Associations between quantitative measures of women's empowerment and access to care and health status for mothers and their children: A systematic review of evidence from the developing world

Reproductive Autonomy in Fertility Research in Sub-Saharan Africa: A Scoping Review

Fertility research in sub-Saharan Africa regularly indicates the need to increase women's reproductive autonomy. However, individual, female-focused conceptualizations of reproductive autonomy tend to neglect the power dynamics both internal and external to couples and other intimate relationships that shape a woman's reproductive autonomy. Furthermore, they disregard the reproductive autonomy of men and other subpopulations and partners in intimate relationships. To identify gaps and evaluate the applicability of the concept, this scoping review clarifies how reproductive autonomy has been assessed and applied in fertility research in sub-Saharan Africa. Eligible for inclusion were empirical peer-reviewed publications, including quantitative, qualitative, and mixed-methods research, published since 1994. Out of 1568 articles screened, 18 met the inclusion criteria. Most publications were quantitative in nature and focused mainly on the reproductive autonomy of women. Our key finding is that the reproductive autonomy of partners in intimate relationships, and of women in particular, is restricted at the community level in order to preserve the status quo of social power structures in society. In line with a reproductive justice approach, more research should focus on the reproductive autonomy of vulnerable and understudied populations as well as on the interpersonal and contextual dynamics that suppress reproductive autonomy in communal settings.

Marital choice, spousal communication, and contraceptive self-efficacy and use among newly married girls in India: Evidence from the UDAYA study

BACKGROUND

Marital choice of girls in India is low, with most marriages arranged entirely by parents and extended family members. Evidence on the relationship between marital choice and reproductive autonomy remains limited in India. This study sought to fill this critical gap by examining the association between marital choice, spousal communication, and contraceptive self-efficacy and use.

METHODS

Data were analysed from the Understanding the Lives of Adolescents and Young Adults (UDAYA) survey, conducted in two north Indian states─ Uttar Pradesh and Bihar across rural and urban settings. Our analytic sample for analysis included 5,018 currently married adolescent and young adult girls aged 18-22 years at wave 2, 2018-19. We employed descriptive statistics, a chi-square test, and unadjusted and adjusted binary logistic regression models.

RESULTS

Overall, 41.1% of girls had contraceptive self-efficacy and 17.5% used contraceptives. Girls' involvement in spouse selection, either solely or jointly with parents -particularly when girls knew their husbands before marriage - was positively associated with spousal communication about fertility and contraception compared to those in parent-arranged marriages. Girls in self-choice marriages were linked to higher contraceptive self-efficacy (AOR: 1.56; 95 % CI: 1.24, 1.97) and increased contraceptive use (AOR: 1.68; 95 % CI: 1.25, 2.26) than parent-arranged marriages. Girls who knew their husbands before marriage in joint decision-making also showed higher odds of contraceptive use (AOR: 1.49; 95 % CI: 1.16, 1.92). However, the association between marital choice and contraceptive use was significant only in urban areas, not in rural areas.

CONCLUSION

Our study demonstrated that girls' involvement in spouse selection was associated with improved spousal communication, greater contraceptive self-efficacy, and increased contraceptive use, with significant contextual differences. Findings emphasized the critical role of girls' agency in marital decisions and effective spousal communication in increasing contraceptive use tailored to specific contexts among newly married girls in India.

The Role of Women's Empowerment in Fertility Preferences and Outcomes: Analysis of the 2017 Indonesia Demographic and Health Survey

BACKGROUND

With a population of 275 million, Indonesia is the world's fourth most populous country and has made considerable efforts to reduce its Total Fertility Rate from 5.6 in 1971 to a target of 2.1 by 2024. Women's empowerment has been identified as a critical factor influencing fertility dynamics, gender equality, reproductive autonomy, and broader socioeconomic development. This study examines the association between four dimensions of women's empowerment and three fertility-related outcomes among married women aged 22 years and older in Indonesia.

METHODS

We used cross-sectional data from 34,017 married women participating in the 2017 Indonesia Demographic and Health Survey (IDHS). An outcome-wide analytical approach was adopted to explore three outcomes: total number of children ever born, ideal number of children, and fertility preference alignment, i.e. whether actual fertility matched stated preferences. Four empowerment domains were assessed: household decision-making, attitudes toward wife beating, attitudes toward refusing sex, and labour force participation. Stepwise multivariate Poisson regression modelling was applied, adjusting for key demographic and socioeconomic covariates.

RESULTS

Our study found that the association between each type of women's empowerment and fertility-related outcomes varied, reinforcing the notion that empowerment does not uniformly affect reproductive behaviour. Among the four empowerment indicators, rejecting all justifications for wife beating emerged as the most consistent and significant predictor across all fertility outcomes. It was association with fewer children ever born (β = 0.03), a lower ideal number of children (β = 0.04), and a higher likelihood of meeting fertility preferences (PR = 1.02). Attitudes toward refusing sex were also significantly associated with fewer children (β = 0.02) and lower fertility ideals (β = 0.07). However, participation in decision-making and labour force participation showed mixed or non-significant associations, indicating that different empowerment dimensions may influence reproductive behaviour in diverse ways.

CONCLUSIONS

Women's empowerment - particularly in the domains of gender-based violence and sexual autonomy - is closely linked to fertility preferences and behaviours. The findings underscore that empowerment is a multidimensional construct, with varying influences across its domains. Strengthening women's autonomy and addressing gender-based violence are essential steps toward enhancing reproductive rights and achieving Sustainable Development Goal 5 in Indonesia. Gender-sensitive data systems and interventions tailored to different aspects of empowerment are urgently needed.

The association of women's empowerment dimensions and antenatal care utilization in Ethiopia; facility based cross-sectional study

BACKGROUND

Women's empowerment is a multidimensional global development goal. Women in low-income countries are often disempowered, which can lead to increased mortality and morbidity by inhibiting their access to essential maternal health care, such as antenatal care. It is impossible to decrease maternal mortality without sufficient and timely antenatal care. However, the association between women's empowerment and antenatal care utilization has been understudied. Therefore, this research aims to assess the association of women's empowerment dimensions with antenatal care use.

METHOD

A facility-based cross-sectional study was conducted from July 1 to August 31, 2022, in public hospitals within Jimma town, Ethiopia. Participants were 305 women who attended childbirth and postpartum services, selected by systematic random sampling. A structured, interviewer-administered questionnaire was used for data collection. Bivariate and multivariable logistic regression analyses were employed to determine the association between variables.

RESULT

Of 305 respondents, 301 provided complete responses, resulting in a response rate of 99.1%. Approximately 187 (62%) study participants utilized adequate antenatal care [95% CI: 56.4-67.6]. In multivariate logistic regression women's empowerment dimensions showed statistically significant association with antenatal care utilization. High general self-efficacy [AOR = 1.89 (1.02-3.50)], high self-esteem [AOR = 3.10 (1.67-5.76)], an internal locus of control [AOR = 2.13 (1.17-3.86)], and labor work participation [AOR = 1.98 (1.06-3.72)]. All these factors were associated with increased antenatal care utilization.

CONCLUSION

Women empowerment dimensions have a positive and statistically significant association with antenatal care use. So, to improve recommended antenatal care utilization by mothers, empowerment of women by health professionals, hospitals, and other stakeholders is very important.

Female Circumcision and Sexual Negotiation Ability of Ethiopian Women

The following study attempts to assess the link between the circumcision status of Ethiopian women and their ability to negotiate sex. From the 2016 Ethiopian Demographic and Health Survey, we analyzed a subsample of 3,445 women aged 15 to 49. Women's sexual negotiation ability was measured by their ability to ask for condom and their ability to refuse sex. We performed a univariate, bivariate, and multiple logistic regression analysis. In the final analysis, only education, residence, media access, and sexually transmitted infections knowledge were independently associated with the sexual negotiation ability of women. Circumcision status was not associated with sexual negotiation ability.

Adapting the Women's empowerment in nutrition index: Lessons from Kenya

Women face a disproportionate burden of malnutrition and food insecurity. Research has shown that women's empowerment can buffer women against nutritional problems. This paper contributes to ongoing efforts to measure women's empowerment that are both context-sensitive and universal, focusing on the recently developed Women's Empowerment in Nutrition Index (WENI). Earlier research has shown it is both a valid construct and positively related to dietary and nutritional outcomes of women in South Asia. We establish that WENI is generalizable to agropastoral and pastoral Kenya, an area with substantially different livelihoods, food system, norms, and institutions than South Asia. We find that a locally contextualized WENI is strongly associated with women's body mass index and dietary diversity as well as household level food insecurity. We also present findings for two shorter variations of WENI: an abbreviated WENI (A-WENI) and a cross context WENI (CC-WENI). A-WENI contains a small subset of WENI indicators identified using machine learning with South Asian data and therefore is context-specific. CC-WENI does not contain indicators specific to the validation context. We find that they perform comparably well with caveats. Thus, as use of WENI expands we recommend adapting WENI for in-depth analyses of women's nutritional empowerment; using CC-WENI for cross-context comparisons; and using A-WENI for rapid appraisals of community level progress in a given context.

