Unveiling the influence of reproductive health on poverty: a cross-sectional study in Magwi County, South Sudan

Objective: To understand the relationship between household poverty and reproductive health characteristics in Magwi County, South Sudan. Background: Household poverty is a significant issue in many countries, including South Sudan. Poverty has been identified as a major obstacle to international development, affecting various aspects of development goals such as food security and health. Despite interventions by organizations like the World Bank, poverty rates in beneficiary countries like South Sudan have not seen significant reductions, suggesting the presence of predictors of poverty from behavioral, structural, and political origins. Methods: The study was conducted using an analytical cross-sectional survey design. The study targeted female and male spouses in households and employed a multistage sampling approach to select participants. Result: The results of the study revealed that the level of household poverty in Magwi County was 42%. The prevalence of household poverty was found to be influenced by reproductive health characteristics. The use of short-acting contraception by women was associated with a higher prevalence of poverty, whereas women who had ever aborted a pregnancy had a lower prevalence of poverty. Unintended pregnancy and inconsistent condom use by men were also associated with higher poverty rates, whereas men with only one sexual partner had lower poverty rates. Conclusion: This study provides valuable insights into the relationship between household reproductive health characteristics and poverty in Magwi County, South Sudan. It emphasizes the need for comprehensive approaches that address both behavioral and structural factors to effectively reduce poverty and improve development outcomes.


Introduction
International development aims to improve the lives of people and populations worldwide.Poverty is recognized as a significant obstacle to achieving sustainable development goals [1,2] .Poverty has a profound impact on various aspects of development, including food security and health [3] .The World Bank has been actively involved in efforts to eradicate extreme poverty and has implemented interventions in countries like South Sudan [4] .However, despite these efforts, poverty rates in beneficiary countries have not seen significant reductions, indicating the presence of predictors of poverty.
Poverty has a direct impact on food security, as it hinders agricultural production and increases the risk of malnutrition [3] .
Children are particularly vulnerable to the effects of poverty, as it can lead to permanent physical and mental damage and hinder their overall development.Poverty also has detrimental effects on maternal health and the health of individuals in general, with countries with high socioeconomic inequalities in access to quality health care experiencing higher maternal mortality rates [5] .South Sudan, one of the poorest countries in the world, faces significant challenges in terms of health outcomes and has the highest maternal mortality ratio.
Furthermore, poverty can contribute to civil conflict, which not only affects national economies but also has global implications.Civil conflict disrupts trade and health systems, leading to the spread of diseases and hampering essential services like vaccination.The regional impact of conflict and the flow of refugees further exacerbate the fluidity of civil conflict.
To address poverty and its far-reaching effects, it is crucial to understand the determinants and predictors of poverty.This study aims to explore the relationship between household reproductive health characteristics and poverty in Magwi County, South Sudan.By examining these factors, we can gain insights into the potential drivers of poverty and inform targeted interventions to alleviate poverty and promote sustainable development.
outcomes, resulting in a reduction in poverty rates in various countries.However, poverty rates remain high in sub-Saharan Africa, with the majority of the world's poorest people residing in this region.In countries like Ethiopia, Nigeria, and Ghana, a significant proportion of the population still lives below the poverty line.

Household reproductive health characteristics
Several studies have examined various reproductive health characteristics at the household level.These characteristics include the utilization of antenatal care, skilled birth attendance, postnatal care, family planning, birth intervals, type of pregnancy, pregnancy planning, and unintended pregnancies.
Antenatal care attendance is crucial for maternal health, but its utilization is not universal, and late attendance is common in many countries.Skilled birth attendance rates vary across countries, with some regions experiencing low rates [6] .Postnatal care utilization is also variable, with some studies reporting low rates of utilization [7,8] .
Family planning utilization is an important reproductive health characteristic, and studies have shown varying rates of utilization across different countries [9,10] .Birth intervals, which refer to the time between pregnancies, can have implications for maternal and child health.Some studies have reported high rates of short birth intervals, which can pose risks to maternal and child health [11] .
The type of pregnancy, such as multiple or singleton pregnancies, has also been studied.Twin pregnancies account for a small percentage of live births globally, with prevalence rates varying across countries [12] .The planning of pregnancies is another important reproductive health characteristic, and studies have shown that a significant proportion of pregnancies are unintended [13] .

Methods
The methodology chapter of the study provides a detailed description of the research design, study population, sample size calculation, sampling procedures, and ethical considerations.The study adopted a positivist approach and used an analytical crosssectional survey design to collect quantitative data

Study population
The study population consisted of household heads and their female spouses residing in Magwi County, with the inclusion criteria being that the female spouse had ever conceived.

