that women in two wives marriage type had 18% lower odds of attaining eight plus ANC contacts compared to women in one wife marriage type (aOR 0.82, 95% CI: 0.69, 0.98). Women in three or more wives marriage type also had 25% lower odds of attaining eight plus ANC contacts compared to women in one wife marriage type, though this was not statistically significant (aOR 0.75, 95% CI: 0.50, 1.14) (Supplementary Table 1). Additionally, women in two wives marriage type and three or more wives marriage type had 23% (aOR 0.77, 95% CI: 0.64, 0.91) and 35% (aOR 0.65, 95% CI: 0.44, 0.96), respectively, lower odds of using assisted skilled birth compared to women in one wife marriage type (Supplementary Table 2). Furthermore, the sensitivity analysis revealed that women in two wives marriage type and women in three or more wives marriage type had 18% (aOR 0.82, 95% CI: 0.67, 1.01) and 29% (aOR 0.71, 95% CI: 0.42, 1.20), respectively, lower odds of using modern contraceptives compared to women in one wife marriage type, but these estimates were not statistically significant (Supplementary Table 3).
The adjusted average marginal effects also showed that women in polygynous marriage were significantly less likely to attain eight plus ANC contacts by an adjusted 4.36 (95% CI: −8.02, −0.70) percentage points (Supplementary Table 4). Similarly, polygynous marriage was associated with 3.60 (95% CI: −5.82, −1.37) percentage points lower with the use of assisted skilled birth (Supplementary Table 5). The use of modern contraception among women in polygynous marriage was also lowered by 4.20 (95% CI: −8.10, −0.31) percentage points (Supplementary Table 6).
Discussion
This study examined the practice of polygynous marriage on the utilisation of skilled ANC, assisted skilled birth, and modern contraceptive uptake among married women of reproductive age in Ghana. Our analysis showed that approximately one out of two women attained eight plus ANC contacts, eight out of 10 women had their deliveries conducted by skilled birth providers, and one out of four women were using modern contraceptives. We also found that more than 1 out of 10 women were in polygynous marriages. Polygynous marriage was found to be associated with lower utilisation of skilled ANC, assisted skilled birth, and uptake of modern contraceptive services.
The prevalence of women who attained eight plus ANC contacts in this study was 47.0%. This prevalence is higher compared to other previous studies in Ghana (Apanga and Kumbeni, Reference Apanga and Kumbeni2021; Kumbeni et al., Reference Kumbeni, Apanga, Yeboah, Kolog and Awuni2021; Anaba and Afaya, Reference Anaba and Afaya2022). For example, Kumbeni et al. (Reference Kumbeni, Apanga, Yeboah, Kolog and Awuni2021) reported the prevalence of eight plus ANC contacts as 31.2%, while Anaba and Afaya (Reference Anaba and Afaya2022) in their study reported a prevalence of 43%. Our study also found that women who had their deliveries by skilled birth providers were 81.4%, and this is slightly higher than the 79% reported by the recent GMHS (Ghana Statistical Service, 2018). While our study was conducted among married women, estimates from previous studies were not limited to only married women. Evidence suggest that married women are more likely to have higher utilisation of ANC services (Sakeah et al., Reference Sakeah, Okawa, Rexford Oduro, Shibanuma, Ansah, Kikuchi, Gyapong, Owusu-Agyei, Williams, Debpuur, Yeji, Kukula, Enuameh, Asare, Agyekum, Addai, Sarpong, Adjei, Tawiah, Yasuoka, Nanishi, Jimba and Hodgson2017) and have assisted skilled birth (Ameyaw et al., Reference Ameyaw, Dickson and Adde2021), compared to unmarried women. Furthermore, the prevalence of modern contraceptive use was 25.4%. This is higher when compared to the 22.2% reported among married women in Ghana (Tesema et al., Reference Tesema, Tesema, Boke and Akalu2022). The higher prevalence in our study may be due to the differences in data collection periods and a reflection of improved uptake of modern contraceptives in Ghana.