Individual- and community-level women's empowerment and complete use of maternal healthcare services: A multilevel analysis of 34 sub-Saharan African countries

BACKGROUND

Current literature on women's empowerment (WE) and maternal healthcare use is limited to individual-level analysis, with a focus on single components of maternal healthcare services. As gender-related community contexts may importantly shape women's ability to seek healthcare services, we examined how both individual- and community-level WE are associated with complete use of maternal healthcare services in sub-Saharan Africa (SSA).

METHODS

We analyzed Demographic and Health Surveys conducted between 2011 and 2022 across 34 SSA countries (N = 194,740 women aged 15-49 years old). Complete care was defined as utilizing four or more antenatal care contacts, facility delivery, and any postnatal care. Based on a globally validated survey-based WE index (SWPER), a composite variable was constructed for individual- and community-level WE for each domain of attitude to violence, social independence, and decision-making: low-low (reference), low-high, high-low, and high-high. Multilevel linear probability models were used adjusting for key sociodemographic factors.

RESULTS

About one-third of women (35.4%) utilized complete care. Women with high empowerment at both individual- and community-levels demonstrated the highest probability of complete care (b = 0.058; 95% CI = 0.051,0.066 for attitude to violence; b = 0.116; 95% CI = 0.108,0.124 for social independence; b = 0.070; 95% CI = 0.063,0.078 for decision-making). Women with low empowerment but living in high empowerment communities (low-high) were more likely to utilize complete care than their counterparts (high-low group), which was particularly evident in the social independence domain.

CONCLUSION

We found a strong contextual effect of WE on complete utilization of maternal healthcare services. Alongside efforts to enhance individual WE, interventions to advance gender equality at the community-level are crucial to facilitate timely access to maternal healthcare in SSA.

A qualitative study to explore mother's experiences of a family MUAC project in two provinces in South Africa

BACKGROUND

In South Africa, severe acute malnutrition remains a significant cause of child mortality. Measuring mid-upper arm circumference (MUAC) is a simple, cost-effective approach to identify malnutrition in communities. The Family MUAC intervention supported community health workers (CHWs) to mentor mothers and child caregivers to measure MUAC, record their findings and access nutrition information from the child's Road-to-Health-Book. Family MUAC was implemented in seven sites in two provinces in South Africa: Gauteng and KwaZulu-Natal. This study aimed to explore mother/caregiver's perceptions and experiences of participating in Family MUAC.

METHODS

Focus group discussions (FGDs) were conducted with mothers purposively selected by CHWs based on their active participation in Family MUAC. Trained qualitative researchers conducted one FGD at each participating site. Coding reliability thematic analysis with topic summaries was employed to analyse the data using Nvivo v12.

RESULTS

Seven FGDs were conducted with a total of 59 participants. Key themes identified were mother's perceptions of the CHW's role, experiences of implementing Family MUAC activities, and perceptions of the broader effect on maternal empowerment and child health. Mothers appreciated the support from CHWs who were perceived as patient and caring, taking time to develop mother's skills and answer questions. CHWs provided ongoing care, encouraged participation and understood the mother's home situation. Mothers experienced group learning positively, and helped each other learn about MUAC measurements. Most mothers experienced measuring MUAC as challenging initially, needing support from CHWs to gain confidence to measure and record findings. Participating in Family MUAC empowered mothers in caring for their child, and improved their relationships with CHWs. Mothers compared support from CHWs to care received at the clinic, saying clinic visits were costly and time-consuming and nurses frequently did not explain their findings. Mothers reported feeling more confident to ask questions during clinic visits after participating in family MUAC.

CONCLUSIONS

Using CHWs to support mothers measuring MUAC in households was acceptable and feasible. CHWs provided ongoing good quality care, relevant advice and support, and empowered mothers. Family MUAC had wide ranging benefits for building relationships and peer support in communities and strengthened mothers perceived role in the care of her child.

Empowerment as an Outcome and a Process: Longitudinal Validation of a Reproductive Empowerment Scale in Plateau State, Nigeria

Measurement of reproductive empowerment (RE) is necessary to understand and address barriers to RE and to evaluate the impact of policies and practices that increase RE as a pathway to improving reproductive health. This study validated an existing RE scale, developed in 2016 for sub-Saharan African (SSA) contexts, using longitudinal survey data from a cohort of women in Plateau State, Nigeria. Psychometric properties were assessed through confirmatory factor analysis, and invariance tests evaluated the scale's consistency across baseline and endline. Longitudinal logistic regression models examined whether changes in RE levels predicted family planning outcomes. The results demonstrate the final RE scale is a valid and predictive tool, comprising 24 items across five subscales that measure empowerment at individual, immediate relational, and distant relational levels. The RE scale also predicts the use of family planning and intention to use modern contraception in the future. This is one of the few RE scales designed specifically for SSA contexts and the only one known to be validated longitudinally. The RE scale provides a robust framework for measuring RE across levels and over time and can be used in SSA contexts to measure RE as a dynamic process and as an outcome.

Adolescent gender beliefs in India: Does mothers' empowerment matter?

Abundant studies have documented the positive impact of mothers' empowerment on children's health and education in the Global South, but little is known about how maternal empowerment shapes children's gender beliefs. Using data from the India Human Development Survey, this study examines the relationship between mothers' empowerment and adolescent children's gender beliefs in India. Recognizing the multidimensionality of women's empowerment, we conduct latent class analysis to identify a six-class empowerment typology based on mothers' education, employment, decision-making power at home, mobility outside the home, and memberships in women's organizations. The results reveal unevenness in different dimensions of mothers' empowerment. Maternal empowerment's association with egalitarian gender beliefs is salient among adolescent girls, but not boys. Adolescent girls with mothers labeled as proactive workers in our empowerment typology hold the most egalitarian gender beliefs, whereas low agency and underprivileged worker mothers' daughters are the least egalitarian. By illustrating the complex interplay between multiple dimensions of maternal empowerment and children's gender beliefs in India, this study advances the empirical and theoretical understanding of women's empowerment and the effects of mothers' behaviors on children's gender beliefs.

Female agency and probable depression in the perinatal period and beyond: Longitudinal findings from rural Pakistan

In Pakistan, a setting with high gender inequality, the relationship between female agency and mental health has not been studied longitudinally or beyond a defined life stage like pregnancy. Using data from the Bachpan cohort of mother-infant dyads in Pakistan, we investigated female agency and depression at two life stages: perinatal (third trimester to 6-months postpartum; n = 1154) and beyond (3- to 4-years postpartum). Modified Poisson models estimated adjusted prevalence ratios (PR) for probable depression (PHQ-9) associated with female agency (freedom of movement and participation in household decision-making) at the two life stages. Among 1154 mothers (average age 26.6 years), female agency was substantially lower during pregnancy than it was at 3-years and depression was more common during postpartum than at 4-years. Low freedom of movement during pregnancy nominally increased the likelihood of postpartum depression (PR: 1.33; 95% CI: 0.98, 1.80). The risk of depression was higher for low- (PR: 1.01; 95% CI: 0.72-1.41) and high- (PR: 1.24; 95% CI: 0.65-2.36) participation in household decision-making compared to moderate, but estimates were imprecise. Results from beyond the perinatal period indicated a stronger relationship between low freedom of movement and subsequent depression (PR: 1.89; 95% CI: 1.12, 3.20; Table 3). Low- (PR: 1.19; 95% CI: 0.67-2.12) and high- (PR: 1.21; 95% CI: 0.67-2.17) decision-making continued to demonstrate a nominal U-shaped relationship with depression, but estimates were imprecise. Overall, restricted freedom of movement beyond the perinatal period, may increase the likelihood of depression. Future research should explore the nuances of participation in decision-making and how it impacts women's mental health.

Level of and trends in women's empowerment inequalities in antenatal care services in Ethiopia: further analysis of the Ethiopia demographic and health surveys, 2000-16

BACKGROUND

Maternal health care services and women's empowerment have received attention in the Sustainable Development Goals. Limited evidence exists on the extent of distribution of antenatal care services across the ladder of women's empowerment in Ethiopia. In this study, we sought to shed light on whether and how such disparities changed over time.

METHODS

Data for the study came from the 2000 and 2016 Ethiopia Demographic and Health Surveys. The outcome variables were three measures of antenatal care services: quality antenatal care, early antenatal care, and four or more antenatal care services. Women's empowerment was measured through a newly developed index, SWPER Global. Specifically, we used two domains of the measure: attitude to violence and social independence. Disparities in antenatal care services were measured using the Erreygers concentration index, Relative Index of Inequality, Average marginal effect, and second difference of the average marginal effects. We decomposed the concentration index to study the contributions of different factors to the empowerment disparities in the services in 2000 and 2016 as well as to the over-time change in the disparities. The Oaxaca-type decomposition technique was applied to investigate social determinants' role on the change in the disparities between 2000 and 2016. A generalized linear regression model was used for the analyses.

RESULTS

According to the concentration index, women's empowerment disparities in the utilization of antenatal care services existed in both surveys, where the services were disproportionately concentrated among women with better levels of empowerment. By the measure of average marginal effect, there were disparities favoring empowered women based mainly on the point estimates, except that the attitude toward violence disparity in 2016 occurred to the advantage of poorly empowered women. However, the confidence intervals suggest mixed findings. The concentration indices showed that disparities mostly increased in 2016 and the change was underpinned by the changes in the inequalities of various factors and sensitivities of antenatal care services with respect to these variables, such as wealth, maternal education, media exposure, place of residence, and women's empowerment itself. Overall, the results of the second difference showed no large change in the disparities between 2000 and 2016. However, relative disparities decreased substantially during the same time.