Study design
The study design used in this research was an analytical crosssectional survey design.This design allowed for the collection of quantitative data through structured interviews and questionnaires.

Study population
The study population consisted of household heads and their spouses residing in Magwi County.Both household heads and their spouses were included in the study to assess reproductive health characteristics and household consumption expenditure.

Eligibility criteria
The eligibility criteria for inclusion in the study were that both spouses had to consent to participate, and the female spouse had to have been in a relationship with the household head for more than a month.

Sample size
The sample size calculation was based on the total number of households in Magwi County, which was obtained from the most recent national census.The formula used to calculate the sample size took into account the population size, expected proportion, precision, and level of confidence.The calculated sample size was 379 households, which included both male and female spouses.

Sampling procedures
The sampling procedures used in the study involved a multistage sampling approach.Magwi County was purposively selected as the study area due to its characteristics of persistent poverty and the availability of poverty eradication interventions.The sampling process started at the Payam level and proceeded to the Boma level, village level, and finally the household level.Stratified sampling and simple random sampling were used to sample the parishes, villages, and households.Convenience sampling was used to select households within each sampled village.

Data collection methods
Data collection methods included structured interviews and questionnaires.The interviews were conducted with both household heads and their spouses, and the questionnaires were used to collect data on reproductive health characteristics and household poverty.The data collection tools were designed specifically for this study and were pretested to ensure their validity and reliability.

Quality control techniques
Quality control techniques were implemented to ensure the accuracy and consistency of the data collected.This included training the interviewers, conducting pilot interviews, and regular supervision and monitoring of the data collection process.The data management and analysis plan involved coding and entering the data into a computer database, cleaning and checking for errors, and conducting statistical analysis.Descriptive and inferential statistics were used to analyze the data and make deductions about the influence of reproductive health characteristics on household poverty.

Ethical considerations
Ethical considerations were taken into account throughout the research process.Informed consent was obtained from all participants, and their privacy and confidentiality were protected.The study was conducted in accordance with ethical guidelines and regulations.

Sociodemographic characteristics
These findings provide a comprehensive overview of the sociodemographic characteristics of the participants in the study.The data collected on age, marital status, duration of the relationship, type of marriage, religious denomination, education level, and employment status provide valuable insights into the demographic profile of the participants.This information is important for understanding the context in which the study was conducted and for interpreting the findings related to the objectives of the study (Table 1).
For the female spouses, the findings show that a significant proportion of them were young mothers and youths in the age bracket of 20-30 years (44.1%).The majority of the female spouses were married (69.9%) and had been in a relationship for more than 5 years (67.5%).In terms of marital status, close to two-thirds of the female spouses were in monogamous marriages (60.9%).Almost all of the female spouses identified as Christians (79.4%) and a significant proportion of them reported having received some formal education (79.4%).Among those who had received education, the majority had completed primary-level education (46.2%).In addition, close to two-thirds of the female spouses were employed (63.3%) [14] .
For the male spouses, the findings indicate that more than a third of them were in the age bracket of 31-40 years (36.7%).Similar to the female spouses, the majority of the male spouses were married (69.9%) and had been in a relationship for more than 5 years (67.5%).In terms of marital status, more than half of the male spouses were in monogamous marriages (59.9%).The majority of the male spouses identified as Christians (88.9%) and a significant proportion of them reported having received some formal education (85.2%).Among those who had received education, the majority had completed primary-level education (43.7%).In addition, a higher proportion of male spouses were employed compared with female spouses (72.0%) [14] .

Poverty assessment
Based on the information provided in Table 2, it can be inferred that a poverty assessment was conducted based on household consumption expenditure.The table presents the findings of this assessment, specifically focusing on different variables related to household expenditure.
The first variable examined in the assessment is monthly household expenditure on food.The table shows that 38.3% of households reported spending < 57 USD on food in the previous 30 days, whereas 61.7% reported spending more than 57 USD.
The second variable assessed is monthly household expenditure on utilities, such as electricity, phone, water, and sanitation.The table reveals that 44.1% of households reported spending < 57 USD on utilities, whereas 55.9% reported spending more than 57 USD.
The third variable examined is monthly household expenditure on transport, including fuel used for transport.The table shows that 57.8% of households reported spending < 57 USD on transport, whereas 42.2% reported spending more than 57 USD.The fourth variable assessed is monthly household expenditure on fuel, excluding fuel used for transport, such as oil, wood, gas for cooking, heating, and cooling.The table reveals that 35.4% of households reported spending < 57 USD on fuel, whereas 64.6% reported spending more than 57 USD.
The fifth variable examined is monthly household expenditure on health, including medicaments, visits to clinics, traditional healers, or doctors.The table shows that 32.7% of households reported spending < 57 USD on health, whereas 67.3% reported spending more than 57 USD.This indicates that a significant proportion of households may be struggling to afford health care expenses.In addition to these variables, the table also provides the headcount index, which is a measure of the level of poverty.The computed headcount index is 41.7%, indicating that 41.7% of households in the assessed area are living in poverty.
The study revealed that 42% of households in Magwi County are classified as poor, with a daily consumption expenditure of < 1.90 USD.In contrast, 58% of households are classified as non-poor, with a daily consumption expenditure of more than 1.90 USD.