Our analysis also showed that the prevalence of women in polygynous marriage in Ghana was 15.3%. Recent demographic and health surveys have reported higher prevalence of polygyny in many West African countries compared to Ghana (Millogo et al., Reference Millogo, Labité and Greenbaum2022). The prevalence of polygyny was 29% in Cote d’ivoire, 33% in Togo, 36% in Nigeria, 39% in Benin, 42% in Burkina Faso, and 43% in Guinea (Millogo et al., Reference Millogo, Labité and Greenbaum2022). The variations in the prevalence of polygyny may be due to differences in religious and sociocultural beliefs. For example, Islam permits polygyny under certain circumstance and a man may marry up to four wives (Kramer, Reference Kramer2020). Therefore, polygyny is more prevalent in countries with a higher Muslim population (Kramer, Reference Kramer2020). In Ghana, more than 70% of the population are Christians (Ghana Statistical Service, 2015), and this might explain why the practice of polygyny is not as prevalent as in other West African countries.
We found that women in polygynous marriages were less likely to attain eight plus ANC contacts compared to those in monogamous marriages. An analysis of pooled DHS data for women aged 15–49 years of four African countries (Nigeria, Mali, Guinea, and Zambia) reported similar findings (Ahinkorah et al., Reference Ameyaw, Dickson and Adde2021a). The WHO revised its ANC policy in 2016 from four plus visits to eight plus contacts. This was to ensure that pregnant women have a positive pregnancy experience as this is associated with lower perinatal morbidity and mortality (World Health Organization, 2018). The current finding in our study suggests that many women in polygynous marriages may not be benefiting from this initiative as they are less likely to meet the recommended eight plus ANC visits. Women in polygynous marriages may not be meeting the eight plus ANC contacts because of limited resources, which has to be shared among cowives (Bove and Valeggia, Reference Bove and Valeggia2008). Although ANC services are free under Ghana’s free maternal healthcare policy, indirect costs such as transportation to and from the health facility, food, and sometimes out of pocket payments would usually have to be catered for by the pregnant woman (Ghana Statistical Service, 2018; Kumbeni et al., Reference Kumbeni, Afaya and Apanga2023). This may likely prevent women from attaining eight plus ANC contacts in polygynous marriages compared to their peers in monogamous marriages. Furthermore, polygynous marriages are more prevalent in rural areas in Ghana where access to ANC services are limited (Lawson and Gibson, Reference Lawson and Gibson2018; Adam et al., Reference Adam, Fusheini and Kipo-Sunyehzi2021), and this might also explain why such women were less likely to attain eight plus ANC contacts.
The study further showed that women in polygynous marriages had less utilisation of assisted skilled birth compared to women in monogamous marriages. This finding is in line with similar findings in Senegal, where women in polygynous marriages were more likely to have home delivery with the assistance of traditional birth attendants or relatives (Faye et al., Reference Faye, Niane and Ba2011). In some polygynous practices, pregnant women may be encouraged to give birth at home in order to prove they were faithful to their husbands (Alatinga et al., Reference Alatinga, Affah and Abiiro2021). Beliefs of privacy have also compelled such women to have their deliveries conducted at home usually by relatives or traditional birth attendants (Faye et al., Reference Faye, Niane and Ba2011; Alatinga et al., Reference Alatinga, Affah and Abiiro2021). Another reason could be that polygynous marriages are associated with lower levels of education among the spouses (Bove and Valeggia, Reference Bove and Valeggia2008; Mabaso et al., Reference Mabaso, Malope and Simbayi2018; Damtie et al., Reference Damtie, Kefale, Yalew, Arefaynie and Adane2021), and lower educational attainment is associated with less utilisation of skilled birth providers services (Amponsah et al., Reference Amponsah, Fusheini and Adam2021). In addition, polygynous marriages are more prevalent in rural areas in Ghana, and the use of assisted skilled birth services is limited in such areas (Lawson and Gibson, Reference Lawson and Gibson2018); Adam et al., Reference Adam, Fusheini and Kipo-Sunyehzi2021. Furthermore, women who deliver at health facilities are thought of as being weak in some cultures. This encourages women to deliver at home as a show of strength, especially in the context spousal rivalry (Yaya et al., Reference Yaya, Bishwajit, Uthman and Amouzou2018).