CONCLUSIONS

While concentration index-based absolute inequalities increased, relative inequalities decreased, suggesting the importance of using both absolute and relative measures in a study. The decomposition analyses suggest that working on the equitable distribution of social determinants could improve empowerment disparities in antenatal care services.

Associations between family planning, healthcare access, and female education and vaccination among under-immunized children

BACKGROUND

Increasing childhood vaccination, family planning, healthcare access, and women's empowerment are targets of the Sustainable Development Goals (SDG). Barriers to healthcare access impede vaccination; tackling goals holistically could create larger gains than siloed efforts. We studied Nepal, Senegal, and Zambia to test the association between childhood vaccinations and other SDG indicators to identify clustered deprivations. We quantified how under-immunized children with few - or no - vaccines and their mothers were vulnerable in SDG areas.

METHODS

We analyzed Demographic and Health Surveys from Nepal, Senegal, and Zambia. Through ordinal logistic regressions, controlling for household/mother's characteristics, we identified strong predictors of the number of vaccine doses one-year-old children received. Through bootstrapping and optimal propensity scores matching, we compared children with no or few vaccine doses (0-2 doses in early 2000s, or 0-4 in late 2010s) to children who received eight doses (DTP1-3, MVC1, Pol1-3, and BCG vaccines).

FINDINGS

Mothers of children who received eight doses were 14-30 % more likely than mothers of children with few or no doses to have accessed a health facility in the last year (95 % CIs were 16-44 % in Nepal 2001, -5 % to 33 % Nepal 2016, 3-26 % Senegal 2005, 1-31 % Senegal 2019, 9-38 % Zambia 2001-02, 7-36 % Zambia 2018), knew on average 0.7-1.5 more contraceptive methods (0.9-2.0 Nepal 2005, 0.1-1.5 Nepal 2016, 0.6-1.7 Senegal 2005, 0.2-1.7 Senegal 2019, 0.1-1.4 Zambia 2001-02, 0.5-1.4 Zambia 2018), and had 10-22 % higher literacy rates (12-32 % Nepal 2001, -7 % to 36 % Nepal 2016, 10-26 % Senegal 2005, -3 to 22 % Senegal 2019, -4 % to 28 % Zambia 2001-02, 5-36 % Zambia 2018).

INTERPRETATION

Children with few or no vaccine doses and their mothers were behind in access to family planning, healthcare, and education compared to fully vaccinated children and their mothers. Such differences can further impede immunizations; integrated education and health services are needed to improve vaccination outcomes.

Inequalities in utilization of maternal health services in Ethiopia: evidence from the PMA Ethiopia longitudinal survey

Background

Previous studies documented the existence of substantial inequalities in the utilization of maternal health services across different population subgroups in Ethiopia. Regularly monitoring the state of inequality could enhance efforts to address health inequality in the utilization of maternal health services. Therefore, this study aimed to measure the level of inequalities in the utilization of maternal health services in Ethiopia.

Method

The study used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) dataset. Longitudinal data was collected from a weighted sample of 1966 postpartum women using multistage stratified cluster sampling techniques between November 2021 to October 2022. We assessed inequality in maternal health services using three indicators: antenatal care four (ANC), skilled birth attendants (SBA), and postnatal care (PNC). Age, economic status, education level, place of residence, and subnational regions were used as dimensions for measuring inequality. The analysis was conducted using Health Equity Assessment Toolkit Plus (HEAT Plus) software. We computed the summary measure of health inequality: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF).

Result

The simple summary measures of inequality difference (D) reported a high level of inequality in the utilization of maternal health services in ANC four, SBA, and PNC across economic, education, residence, and subnational regions. The difference (D) in maternal health service utilization between advantaged and disadvantaged population groups exceeded 20 percentage points in all four dimensions of inequality for the three maternal health indicators. Similarly, the complex summary measures of inequality (PAR and PAF) also showed high levels of inequality in the utilization of ANC four, SBA, and PNC across all four dimensions of inequality. However, there was no age-related inequality in the use of maternal health services.

Conclusion

A high level of socioeconomic and geographic area related inequality was observed in the utilization of ANC four, SBA, and PNC services in Ethiopia. Women from socioeconomically disadvantaged subgroups and women from disadvantaged geographic areas significantly lagged behind in the utilization of maternal health services. Therefore, implementing targeted interventions for the most disadvantaged groups can help to reduce inequality in accessing maternal health services.

Minimum dietary diversity behaviour among children aged 6 to 24 months and their determinants: insights from 31 Sub-Saharan African (SSA) countries

BACKGROUND

Feeding practices during infancy have a significant impact on a child's cognitive development and long-term health outcomes. Dietary diversity guidelines from the WHO and UNICEF recommend a diverse range of foods for children aged below 24 months for their optimal growth and development. However, in sub-Saharan Africa (SSA), little is known about the extent to which dietary diversity behaviour in children aged 6 to 24 months aligns with the recommendations and the factors associated with the differentials in dietary behaviour. This study aimed to fill this gap.

METHODS

This study employed an analytical cross-sectional approach, drawing on recent Demographic and Health Survey (DHS) data from 31 SSA countries. The study included a weighted sample of 44,071 children aged between 6 and 24 months, and their respective mothers aged 15-49 years. The primary outcome was Minimum Dietary Diversity (MDD) categorised per WHO recommendation. Multivariable logistic regression was used to examine the association of MDD with demographic and socio-economic characteristics.

RESULTS

The pooled MDD intake among children aged 6-24 months in SSA was 11% ranging from as low as 1.3% in Burkina Faso to 32.9% in South Africa. Children of mothers aged 45-49 years had 52% significant higher likelihood of MDD compared to those aged 15-19 years (AOR = 1.52, 95% CI:1.03, 2.24). Higher maternal education levels also increased MDD odds in the children: 22% higher for mothers who had attained secondary education (AOR = 1.22, 95% CI:1.07, 1.39), and 36% higher for those with education beyond secondary level (AOR = 1.36, 95% CI:1.09, 1.71) compared to no education. Children of rich mothers had 44% higher odds of MDD than those with poor mothers (AOR = 1.44, 95% CI:1.27, 1.62). Increased antenatal visits, and urban residence also contributed to higher MDD odds.

CONCLUSION

Based on the current global estimate of approximately 28% MDD rate, the reported 11% MDD intake among children in this study is relatively low. There is a positive association between MDD intake in children and several factors, including maternal education, antenatal visits, wealth index, and residency. These findings highlight the need for policymakers and other stakeholders to give urgent attention to empowering parents to ensure adequate nutrient intake among children for better child growth and development.

The role of community-level men's and women's inequitable gender norms on women's empowerment in India: A multilevel analysis using India's National Family Health Survey-5

BACKGROUND

Lower empowerment of women is a critical social issue with adverse public health implications. In India, deeply ingrained gender norms shape a patriarchal structure that creates systemic disadvantages for women relative to men. These gender norms-socially constructed expectations about the roles, behaviors, and attributes of men and women-perpetuate inequality and limit women's opportunities.

OBJECTIVES

The aim of this study was to examine the association between community-level men's and women's gender norms on women's empowerment in India. Women's empowerment was defined using four measures: freedom of movement, decision-making power, economic empowerment, and health empowerment.

METHODS

Using a nationally representative demographic health survey data from 2019-21 of 63,112 married women who participated in the women's empowerment module and 101,839 men surveyed, we constructed community-level men's and women's inequitable gender norms variables as our independent variable using attitudes towards wife-beating questions. We used random effects logistic regression models to examine if community-level men's and women's inequitable gender norms were independently associated with the different dimensions of women's empowerment.

RESULTS

One standard deviation increase in community-level men's and women's inequitable gender norms was associated with reduced odds of freedom of movement, decision-making power, and health empowerment. No statistically significant association was observed between community-level men's and women's gender norms and economic empowerment.

CONCLUSION

Inequitable gender norms are a risk factor that is negatively associated with several dimensions of women's empowerment. Our findings support our hypotheses that women's empowerment is impacted separately by men's and women's gender norms. Our study underscores the pressing need for concerted efforts to challenge and transform inequitable gender norms, paving the way for achieving gender equality and women's empowerment, as envisioned by the Sustainable Development Goals.

Psychometric validation of the Chinese version of the empowerment scale for pregnant women

Empowering pregnant women is a crucial process that healthcare providers should evaluate, as empowerment is a meaningful indicator that can reflect the impact of health promotion and education in antenatal care. The Empowerment Scale for Pregnant Women (ESPW) is a reliable and valid instrument for measuring empowerment. The cross-sectional study was conducted to translate and validate the psychometric properties of the ESPW among 526 pregnant women in China. The forward-backward method was used to translate the English version of the ESPW into the Chinese version. Reliability was examined with the internal consistency and test-retest coefficients. Validity was analyzed with structural, dimensionality, convergent, discriminant, and concurrent validity. The Cronbach's α value of 0.97 and the intraclass correlation coefficient of 0.98 (95% confidence interval [CI], [0.96, 0.99]) demonstrated excellent internal consistency and test-retest reliability. Exploratory factor analysis revealed that five factors with eigenvalues > 1 explained 68.41% of the total variance. Confirmatory factor analysis verified an acceptable model that fit the data exceptionally. The Chinese-translated version of the ESPW (CV-ESPW) had acceptable convergent and discriminant validity. Concurrent validity was supported by the correlation between the total scores of the CV-ESPW and the Chinese version of the Patient Perceptions of the Empowerment Scale (r = 0.64, p < 0.001). The CV-ESPW is a valid and reliable assessment tool for measuring pregnant women's empowerment in China and can potentially contribute to evaluating the effectiveness of programs that empower pregnant women.