Reproductive health characteristics
Reproductive health characteristics encompass various aspects of reproductive health, including pregnancy history, contraceptive use, antenatal care attendance, delivery practices, and history of infertility or sexually transmitted infections (STIs).In a study conducted in Magwi County, South Sudan, researchers examined the reproductive health characteristics of both female and male spouses (Table 3).
The findings revealed that 57.5% of the women had experienced more than 3 pregnancies, and 86.3% had no history of spontaneous abortion.Among those who had experienced spontaneous abortion, 55.8% had encountered it once.In Jolem.Global Reproductive Health (2024) 9:e0082 addition, 63.6% of the women had a history of pregnancy complications, whereas 96.3% had no history of multiple pregnancies.Of the females, 55.8% had given birth to 3 children, and 53.8% had used some form of family planning.Among those who had used family planning, the majority had utilized shortacting contraceptives (90.2%).Almost all of the female spouses reported always attending antenatal care (90.5%), with more than two-thirds attending more than 4 visits (66.8%).Moreover, the majority of women reported delivering all their pregnancies in a health facility (72.6%) and seeking postnatal care after birth (57.3%).
The study also shed light on the reproductive health characteristics of men in the sample population.Almost all of the men had not undergone a vasectomy (98.4%), and 54.7% were not using condoms.Among those using condoms, the majority reported using them occasionally (69.2%).The majority of men reported no history of STIs (83.4%) and had fathered children of both sexes (62.3%).In addition, approximately half of the men reported having one sexual partner (50.5%), and the majority reported never engaging in intercourse under the influence of substances (85.0%).
The findings in Table 4 provide an introduction to the results of the factor analysis conducted on the variables related to reproductive health characteristics of households in Magwi County.The purpose of the analysis was to identify the variables that had the highest interrelationships and could be considered definitive of the reproductive health characteristics of the households.
The table presents the results of the principal component analysis, which is a data reduction technique used to identify the underlying factors or components that explain the variation in the variables.In this case, the analysis revealed the presence of 7 principal components (C1-C7).
Each component is associated with specific variables and represents a distinct aspect of reproductive health.For example, component 1 (C1) is highly correlated with the nature of STIs suffered by women, component 2 (C2) is highly correlated with the use of any form of family planning, component 3 (C3) is highly correlated with the sex distribution of children born to men.
The findings in Table 5 provide information on the cluster analysis conducted using the K-means clustering technique.The table displays the final cluster centers for different variables related to reproductive health characteristics in households in Magwi County.The clusters are labeled as 1, 2, and 3, with cluster 3 being the largest, representing 36.4% of the total cluster.Cluster 1 represents 30.2% and cluster 2 represents 33.4%.
Based on the findings, the reproductive health characteristics of households in Magwi County can be determined by looking at the variables in cluster 3.These characteristics include a history of STIs suffered by women, the use of any form of family planning by women, the sex distribution of children born to men, the history of pregnancy complications, the frequency of antenatal care visits, gravidity (number of pregnancies carried), and condom use among men who have not undergone vasectomies.
The most definitive reproductive health characteristics that cut across both spouses are the sex distribution of children born to men, a history of STIs among women, and the gravidity of women.These characteristics have coefficients ≥ 1.5, indicating their significance in defining the reproductive health profile of households in Magwi County.