We also found lower utilisation of modern contraceptives among women in polygynous marriages compared to those in monogynous marriages. While a previous study in Nigeria found no statistically significant association between monogamy and use of contraception (Audu et al., Reference Audu, Yahya, Geidam, Abdussalam, Takai and Kyari2007), our finding is corroborated by a pooled analysis across 10 countries in West Africa, including Ghana (Millogo et al., Reference Millogo, Labité and Greenbaum2022). Whereas the current study and that of Millogo and colleagues were conducted using nationally representative data from DHS surveys, the study in Nigeria used a cross-sectional sample, which was not nationally representative. This might have accounted for the differences in the findings. Our finding may be related to competition for fertility among cowives, as culturally, younger wives may have a greater desire to enhance their status by giving birth to more children than older wives (Abdi et al., Reference Abdi, Okal, Serour and Temmerman2020). Furthermore, the competition for fertility between cowives may intensify when the women are more directly dependent on the man for emotional fulfilment or access to resources (Abdi et al., Reference Abdi, Okal, Serour and Temmerman2020). It may also be because women in polygynous marriages have less autonomy and may find it challenging to negotiate for access to modern contraceptive services (Bove and Valeggia, Reference Bove and Valeggia2008).
Our sensitivity analysis also demonstrated that the greater the number of wives in a marriage, the less likelihood that the women will utilise reproductive health services. Though some of the estimates of our sensitivity analysis were not statistically significant, all of the estimates were in a direction that showed that the higher the number of wives in a polygynous marriage, a woman in such a marriage had a lower odds of utilising skilled ANC service, assisted skilled birth and modern contraceptive services. A plausible reason for this finding is that the greater the number of wives in a marriage, the more there is competition for the use of scarce resources (Abdi et al., Reference Abdi, Okal, Serour and Temmerman2020). Another possible explanation for our finding might also be competition for emotional satisfaction from the husband and less autonomy for such women (Bove and Valeggia, Reference Bove and Valeggia2008; Abdi et al., Reference Abdi, Okal, Serour and Temmerman2020).
The findings from this study have several policy implications on reproductive health service utilisation for women in polygynous marriages in Ghana. There is currently no policy in Ghana to cater for the special reproductive healthcare needs of women in polygynous marriages. It is important to recognise the prevalence of polygyny in Ghana, particularly in the context of it being a predictor of the utilisation of reproductive health services. This calls for policymakers to prioritise marriage type in their standardised data collection tools as well as stratifying indicators of health service utilisation by marriage type. We believe this would be an opportunity for providers of reproductive health service to identify women in polygynous marriages and provide them with their health needs, including quality family planning and maternal health counselling, and male partner engagement services.
The study had strengths and limitations. This is the first study to assess the role of polygyny on skilled ANC, assisted skilled birth, and modern contraceptive use among married women in Ghana. We also used a nationally representative dataset which allows for our findings to be generalisable within Ghana. However, causality cannot be inferred from this study because a cross-sectional study design was used. We could not control for some potential confounders (e.g., health provider-related factors) as we were limited to variables available in the GMHS dataset. Data were collected from women with regard to events in the past 5 years and recall bias might have been introduced, but we expect recall bias to be similar among women who were either in a polygynous marriage or monogamous marriage.
Conclusion
Our findings highlight the need for policymakers to pay special attention to women in polygynous marriages and implement interventions to address their unique reproductive healthcare needs. Policymakers should prioritise marriage type in their standardised data collection tools as well as stratifying indicators of health service utilisation by marriage type. We believe this would be an opportunity for providers of reproductive health service to identify women in polygynous marriages and provide them with their health needs, including quality family planning and maternal health counselling, and male partner engagement services.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0021932023000299
Acknowledgement
We thank DHS for making the data available to us.
Author contribution
MTK and PAA conceptualised and designed the study. MTK conducted the data analysis. MTK, JNA, FAZ, and AA contributed to the original drafting of the manuscript. All authors reviewed and approved the final manuscript.
Funding statement
This research received no specific grant from any funding agency, commercial entity, or not-for-profit organisation.
Competing interests
The authors report there are no competing interests to declare.
Ethics approval and consent to participate
The research was performed following the ethical standards of the 1975 Declaration of Helsinki, as revised in 2008. We used deidentified publicly available secondary data from DHS which did not require ethical approval. Details of ethical approval and consent to participate for DHS surveys are available elsewhere (Demographic and Health Survey, 2023).
Consent for publication
Not applicable.
Availability of data and material
Data for this study are available upon request from the corresponding author.