Investigating the relationship between health and gender equality: What role do maternal, reproductive, and sexual health services play?

Examining the causal nexus between health services and gender equality is of paramount significance in policy formulation and academic inquiry. This paper concentrates on maternal, sexual, and reproductive health, offering a critical narrative review of empirical research exploring the causal relationship between enhanced women's health, stemming from either overall healthcare amelioration or specific interventions, and broader gender equality objectives. A conceptual framework is devised to elucidate the causal pathways between health and gender equality across various dimensions. The final review encompasses 30 empirical papers, revealing both direct and indirect effects of improved maternal, reproductive, and sexual health outcomes on labour participation and educational investment, with fertility decisions and autonomy serving as primary intermediary factors. Evidence predominantly indicates that interventions like contraception, family planning, and abortion policies yield enduring effects beyond health, influencing reproductive choices. Specific medical procedures, such as caesarean deliveries and sterilization, also impact fertility and labour market outcomes. Furthermore, public healthcare infrastructure contributes to combating gender-based violence by facilitating incident reporting and access to protection. Recognizing, documenting, and monitoring these co-benefits arising from improved women's health are pivotal for delineating future health sector priorities and advancing the global gender equality and sustainable development agenda.

What factors influence women's empowerment in Ethiopia? A multilevel analysis of Ethiopia's demographic and health survey data

Background

Women's empowerment has been a global priority, as countries can achieve significant growth and economic development by empowering women. Understanding the individual and community-level factors that influence women's empowerment is crucial for policymakers to develop effective policies and to improve women's empowerment.

Method

A community-based cross-sectional survey was conducted in 11 administrative regions of Ethiopia. The analysis included a weighted sample of 7,108 married women of reproductive age (15-49 years) from the 2,016 Ethiopian Demographic and Health Survey (EDHS). A multilevel mixed-effect binary logistic regression analysis was used to examine the individual and community-level factors associated with women's empowerment. In the final model, significant variables were identified using a p-value of <0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI).

Results

The overall magnitude of women's empowerment was 23.7% (95% CI: 22.7-24.7). Only 30.9% of women reported participating in household decision-making, and 32.5% disagreed with all the reasons justifying wife-beating. At individual-level, factors positively associated with women's empowerment included secondary (AOR: 2.72 (1.77-4.23), and higher (AOR: 3.65 (1.81-7.34) education. However, belonging to the Muslim religion was negatively associated with women's empowerment (AOR: 0.63 (0.47-0.85). At the community level, wealthy communities were positively associated with women's empowerment (AOR: 1.60 (1.05-2.44). Conversely, residing in rural areas (AOR: 0.49 (0.29-0.83), and living in the Afar (AOR: 0.35 (0.17-0.70), Amhara (AOR: 0.45 (0.26-0.79), Oromia (AOR: 0.43 (0.26-0.73), South Nation Nationalities, and Peoples (SNNP) (AOR: 0.42 (0.24-0.75), and Gambella (AOR: 0.36 (0.20-0.66) regional states were negatively associated with women's empowerment.

Conclusion

The overall magnitude of women's empowerment in this study was low. Factors that positively influenced empowerment included attending secondary and higher education, as well as residing in communities with higher wealth status. On the other hand, being Muslim, residing in rural areas, and living in the Afar, Amhara, Oromia, SNNPR, Gambella, and Tigray regions were negatively associated with women's empowerment. As a result, the government of Ethiopia needs to design community-based women's empowerment strategies and involve women in income-generation activities that improve their participation in household decision-making to empower them.

Impacts of women's work and childcare on child illness among Bangladeshi Shodagor communities

For decades, women's employment has been seen as crucial for achieving greater autonomy and empowerment for women, and for promoting better health and nutrition outcomes for children, particularly in low- and middle-income countries (LMIC). However, numerous empirical studies of the relationship between women's work and child outcomes have shown mixed results. Our study tests the assumptions of a model that suggests loss of maternal care during working hours may produce negative health outcomes for children. We use longitudinal data collected from traditionally semi-nomadic, boat-dwelling Shodagor families in Matlab, Bangladesh to determine the importance of maternal care as a mechanism influencing the relationship between women's work and child illness. We use Bayesian linear mixed models to assess the influence of occupation and amount of care on average days of child illness per month, and also to examine the role that allomothers play in buffering against potential negative impacts of lost maternal care on child illness. Results show that children who receive more care from mothers experience fewer days of illness, and that availability of high-quality alloparents mediates the relationship between maternal work and child health. These results indicate that both the care and resources provided by mothers influence children's biological outcomes. This has important implications for policy and aid interventions in LMIC, which have been developed to capitalize on an assumed positive relationship between maternal work and child health and nutrition.

Adaptation and psychometric assessment of a sexual and reproductive empowerment scale in Arabic among refugee and non-refugee adolescent girls

BACKGROUND

Sexual and reproductive empowerment (SRE) is an important determinant of women's and girls' health yet measuring it is complex due to cultural and domain-specific variations. This study describes the process of adapting an SRE scale consisting of four domains (self-efficacy; future orientation; social support; and safety) and testing its psychometric properties among Arabic speaking adolescent girls in Lebanon.

METHODS

An SRE scale developed in a Western context was adapted in four steps: (1) reviewing the scale and selecting culturally appropriate domains for translation to standard Arabic; (2) conducting cognitive interviews with 30 11-17-year-old adolescent girls in Lebanon; (3) administering the scale to 339 refugee adolescent girls who participated in an early marriage intervention; and (4) conducting confirmatory factor analysis (CFA) on the data to assess the scale's psychometric properties.

RESULTS

The original model for the 13-item, four-domain adapted scale demonstrated poor fit in CFA. After iteratively removing two items, scale properties were improved, albeit were not optimal. The validity and reliability results for the self-efficacy domain were acceptable. Cognitive interview data revealed that Arab adolescent girls understood self-efficacy in relational terms, recognizing that autonomous decision-making is not necessarily favored but is influenced by parents and family.

CONCLUSIONS

This study presents an effort to customize an SRE scale for use in studies on the health of adolescent girls in an Arab cultural context. Findings from cognitive interviews highlight the importance of taking into consideration relationality in adolescent sexual and reproductive decision-making. The self-efficacy domain in the adapted scale demonstrates acceptable psychometric properties and is recommended for use in health studies to capture SRE.

Birth weight mediates the association of maternal undernutrition with child undernutrition prevalence in West Africa

BACKGROUND

Maternal nutritional status before and during pregnancy is an important determinant of foetal health. In West Africa, maternal and child undernutrition remains a major public health problem and it is important to establish the mechanistic pathway linking the two disorders to help address the problem. We therefore assessed the mediating role of low birth weight (LBW) in the relationship of maternal undernutrition with child undernutrition in West Africa.

METHODS

We included recent (2010-2019) DHS data from thirteen West African countries. Poisson regression model with robust standard errors was used to assess the relationship between maternal undernutrition (body mass index and anaemia) and child undernutrition (stunting, wasting, underweight, and anaemia). Structural equation modelling was used to conduct the mediation analysis.

RESULTS

Prevalence of stunting, wasting, underweight, and anaemia among under-five children in West Africa was found to be 32.4%, 8.1%, 20.1%, and 71.5%, respectively. We found children of underweight mothers to be more likely to be undernourished (stunted, wasted, and underweight) and anaemic compared to children of normal-weight mothers. Also, children of anaemic mothers were more likely to be stunted and anaemic but not wasted compared with children of non-anaemic mothers. LBW mediated the observed relationships between maternal BMI and childhood stunting (22.6%), and maternal anaemia and childhood stunting (24.9%), wasting (11.7), and anaemia (6.6%).

CONCLUSION

We found maternal undernutrition to be associated with child undernutrition in West Africa with LBW noted to be a mediator of the observed relationship. We recommend that, to address the child undernutrition problem in West Africa, governments and policymakers must integrate measures to address the burden of LBW.

A Scoping Review of Barriers and Facilitators for Preconception Care: Lessons for Global Health Policies and Programs

Preconception care (PCC) encompasses a set of actions taken before pregnancy to support the health and well-being of women before conception to improve maternal and child health (MCH) outcomes. The utilization of PCC services is influenced by multifaceted factors that can either enable or impede women's capacity to access and utilize them effectively. This scoping review examined the barriers and facilitators influencing the utilization of PCC services among women of reproductive age (15-49 years) at both individual and community levels. Through an extensive review of published articles from 2004 to 2021, including peer-reviewed sources, barriers and facilitators were identified. At the individual level, barriers included limited knowledge about PCC, neglect of self-health, and financial constraints. Community-level barriers encompassed insufficient supply of supplements, restricted access to health care, high health care costs, and setbacks due to delayed delivery of MCH services. Conversely, individuals reported that credible sources of information, such as friends, family, and community health volunteers, facilitated their engagement with PCC services. At the community level, facilitators included government-regulated supply chains for supplements and the involvement of community workers in health monitoring. Understanding and addressing these factors can help improve the utilization of PCC services among women of reproductive age (WRA) and improve MCH outcomes.