Household reproductive health characteristics and household poverty
Table 6 provides a cross-tabulation of the cluster components, offering detailed descriptions of each component within each cluster.This illustrates the distribution of variables across 3 distinct clusters.
In cluster 1, 25.5% of the women had a history of STIs, 59.8% had used any form of family planning, 44.1% had given birth to female children only, 57.8% had a history of pregnancy complications, 31.4% attended < 4 antenatal care (ANC) visits, 18.6% had carried 2 pregnancies, and 45.1% of men in this cluster used condoms.
In cluster 2, 17.7% of the women had a history of STIs, 47.8% had used any form of family planning, and no women had given birth to children.In addition, 61.9% of men in this cluster had a history of pregnancy complications, 33.6% attended < 4 ANC visits, and 36.3% of men used condoms.In cluster 3, 23.6% of the women had a history of STIs, 56.9% had used any form of family planning, 2.4% had given birth to female children only, 20.3% had given birth to male children only, and 77.2% of men had fathered children of both sexes.Furthermore, 70.7% of women had a history of pregnancy complications, 35.0%attended < 4 ANC visits, 74.0% had carried 3 pregnancies, and 50.4% of men used condoms.

Reproductive health characteristics
The findings in Table 7 reveal the relationship between household reproductive health characteristics and household poverty in Magwi County.The table presents various variables and their corresponding percentages and counts for poor and non-poor households.The Continence Probability Ratio (cPR) column represents the crude prevalence ratio, which indicates the association between each characteristic and household poverty.The "P value" column indicates the statistical significance of the relationship.
Based on the table, 6 characteristics show statistically significant relationships with household poverty.These characteristics are: • The particular type of contraception used so far: The use of short-acting contraceptives is associated with a higher prevalence of household poverty (cPR: 1.155, CI: 1.025-1.301,P = 0.018).• History of abortion: Having a history of abortion is associated with a lower prevalence of household poverty (cPR: 0.843, CI: 0.727-0.978,P = 0.024).• History of unintended pregnancy: Having a history of unintended pregnancy is associated with a higher prevalence of household poverty (cPR: 1.153, CI: 1.082-1.228,P = 0.000).• Use of condoms for men without vasectomies: Not using condoms for men without vasectomies is associated with a higher prevalence of household poverty (cPR: 0.934, CI: 0.876-0.996,P = 0.038).• Frequency of using condoms: Always using condoms is associated with a higher prevalence of household poverty (cPR: 1.627, CI: 1.500-1.766,P = 0.000).• Number of sexual partners currently: Having multiple sexual partners is associated with a lower prevalence of household poverty (cPR: 0.779, CI: 0.744-0.815,P = 0.000).
The relationship between household reproductive health characteristics and household poverty among households in Magwi County was examined in this study.The researchers analyzed various variables related to reproductive health and their association with household poverty.The findings of the study revealed that certain reproductive health characteristics were significantly associated with household poverty.After adjusting for confounders, the variables that were significant in the bivariate analysis remained significant in the multivariate analysis Table 8.
The prevalence of household poverty was found to be higher among households in which women had used short-acting contraception.The adjusted prevalence ratio (aPR) for this variable was 1.139 (95% CI: 1.021-1.272,P = 0.020).This suggests that the use of short-acting contraceptives is associated with a higher likelihood of household poverty.
In contrast, the prevalence of household poverty was lower among households in which women had ever aborted a pregnancy.The aPR for this variable was 0.840 (95% CI: 0.723-0.976,P = 0.023).This indicates that having a history of abortion is associated with a lower likelihood of household poverty.
Furthermore, the prevalence of household poverty was higher among households in which women had a history of unintended pregnancy.The aPR for this variable was 1.148 (95% CI: 1.082-1.219,P = 0.000).This suggests that a history of unintended pregnancy is associated with a higher likelihood of household poverty.
Interestingly, the prevalence of household poverty was lower among households in which men were using condoms.The aPR for this variable was 0.929 (95% CI: 0.874-0.987,P = 0.017).This indicates that men using condoms is associated with a lower likelihood of household poverty.
However, the prevalence of household poverty was higher in households in which men used condoms inconsistently.The aPR for this variable was 1.420 (95% CI: 1.101-1.821,P = 0.000).This suggests that inconsistent condom use by men is associated with a higher likelihood of household poverty.
In addition, the prevalence of household poverty was lower among households in which men had only one sexual partner.The aPR for this variable was 0.837 (95% CI: 0.787-0.890,P = 0.000).This indicates that men having only one sexual partner is associated with a lower likelihood of household poverty.