Empowerment Among Adolescent Girls in Nepal: A Concept Mapping Exploratory Study

BACKGROUND

The concept of empowerment is challenging to operationalize and measure; it is multidimensional, the outcomes are not always directly observable, and meanings of empowerment are highly contextual and socially and culturally situated. This study aimed to explore perspectives of empowerment among adolescent girls in Nepal to identify statements for inclusion in a context-specific empowerment measure.

METHODS

We used a participatory and mixed method research method called concept mapping in 3 districts in Nepal. Three sequential concept mapping sessions were used to solicit, organize, and process how participants responded to the prompt: "The life of an adolescent girl improves when she has/can…" The Concept Systems Global software was used to manage and analyze the concept mapping brainstorming, sorting, and rating data using established tools, such as multidimensional scaling and cluster analysis.

RESULTS

Concept mapping was conducted with 113 participants, including national experts, program staff, adolescents, and their mothers. They identified 105 items that fall into a 4-cluster solution: education and knowledge, decision-making, supports and skills, and physical infrastructure. Rating data uncovered there was some overlap between the top 10 most important items between the national-level experts and other stakeholder groups; however, several components associated with empowerment differed by stakeholder group in terms of importance.

CONCLUSION

This research represents a critical step in exploring definitions of empowerment among adolescent girls in the Nepal context and with expert input. These results led to the development of a contextually specific definition of empowerment. Researchers and practitioners interested in developing context-specific understandings of complex topics that incorporate community voices and perspectives could use a similar concept mapping approach in other countries to explore various topics with diverse populations.

Maternal dietary diversity increases with women's high decision-making autonomy in Northwest Ethiopia, 2022

Background

Dietary diversification is one of several approaches for improving micronutrient levels in women of reproductive age. Therefore, this study aimed to assess the magnitude of minimum dietary diversity among pregnant women, explore the association between women's decision-making autonomy and dietary diversity, and identify other potential determinants of dietary diversity in Northwest Ethiopia.

Method

A community-based cross-sectional study of 621 pregnant women was conducted from November 2022 to December 2022. A cluster random sampling technique was employed. A binary logistic regression model was used to explore the association between dietary diversity and women's decision-making autonomy. Adjusted odds ratios with 95 % CIs were estimated to identify factors associated with the dietary diversity of pregnant women, and they were considered to be statistically significant at a P-value <0.05.

Results

The minimum dietary diversity among pregnant women was 22.4 %. The study revealed a significant association between dietary diversity and women's decision-making autonomy (AOR: 2.82, 95 % CI: 1.73, 4.59; p value: 0.001). Primary education and above (AOR = 4.0, CI: 2.1, 7.67), monthly income 1000-2000 ETB (AOR = 4.46, CI: 2.53, 7.87) and >2000 ETB (AOR = 6.05, CI: 3.16, 11.59), having nutritional information (AOR = 2.15, CI: 1.32, 3.51), being food secure (AOR = 2.63, CI:1.6, 4.34), morbidity status (AOR: 0.278, CI: 0.14, 0.56), ANC visits one time (AOR = 2.08, CI = 1.003, 4.33) and two or three times (AOR = 2.45, CI: 1.15, 5.24) were potential predictors of pregnant women's dietary diversity.

Conclusion

Maternal dietary diversity was significantly associated with women's decision-making autonomy. Thus, the government should strengthen women's empowerment, rights, access to education, and economic opportunities.

Associations between women's bargaining power and the adoption of rust-resistant wheat varieties in Ethiopia

The dynamics in intra-household decision-making are often neglected in literature on the adoption of agricultural innovations. However, households' farm management decisions are often made following negotiations between female and male farmers. These may differ in terms of individual bargaining power and personal preferences. A better understanding of the links between gender roles in household decision-making and the adoption of technologies is postulated to enhance the uptake of innovations in smallholder farming systems. In this study, we use survey data from 1,088 wheat-producing households in Ethiopia to analyze the links between women's role in household decisions concerning crop production and the adoption and turnover rates of rust-resistant wheat varieties. We interviewed female and male respondents from the same households, but separately, which facilitated capturing individual perceptions and the intra-household dynamics in decision-making. To account for observed heterogeneity that may simultaneously determine the level of women's agency and varietal adoption by households, we employed Inverse Probability-Weighted Regression Adjustment (IPWRA). A positive association was found between women's role in decision-making concerning choice of wheat seed and household adoption of rust-resistant wheat varieties and wheat varietal turnover. Spouses may be in agreement or have different opinions regarding their decision-making roles. The disagreement scenario in which the wife claims to have a role in decision-making is associated with lower adoption rates of rust-resistant wheat varieties and less frequent testing of new varties in recent growing seasons, compared to a scenario where both spouses agree that wives do not have a role. We conclude that gender-disaggregated data and the examination of intra-household decision-making can offer novel and valuable insights for designing and implementing strategies to enhance the uptake of agricultural technologies among smallholders. The results emphasize the need to include complementary perspectives on the intra-household decision-making process.

Women's empowerment and child anthropometric failures across 28 sub-Saharan African countries: A cross-level interaction by Gender Inequality Index

Background

Child undernutrition remains a major global health issue, particularly in sub-Saharan Africa (SSA). Given the important role mothers play in early childhood health and development, we examined how individual-level women's empowerment and country-level Gender Inequality Index (GII) are jointly related with child undernutrition in SSA.

Methods

We pooled recent Demographic and Health Surveys from 28 SSA countries. For 137,699 children <5 years old, undernutrition was defined using anthropometric failures (stunting, underweight, wasting). Women's empowerment was assessed using three domains of Survey-based Women's EmPowERment (SWPER) index: attitude to violence, social independence, and decision-making; and country-level gender inequality was measured using GII from United Nations Development Programme. Three-level logistic regression was conducted to examine the joint associations of SWPER and GII as well as their interactions with child anthropometric failures, after adjusting for sociodemographic covariates.

Results

Overall, 32.85% of children were stunted, 17.63% were underweight, and 6.68% had wasting. Children of mothers with low-level of empowerment for all domains of SWPER had higher odds of stunting (attitude to violence: OR=1.15; 95% CI, 1.11-1.19; social independence: OR=1.21; 95% CI, 1.17-1.25; decision-making: OR=1.16; 95% CI, 1.12-1.20), and consistent results were found for underweight and wasting. Independent of women's empowerment, country-level GII increased the probability of underweight (ranging ORs=1.46; 95% CI, 1.15-1.85 to 1.50; 95% CI, 1.18-1.90) and wasting (ranging ORs=1.56; 95% CI, 1.24-1.97 to 1.61; 95% CI, 1.27-2.03). Significant interaction was found between women's empowerment and country-level GII for stunting and underweight (p<0.05).

Conclusions

In SSA countries with greater gender inequality, improving women's social independence and decision-making power in particular can reduce their children's risk of anthropometric failures. Policies and interventions targeted at strengthening women's empowerment should consider the degree of gender inequality in each country.

Health consequences of structural sexism: Conceptual foundations, empirical evidence and priorities for future research

A nascent body of work has begun exploring the health consequences of structural sexism. This article provides an overview of the concept of structural sexism and an elaboration of the potential pathways connecting it to health. Next, it reviews existing measurement approaches and the current state of empirical evidence on the relationship between structural sexism and health in the United States. Finally, it highlights key priorities for future research, which include: expanding and refining measures, increasing public data availability, broadening the scope of inquiry to include a wider range of outcomes, exploring mechanisms, incorporating intersectionality, and applying a life course lens.

Women's health and rights in the twenty-first century

In the twenty-first century, the complex relationship between women's health and rights has been influenced by a range of interconnected challenges, including gender inequity, reproductive health disparities, maternal mortality and morbidity, and women's inability to access life-saving, high-quality healthcare services including family planning. Going forward, the world needs to find ways to implement the unfinished agenda of the International Conference on Population and Development (ICPD) 1994 and the Sustainable Development Goals (SDGs), thus prioritizing health and rights for women and girls as essential not only to their survival but also to their progress, agency and empowerment. It is also important to consider the interconnection between women's health and rights and climate change, with its disproportionate impact on the well-being of girls and women, and to address the impact and opportunities afforded by digital technologies. By embracing a holistic approach, societies might be able to advance the cause of women's health and rights in a more inclusive and sustainable manner.

The EMERGE framework to measure empowerment for health and development

RATIONALE

Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed.

OBJECTIVE

We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development.

METHOD

We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures.

RESULTS

Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights.

CONCLUSION

The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

Women's involvement in decision-making and association with reproductive health behaviors: findings from a cross-sectional survey in Niger

BACKGROUND

Though women in Niger are largely responsible for the familial health and caretaking, prior research shows limited female autonomy in healthcare decisions. This study extends current understanding of women's participation in decision-making and its influence on reproductive health behaviors.

METHODS

Cross-sectional survey with married women (15-49 years, N = 2,672) in Maradi and Zinder Niger assessed women's participation in household decision-making in health and non-health issues. Analyses examined [1] if participation in household decision-making was associated with modern contraceptive use, antenatal care (ANC) attendance, and skilled birth attendance at last delivery and [2] what individual, interpersonal, and community-level factors were associated with women's participation in decision-making.

RESULTS

Only 16% of the respondents were involved-either autonomously or jointly with their spouse-in all three types of household decisions: (1) large purchase, (2) visiting family/parents, and (3) decisions about own healthcare. Involvement in decision making was significantly associated with increased odds of current modern contraceptive use [aOR:1.36 (95% CI: 1.06-1.75)] and four or more ANC visits during their recent pregnancy [aOR:1.34 (95% CI: 1.00-1.79)], when adjusting for socio-demographic characteristics. There was no significant association between involvement in decision-making and skilled birth attendance at recent delivery. Odds of involvement in decision-making was significantly associated with increasing age and household wealth status, listening to radio, and involvement in decision-making about their own marriage.

CONCLUSION

Women's engagement in decision-making positively influences their reproductive health. Social and behavior change strategies to shift social norms and increase opportunities for women's involvement in household decision making are needed. For example, radio programs can be used to inform specific target groups on how women's decision-making can positively influence reproductive health while also providing specific actions to achieve change. Opportunities exist to enhance women's voice either before women enter marital partnerships or after (for instance, using health and social programming).

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis

BACKGROUND

Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu.

METHODS

Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation.

RESULTS

The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones.

CONCLUSIONS

MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

Continuum of care in maternal and child health in Indonesia

AIM

This paper aims to empirically analyze the socioeconomic and demographic correlates of maternal and child health (MCH) care utilization in Indonesia using the continuum of care (CoC) concept.

BACKGROUND

The concept of CoC has emerged as an important guiding principle in reproductive, maternal, newborn, and child health. Indonesia's maternal mortality rate, neonatal mortality, and under-five mortality rates are among the highest in the Southeast Asian region.

METHODS

Using pooled data from four successive waves of the nationally representative Indonesian Demographic and Health Survey (IDHS) conducted in the years 2002, 2007, 2012, and 2017, we use multivariate regression models to analyze care across four components of the continuum: antenatal care (ANC), institutional delivery, postnatal care for children, and full immunization (IM).

FINDINGS

CoC at each stage of MCH care has improved continuously over the period 2002-2017 in Indonesia. Despite this, just less than one out of two children receive all four components of the CoC. The overall coverage of CoC from its second stage (four or more ANC visits) to the final stage (full child IM) is driven by the dropouts at the ANC visit stage, followed by the loss of postnatal checkups and child IM. We find that the probability of a child receiving CoC at each of the four stages is significantly associated with maternal age and education, the household's socioeconomic and demographic characteristics, and economic status.

CONCLUSION

Complete CoC with improved, affordable, and accessible MCH care services has the potential to accelerate the progress of Sustainable Development Goal 3 by reducing maternal and childhood mortality risks. Our findings show that in Indonesia, the CoC continuously declines as women proceed from ANC to other MCH services, with a sharp decline observed after four ANC visits. Our study has identified key socioeconomic characteristics of women and children that increase their probability of failing to access care.

Intrahousehold empowerment gaps and dietary diversity in China

Objective

This article analyzes the relationship between intrahousehold empowerment gaps and food and nutrition security using quantitative data collected through a household survey organized by the Agricultural Information Institute, Chinese Academy of Agricultural Sciences (CAAS-AII), in 2023.

Methods

Based on empowerment theory, this study measured the relative empowerment of spouses from the Abbreviated Women's Empowerment in Agriculture Index (A-WEAI).

Results

From the micro-level evidence of 468 rural households, this study found that intrahousehold empowerment gaps harm the diversity of household diets. In particular, reducing gender gaps in access to resources, leadership, and income can help diversify household diets. However, data on the impact of shortening the difference in working hours between wives and husbands for the benefit of food safety are yet to be conclusive. Additionally, gender gaps in the group of non-coresident mothers-in-law and non-migrants hurt household food security.

Conclusion

The paper also provides further justification for policies and interventions that aim to improve women's bargaining position in the household.

Diarrheal disease and associated factors among children aged 6 to 59 months in Oda Bultum District, Eastern Ethiopia: a community-based cross-sectional study

BACKGROUND

Diarrhea is a serious health problem in children under the age of five that is both preventable and treatable. In low-income countries like Ethiopia, children under the age five years frequently experience diarrhea. However, the burden and associated factors of these diarrheal diseases are understudied in Eastern Ethiopia, Thus, this study aimed to determine the factors associated with the prevalence of diarrheal diseases in Eastern Ethiopia from September 1-30, 2022.

METHODS

A cross-sectional study was conducted on the total of 602 children aged 6 to 59 months in Oda Bultum district in eastern Ethiopia. A multistage sampling method was used. Three kebeles were selected from nine kebeles by the lottery method. Data was entered into Epi data 4.0.2 and exported to SPSS version 21 for analysis. Descriptive analysis was used for frequency, mean, and standard deviations. In addition, bivariable, and multivariable Poisson regression model was used to identify predictors of diarrhea along with a 95% confidence interval. Finally, statistical significance was declared at a p-value of 0.05.

RESULT

A total of 602 children were included in this study. The prevalence of diarrhea 7.4% (47/602), 95% CI; 5.5-9.7%) among the children. Factors such as being unvaccinated for any vaccine (AOR = 10.82, 95%CI; 4.58-25.48) and born from a mother who had medium level of empowerment (AOR = 0.34, 95%CI; 0.11-0.88) in the household had statistically significant association with diarrhea among the children compared to their counterparts.

CONCLUSION

The study found that nearly one out of thirteen children aged 6 to 59 months had any form of diarrheal diseases in Oda Bultum District, Eastern Ethiopia. In addition, the study revealed that children who were vaccinated for their age developed diarrhea less likely compared to those who did not receive any form of vaccine for their age. Moreover, children with mothers who had a medium level of empowerment were less likely to get diarrhea than children with mothers who had a low level of empowerment.

Barriers to healthcare utilization among married women in Afghanistan: the role of asset ownership and women's autonomy

Women face multiple socio-economic, cultural, contextual, and perceived barriers in health service utilization. Moreover, poor autonomy and financial constraints act as crucial factors to their healthcare accessibility. Therefore, the objective of the present study is to study the association between health care utilization barriers and women empowerment, including asset ownership among currently married women in Afghanistan. Data of 28,661 currently married women from Afghanistan demographic health survey (2015) was used to carry out this study. Barriers to access healthcare were computed based on problems related to permission, money, distance, and companionship, whereas women empowerment and asset ownership were computed as potential covariates along with other socio-economic risk factors. Bivariate and logistic analysis was carried out to study the association and odds of explanatory variables. Our results confirm the significant and strong association between the barriers to access healthcare and various explanatory variables. Women having any decision-making autonomy are less likely to face any odds [(AOR = 0.56, p < 0.001), CI: 0.51-0.61] among the currently married women than those who don't have any decision-making authority. Similarly, women who justify their beating for some specific reasons face the greater difficulty of accessing health care [(AOR = 1.76, p < 0.001), CI: 1.61-1.93]. In terms of asset ownership, women having any asset ownership (land or household) are less likely to face any barriers in health services utilization given the lower odds [(AOR = 0.91, p < 0.001), CI: 0.90-0.98]. Accessing maternal health is a crucial policy challenge in Afghanistan. A substantial proportion of women face barriers related to approval, money, distance, and companionship while accessing the health services utilization in Afghanistan. Similarly, women empowerment and asset ownership are significantly associated with health service accessibility. This paper therefore suggests for some policy interventions to strengthen the healthcare needs of women and ensure healthcare accessibility by scaling down these potential barriers like poor autonomy, asset ownership and domestic violence.

Engaging men in women's empowerment: impact of a complex gender transformative intervention on household socio-economic and health outcomes in the eastern democratic republic of the Congo using a longitudinal survey

BACKGROUND

In the Democratic Republic of the Congo, women in (peri-)urban areas are commonly engaged in small trade, which allows them to meet the basic needs of their families. Microsaving approaches are a low-risk option to obtain financing for economic activities. A project combining men's sensitization on gender equity and women's empowerment through village savings and loan associations were implemented in North and South Kivu to raise the household economic level.

OBJECTIVE

This study assessed how involving men in gender equity affects women's health and socio-economic outcomes, including food security.

METHODS

A cohort study was conducted with 1812 women at the baseline; out of them 1055 were retrieved at the follow-up. Baseline data collection took place from May to December 2017 and the follow-up from July 2018 to January 2019. To identify socio-economic changes and changes of gender relations, linear and logistic regressions were run.

RESULTS

Results showed that the household income improved with intervention (coefficient = 0.327; p = 0.002), while the capacity to pay high bills without contracting debts decreased (coefficient = 0.927; p = 0.001). We did not find enough statistically significant evidence of the influence of the intervention on skilled birth attendance (coefficient = 0.943; p = 0.135), or family planning use (coefficient = 0.216; p = 0.435) nor women's participation in the decision-making (coefficient = 0.033; p = 0.227) nor on couple's cohesion (coefficient = 0.024; p = 0.431). Food insecurity levels decreased over time regardless of being in the intervention or control area.