Poverty assessment
Based on the findings presented in Table 2, a poverty assessment was conducted using household consumption expenditure as the basis.The table provides information on various variables related to household expenditure, including food, utilities, transport, fuel, and health.The percentages of households spending < 57 USD on each of these variables are reported.
The findings reveal that a significant proportion of households are facing challenges in affording basic necessities.For instance, 38.3% of households reported spending < 57 USD on food, indicating potential food insecurity.Similarly, 44.1% of households reported spending < 57 USD on utilities, suggesting limited access to essential services such as electricity and water.Furthermore, 57.8% of households reported spending < 57 USD on transport, indicating potential difficulties in accessing transportation.In addition, 35.4% of households reported spending < 57 USD on fuel, which may indicate challenges in meeting energy needs for cooking and heating.Moreover, 32.7% of households reported spending < 57 USD on health, highlighting potential barriers to accessing health care services.
The computed headcount index of 41.7% indicates that a significant proportion of households in the assessed area are living in poverty.This aligns with the findings of prior research that have examined poverty and its determinants.For example, Li et al [15] found that vulnerabilities related to climate change, living habits, and medical accessibility were positively associated with health poverty among rice farmers in China.Khan et al [16] highlighted the financial risks and potential poverty resulting from large and unpredictable health payments in Bangladesh.Carter and Barrett [17] discussed the economic theory of poverty traps and persistent poverty, providing insights into the dynamics of long-term structural poverty.

Reproductive health characteristics
The findings of this study on household reproductive health characteristics and household poverty in Magwi County reveal several significant relationships.The use of short-acting contraceptives is associated with a higher prevalence of household poverty, whereas having a history of abortion is associated with a lower prevalence of household poverty.In addition, a history of unintended pregnancy, not using condoms for men without vasectomies, always using condoms, and having multiple sexual partners are all associated with a higher or lower prevalence of household poverty.
These findings align with prior research on the relationship between reproductive health and poverty.For example, a systematic review by Vyas and Watts [18] found that economic empowerment can have varying effects on women's risk of intimate partner violence in low and middle-income countries.This suggests that financial autonomy, which may be influenced by reproductive health choices, can be both protective and associated with increased risk.
Another study by Dehury and Mohanty [5] examined the relationship between multidimensional poverty, household environment, and short-term morbidity in India.They found that households classified as multidimensional poor and living in a poor household environment had a higher prevalence of shortterm morbidities.This supports the idea that poverty and household environment can impact health outcomes, including reproductive health.
Furthermore, Baumer and South [19] explored community effects on youth sexual activity and found that neighborhood disadvantage, which is often associated with poverty, can influence adolescent sexual behavior.This suggests that the social and economic context in which individuals live can shape their reproductive health choices and outcomes.
In addition, studies have shown that unequal power relations and partner violence are associated with women's reproductive health.For example, Vyas and Jansen [20] found that violence against women in Tanzania was associated with unequal power relations and men's harmful expressions of masculinity.This highlights the importance of considering power dynamics in understanding the relationship between reproductive health and poverty.
Moreover, decision-making power within households has been found to influence contraceptive use.Olaolorun and Hindin [21] conducted a study in Nigeria and found that women who were involved in making household decisions had higher odds of using modern contraception.This suggests that women's agency and decision-making power can play a role in their reproductive health outcomes.
Limitations of the presented work include the focus on a specific geographic area (Magwi County) and the reliance on selfreported data, which may be subject to recall bias.In addition, the poverty assessment is based on household consumption expenditure, which may not capture all dimensions of poverty, such as education, housing, and social exclusion.In addition, the assessment provides a snapshot of poverty at a specific point in time and may not capture the dynamic nature of poverty.
Future directions could involve expanding the study to other regions and using more objective measures of reproductive health and poverty.This could involve examining the impact of factors such as education, employment, and social protection programs on poverty levels.Qualitative research could provide deeper insights into the experiences and perspectives of individuals living in poverty and how it intersects with reproductive health.In addition, further investigation into the specific challenges faced by households in accessing health care services and potential strategies to address these challenges could be valuable.

Conclusion
The poverty assessment based on household consumption expenditure reveals that a significant proportion of households in the assessed Magwi are facing challenges in affording basic necessities, indicating a high prevalence of poverty.The findings also highlight the significant relationships between reproductive health characteristics and household poverty, emphasizing the need to consider the intersectionality of poverty and reproductive health.Future directions could involve expanding the study to other regions, using more objective measures of reproductive health and poverty, and conducting qualitative research to gain deeper insights into the experiences and perspectives of individuals living in poverty and their reproductive health outcomes.

Table 1
Socio demographic characteristics of the respondents (female and male).

Table 2
Household poverty assessment.

Table 3
The reproductive health characteristics of households in Magwi County, South Sudan.

Table 4
Principal component analysis.

Table 5
Final cluster centers.

Table 6
Cross tabulation of the cluster components to determine the actual descriptions of each component in each cluster 1.

Table 7
The relationship between household reproductive health characteristics and household poverty among households in Magwi County (unadjusted).

Table 8
The relationship between household reproductive health characteristics and household poverty among households in Magwi County (adjusted).