CONCLUSION

Empowering women while sensitizing men on gender aspects improves financial well-being (income). Time, security, and strong politics of government recognizing and framing the approach are still needed to maximize the benefit of such projects on social factors such as women's participation in decision-making and social cohesion.

At the Heart of Resilience: Empowering Women's Agency in Navigating Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death among women globally, emphasizing the need for a healthcare approach that empowers women through agency. This review focuses on the critical role of women's agency in navigating CVD, integrating insights from various fields, including medicine, education, psychology, and sociology. The review highlights the shift toward patient-centred care, a framework in which women are recognized as key decision-makers, a crucial change given the historical underemphasis on women's health issues in medical practice. The diagnosis of CVD in women often involves emotional and psychological challenges. Unexpected diagnoses significantly disrupt perceived well-being, and prolonged diagnostic processes lead to professional skepticism and neglect of symptoms, resulting in delayed or inaccurate diagnoses and strained healthcare relationships. Effective management of CVD necessitates continuous self-management and a holistic approach to care, particularly for those with trauma who are at increased risk of cardiac incidents. Empowerment for women with CVD involves promoting self-confidence, autonomy, and active patient participation in healthcare. Implementing comprehensive care models is crucial for improving chronic CVD management, highlighting the need for healthcare systems that prioritize patient agency and empowerment. From the perspective of a woman with lived experience, this article examines the impact of CVD on women's agency throughout the diagnostic journey. By highlighting women's agency rather than particular behavioural changes, this review offers a comprehensive analysis that can shape policy, stimulate new research, and foster a more equitable, efficient, and empathetic healthcare system for women with CVD.

Measuring the intangible resources caregivers need to provide nurturing care during the complementary feeding period: a scoping review in low- and lower-middle-income countries

OBJECTIVE

Caregivers require tangible (e.g. food and financial) and intangible resources to provide care to ensure child health, nutrition and development. Intangible resources include beliefs and knowledge, education, self-efficacy, perceived physical health, mental health, healthy stress levels, social support, empowerment, equitable gender attitudes, safety and security and time sufficiency. These intangible caregiver resources are included as intermediate outcomes in nutrition conceptual frameworks yet are rarely measured as part of maternal and child nutrition research or evaluations. To facilitate their measurement, this scoping review focused on understudied caregiver resources that have been measured during the complementary feeding period in low- and lower-middle-income countries.

DESIGN

We screened 9,232 abstracts, reviewed 277 full-text articles and included 163 articles that measured caregiver resources related to complementary feeding or the nutritional status of children 6 months to 2 years of age.

RESULTS

We identified measures of each caregiver resource, though the number of measures and quality of descriptions varied widely. Most articles (77 %) measured only one caregiver resource, mental health (n 83) and social support (n 54) most frequently. Psychometric properties were often reported for mental health measures, but less commonly for other constructs. Few studies reported adapting measures for specific contexts. Existing measures for mental health, equitable gender attitudes, safety and security and time sufficiency were commonly used; other constructs lacked standardised measures.

CONCLUSIONS

Measurement of caregiver resources during the complementary feeding period is limited. Measuring caregiver resources is essential for prioritising caregivers and understanding how resources influence child care, feeding and nutrition.

Gender inequality and utilization of ART: an international cross-sectional and longitudinal analysis

STUDY QUESTION

What is the association between a country's level of gender equality and access to ART, as measured through ART utilization?

SUMMARY ANSWER

ART utilization is associated with a country's level of gender equality even after controlling for the level of development.

WHAT IS KNOWN ALREADY

Although gender equality is recognized as an important determinant of population health, its association with fertility care, a highly gendered condition, has not been explored.

STUDY DESIGN, SIZE, DURATION

A longitudinal cross-national analysis of ART utilization in 69 countries during 2002-2014 was carried out.

PARTICPANTS/MATERIALS, SETTING, METHODS

The Gender Inequality Index (GII), Human Development Index (HDI), and their component indicators were modelled against ART utilization using univariate regression models as well as mixed-effects regression methods (adjusted for country, time, and economic/human development) with multiple imputation to account for missing data.

MAIN RESULTS AND THE ROLE OF CHANCE

ART utilization is associated with the GII. In an HDI-adjusted analysis, a one standard deviation decrease in the GII (towards greater equality) is associated with a 59% increase in ART utilization. Gross national income per capita, the maternal mortality ratio, and female parliamentary representation were the index components most predictive of ART utilization.

LIMITATIONS, REASONS FOR CAUTION

Only ART was used rather than all infertility treatments (including less costly and non-invasive treatments such as ovulation induction). This was a country-level analysis and the results cannot be generalized to smaller groups. Not all modelled variables were available for each country across 2002-2014.

WIDER IMPLICATIONS OF THE FINDINGS

Access to fertility care is central to women's sexual and reproductive health, to women's rights, and to human rights. As gender equality improves, so does access to ART. This relation is likely to be reinforcing and bi-directional, with progress towards global, equitable access to fertility care also improving women's status and participation in societies.

STUDY FUNDING/COMPETING INTEREST(S)

External funding was not provided for this study. G.D.A. declares consulting fees from Labcorp and CooperSurgical. G.D.A. is the founder and CEO of Advanced Reproductive Care, Inc., as well as the Chair of the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) and the World Endometriosis Research Foundation, both of which are unpaid roles. G.M.C. is an ICMART Board Representative, which is an unpaid role, and no payments are received from ICMART to UNSW, Sydney, or to G.M.C. to undertake this study. O.F., S.D., F.Z.-H., and E.K. report no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Determinants of unmet need for family planning: Evidence from the 2018 Turkey Demographic and Health Survey

Unmet need for family planning is a valuable concept to indicate the discrepancy between women's fertility preferences and contraceptive use. Unmet need may lead to unintended pregnancies and unsafe abortions. These may result in health deterioration and reduced employment opportunities for women. The 2018 Turkey Demographic and Health Survey report indicated that the estimated unmet need for family planning doubled from 2013 to 2018, returning to the high levels of the late 1990s. Considering this unfavourable change, this study aims to investigate the determinants of unmet need for family planning among married women of reproductive age in Turkey by using the 2018 Turkey Demographic and Health Survey data. Logit model estimations revealed that women who were at older ages, more educated, wealthier, and had more than one child were less likely to have unmet need for family planning. Employment statuses of women and their spouses and place of residence were significantly associated with unmet need. Results emphasised that training and counselling to enhance the use of family planning methods should effectively target young, less educated, and poor women.

Effectiveness of nutrition counseling for pregnant women in low- and middle-income countries to improve maternal and infant behavioral, nutritional, and health outcomes: A systematic review

Background

Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s.

Objectives

We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes.

Search Methods

We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search.

Selection Criteria

We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs.

Data Collection and Analysis

Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately.

Main Results

Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment).

Authors’ Conclusions

Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Magnitude and trends in inequalities in healthcare-seeking behavior for pneumonia and mortality rate among under-five children in Bangladesh: Evidence from nationwide cross-sectional survey 2007 to 2017

Background and Aims

Bangladesh did not have enough evidence on the current estimates and trend in inequities in the under-five mortality rate (U5MR). There is also a shortage of evidence on trends and inequalities in healthcare-seeking for pneumonia among under-five children (U5C) in Bangladesh. Hence, this study investigated the inequalities in U5MR and health care seeking for pneumonia in U5C through socioeconomic and geographic disparities in Bangladesh between 2007 and 2017.

Methods

Data from 2007, 2011, 2014, and 2017 Bangladesh Demographic and Health surveys were analyzed using the Health Equity Assessment Toolkit (HEAT) software by World Health Organization (WHO). The data on U5MR and healthcare-seeking for pneumonia were first disaggregated into five equity dimensions: wealth status, education, child sex, place of residence, and administrative divisions. Second, using summary metrics such as difference (D), population attributable risk (PAR), ratio (R), and population attributable fraction (PAF), inequalities were assessed.

Results

The U5MR declined from 73.9 deaths per 1000 live births in 2007 to 48.6 deaths in 2017, while the prevalence of healthcare-seeking for pneumonia in U5C fluctuated over time (34.6% in 2007, 35.4% in 2011, 42.0% in 2014, and 39.8% in 2017). Profound socioeconomic and geographic disparities in U5MR and the prevalence of healthcare-seeking for pneumonia in U5C favored the wealthy, educated, and urban residents. At the same time, the Sylhet division showed the worst situation for U5MR. There were also sex-related disparities in U5MR (PAR = -4.5, 95% confidence interval: -5.3 to -3.7) with higher risk among male children than females.

Conclusion

These results indicate that improving disadvantaged women, such as the poor, uneducated, and rural inhabitants, who exhibit disproportionate disparities in U5MR and healthcare-seeking behavior is important. To reduce childhood mortality, it is essential to improve healthcare-seeking for pneumonia among U5C. Facilitating women for better education and economic encompasses would help reducing disparity.

Diagnosing norms and norm change in rural Bangladesh: an exploration of gendered social norms and women's empowerment

BACKGROUND

Gender-transformative public health programs often aim to address power inequities between men and women and promote women's empowerment. However, to achieve transformative change, it is necessary to first identify the underlying norms that perpetuate these power imbalances. The objective of our study was to use Bicchieri's theory of social norms and model of norm change to identify gendered norms and evidence of norm change amongst participants of the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) trial in rural Sylhet Division, Bangladesh.

METHODS

We conducted ten life history interviews, 16 key informant interviews, and four focus group discussions with women and men in communities within the FAARM study site in rural, north-eastern Bangladesh. We performed a thematic analysis as well as a relational analysis of the data.

RESULTS

We found that social norms dictated the extent and ways in which women participated in household decisions, the locations they could visit, and their autonomy to use household resources. We also found evidence of changes to gendered social norms over time and the desire amongst some men and women to abandon restrictive norms. Certain intersecting factors, such as education and employment, were identified as facilitators and barriers to women's empowerment and the related gendered expectations.

CONCLUSIONS

Our findings corroborate existing norms literature, which highlights the strong role social norms play in influencing women's empowerment and behaviour. Our study provides an example of rigorous qualitative methodology that others may follow to assess gendered social norms that can be targeted for transformative change.

Long-run intergenerational health benefits of women empowerment: Evidence from suffrage movements in the US

An ongoing body of research documents that women empowerment is associated with improved outcomes for children. However, little is known about the long-run effects on health outcomes. This paper adds to this literature and studies the association between maternal exposure to suffrage reforms and children's old-age longevity. We utilize changes in suffrage laws across US states and over time as a source of incentivizing maternal investment in children's health and education. Using the universe of death records in the US over the years 1979-2020 and implementing a difference-in-difference econometric framework, we find that cohorts exposed to suffrage throughout their childhood live 0.6 years longer than unexposed cohorts. Furthermore, we show that these effects are not driven by preexisting trends in longevity, endogenous migration, selective fertility, and changes in the demographic composition of the sample. Additional analysis reveals that improvements in education and income are candidate mechanisms. Moreover, we find substantial improvements in early-adulthood socioeconomic standing, height, and height-for-age outcomes due to childhood exposure to suffrage movements. A series of state-level analyses suggest reductions in infant and child mortality following suffrage law change. We also find evidence that counties in states that passed the law experienced new openings of County Health Departments and increases in physicians per capita.

Peer support interventions in maternal and child healthcare delivery in sub-Saharan Africa: protocol for a realist review

BACKGROUND

Peer support has been proposed as a promising policy intervention for addressing adverse maternal and child healthcare (MCH) outcomes in sub-Saharan Africa (SSA). Existing reviews on peer support largely draw on evidence from high-income countries or focus on single services like breastfeeding, nutrition or postnatal care. In contrast, this review aims to provide a comprehensive overview of the empirical literature on peer support interventions across various MCH services in sub-Saharan Africa. Specifically, we aim to understand how, why, for whom, and in what circumstances different forms of MCH peer support interventions contribute to improving healthcare outcomes in sub-Saharan Africa.

METHODS

This review follows five iterative steps for undertaking realist reviews (1) defining the review scope; (2) developing initial programme theories; (3) searching for evidence; (4) selecting and appraising evidence; and (5) extracting, analysing and synthesising evidence. Four databases-Cochrane Library, PubMed, CINAHL, and EMBASE-were repeatedly searched between March and June 2021. From a large volume of records retrieved from the database and citation search, 61 papers have been selected for review. We will conduct a second search of the same database covering June 2021 to the present before the final extraction and synthesis. The final list of selected papers will be imported into NVivo 12 software and organised, extracted, analysed and synthesised iteratively to examine and illustrate the causal links between contexts, mechanisms and outcomes of MCH peer support interventions in SSA. We have drawn on the existing literature on peer support in healthcare generally to develop initial programme theories. We will then use the empirical literature on MCH peer support interventions in SSA, inputs from a stakeholders' workshop in Ghana and a conference presentation to refine the initial programme theory.

DISCUSSION

The review will develop an explicit theory of peer support intervention in healthcare delivery and provide insights for developing evidence-informed policy on the intervention. Drawing lessons from the different national contexts and diverse areas of MCH in SSA, the review will provide an analytically generalizable programme theory that can guide intervention design and implementation. While focusing on MCH peer support interventions in SSA, the review contributes to evolving conversations on the use of theory for health policy planning and complex intervention design and implementation globally.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42023427751 .

Women's Sexual Empowerment and Its Relationship to Contraceptive Use in Bangladesh: Findings From a Recent National Survey

Objectives: This study aimed to assess the relationship between women's sexual empowerment and contraceptive use among married Bangladeshi women from a nationally representative sample. Methods: Secondary data analysis was conducted using the Bangladesh Demographic and Health Survey (BDHS) 2017-18. The investigation covered a total of 14,515 married, non-pregnant women who were residing with their spouses. Multivariable logistic regression analysis was fitted to assess the relationship between the variables of interest. Results: A unit increase in the sexual empowerment scale increases the odds of contraceptive use by 13%. While increasing age, being Muslim, having a spouse who is older by more than 10 years, and living in rural areas are associated with lower odds of using contraceptives than their respective counterparts, secondary or higher levels of education, having more living children, exposure to TV or radio, and employment are associated with higher odds of using contraceptives. Conclusion: The study's findings point to the need for addressing women's perceptions of their right to sexual and reproductive health and equity in order to further efforts to achieve universal access to reproductive health services.

Role of marriage, motherhood, son preference on adolescent girls' and young women's empowerment: Evidence from a panel study in India

BACKGROUND

Marriage is a key determinant of health and well-being of adolescent girls and young women (AGYW) in India. It is a key life event in which girls move to their marital households, often co-residing with their in-laws and begin childbearing. The change in the normative environment in conjunction with cultural norms surrounding son preference influences women's overall life course. However, there is scant research about the association between these life transitions and changes in empowerment among AGYW in India.

METHODS

Using two waves of data from prospective cohort panel dataset that followed unmarried (6,065 observations in each wave) and married AGYW (3,941 observations from each wave) over a three-year period from Uttar Pradesh and Bihar, we examined how marriage, childbearing, and having a son is associated with changes in AGYW's empowerment, especially considering whether AGYW marry into patrilocal households (household with in-laws) as an effect modifier. Empowerment indicators included freedom of movement or mobility, decision-making power, access to economic using Kabeer's framework as our theoretical approach.

RESULTS

Marriage was associated with lower freedom of movement with a pronounced effect on those who co-resided with their in-laws. Marriage was associated with greater decision-making power for AGYW who did not co-reside with the in-laws. Motherhood was positively correlated with greater freedom of movement, marginally higher intrahousehold decision-making power, and better access to economic resources. No statistically significant evidence that having at least one son compared to having daughters only (or no daughters) conferred additional changes in girls' freedom of movement, intrahousehold decision-making power, and access to economic resources.

CONCLUSION

Findings highlight the importance of understanding the vulnerabilities of being newly married in adolescence and emphasize the need for having interventions that target newly married AGYW along with mothers-in-law to empower them.

Women's Autonomy and Anemia in Children under Five Years of Age: A Peruvian Population-Based Survey

To determine the association between women's autonomy and the presence of childhood anemia in children under five years of age in Peru, a cross-sectional study utilizing data from the 2019 Demographic and Family Health Survey was carried out. The study employed generalized linear models with a Poisson distribution and log link function. Crude and adjusted prevalence ratios (aPR) were calculated, along with their corresponding 95% confidence intervals (CI), to assess the association of interest. A total of 15,815 women and their children under five years of age were analyzed. The prevalence of childhood anemia was 30.4% (95%CI: 29.5-31.3%), while the proportions of low, moderate and high autonomy of the mothers were 44.5%, 38.4% and 17.1%, respectively. Children under five years of age of women with a low level of autonomy were more likely to have anemia (aPR: 1.10; 95%CI: 1.00-1.21). Three out of ten children under five years of age suffer from anemia, and four out of ten mothers have a low level of autonomy. A low level of women's autonomy was associated with a higher probability of anemia in children under 5 years of age.

Fathers' experiences of childcare and feeding: A photo-elicitation study in a low resource setting in urban Addis Ababa, Ethiopia

Children's health and wellbeing studies focus mainly on mothers' roles while very little is known about the experiences/challenges that fathers face in fulfilling their responsibilities. Therefore, this study aims to explore the fathers' lived experiences of childcare and feeding in an urban low-income setting. This qualitative study was conducted in Addis Ababa, Ethiopia. Photo-elicitation was used to facilitate the in-depth interviews with fathers of children below the age of five years. All interviews were audio-recorded, transcribed and translated verbatim, followed by a thematic analysis approach. The overarching theme of this study was "Fatherhood as an enduring identity", which comprised of three sub-themes: 1) Blessings of fatherhood, 2) Adjusting to fathering roles, and 3) Struggles/demands of fatherhood in a low-resource setting. Fathers expressed that having children or becoming parents was a blessing. They expressed their love, devotion, and attachment to their children. Some used the term "my second chance in life" underscoring the importance. Although fathers strived relentlessly to spend time and care for their children, they faced challenges such as internal struggles adjusting to and fatherhood whilst maintaining a sense of their former self. As well, providing for their families amidst added pressures imposed by the external environment, such as poor housing conditions, a lack of employment opportunities, the then COVID-19 pandemic, further increased their stressors. Most fathers were engaged in child care and feeding, suggesting that like mothers, fathers should be viewed as potential agents for implementing nutrition interventions in this setting. However, if interventions are to be successful, they need to incorporate components that boost fathers' livelihoods and general wellbeing.