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

Women's empowerment and child nutrition in a context of shifting livelihoods in Eastern Oromia, Ethiopia

Agriculture, and particularly livestock and animal source foods, has been closely linked to improvements in human nutrition. Production, income, and women's empowerment improve household food security and child nutritional outcomes in interacting ways. Khat production in Eastern Ethiopia is changing the economic and livelihood landscape for communities that have traditionally relied upon small-scale mixed agriculture and livestock production. How this shifting livelihood landscape and the empowerment of women in these communities are affecting nutritional outcomes has not been investigated. Using cross-sectional data collected during formative research for the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) project, we developed models to examine the roles of livelihood activities, including livestock production, staple crop production, and khat production, and women's empowerment in child nutrition outcomes. Survey participants were randomly selected mothers of children aged 10-15 months from Haramaya district, Eastern Hararghe, Oromia, Ethiopia. Nested logistic regression models were performed for each nutrition outcome: children's animal source food consumption, children's dietary diversity, and child stunting, wasting, and underweight. Explanatory variables included those for livelihood (tropical livestock unit, crop production, and khat production ladder) and women's empowerment (as indicated by domains of the Women's Empowerment in Agriculture Index), and covariates including child sex, mother's age, mother's education, assets, income, and kebele. Results indicated that khat production and tropical livestock units were not significantly associated with any of the child nutrition outcomes. However, results did indicate that the odds of reporting child animal source food consumption in households where the mother was empowered in the leadership domain was 3.33 times that in households where the mother wasn't (p < 0.05). In addition, the odds of having a stunted child in households where the mother was empowered in the time domain was 2.68 times that in households where the mother wasn't (p < 0.05). The results from this study both support and complicate the existing literature on the associations between women's empowerment in agriculture and child nutrition outcomes, underscoring the important role that livelihood, contextual factors, and location may have on the complex relationship between empowerment domains and nutritional outcomes.

Women's empowerment and contraceptive use: Recent evidence from ASEAN countries

BACKGROUND

A fundamental element of gender equity are women's rights to reproductive choice. Women's empowerment is often linked to enabling decisions around contraceptive use and reduced fertility worldwide, although limited evidence is currently available around contraceptive use and decision making in ASEAN countries.

OBJECTIVE

To examine the association between women's empowerment and contraceptive use in five selected ASEAN member states.

METHODS

Data from the latest Demographic and Health Survey of Cambodia, Indonesia, Myanmar, The Philippines, and Timor-Leste were used. The main outcome was contraceptive use among married women (15-49 years) from these five countries. We considered four indicators of empowerment: labor force participation; disagreement with reasons for wife beating; decision-making power over household issues; and knowledge level.

RESULTS

Labor force participation was found to be significantly associated with contraceptive use in all nations. Disagreement with justification of wife beating was not significantly related to contraceptive use in any country. Decision-making power (higher) was only associated with contraceptive use in Cambodia, while higher knowledge levels were associated with contraceptive use in Cambodia, and Myanmar.

CONCLUSION

This study suggests women's labor force participation is an important determinant of contraceptive use. Policies designed to open the labor market and empower women through education should be implemented to enable women's participation. Gender inequality may also be tackled by engaging women in decision-making processes at national, community and family levels.

Expanding the Role of Women in Vector Control: Case Studies From Madagascar, Rwanda, and Zambia

BACKGROUND

Historically, vector control, including entomological monitoring, has been a field dominated by men. Each year, the U.S. President's Malaria Initiative (PMI) VectorLink project hires 50,000 to 70,000 seasonal workers across the countries in which it works to implement vector control activities, creating an economic opportunity for both men and women. Remaining barriers to women's employment in vector control include social and cultural norms regarding acceptability of formal employment for women, perceptions that women are not fit to serve as spray operators, and a historical context of male-dominated fields such as entomology.

METHODS

We use PMI VectorLink project data from Madagascar, Rwanda, and Zambia for 2019-2021 and key informant interviews with project staff in these countries to examine levels of female employment, effectiveness and efficiency of female versus male malaria spray operators, and strategies to expand the role of women in vector control.

RESULTS

The percentage of female seasonal employees ranges from 25% in Madagascar to 32% in Rwanda and 45% in Zambia. The percentage of women in leadership positions ranges from 32% in Madagascar and Rwanda to 38% in Zambia. Men and women are equally effective and efficient as spray operators. Best practices for recruiting and retaining women in vector control include engaging community leaders in recruitment, implementing affirmative action hiring policies, mentoring women to progress to leadership positions, and ensuring equitable, safe, and attractive workplaces.

DISCUSSION

As vector control programs transition away from donor funding and are increasingly government led, sustaining gains in female empowerment is critical. Country programs should work closely with national, regional, district, and local leaders to demonstrate the importance of hiring women in vector control-including leadership positions-and the impact on female economic empowerment, community well-being, and success of vector control programs.

Linkages between women's empowerment, religion, marriage type, and uptake of antenatal care visits in 13 West African countries

Characteristics which reflect a particular context and unique to individuals, households, and societies have been suggested to have an impact on the association between women's empowerment and women's well-being indicators. However, there is limited empirical evidence of this effect. We used access to antenatal care (ANC) to examine the main and interaction effects of women's empowerment, religion, marriage type, and uptake of services in 13 West African countries. Data was extracted from Phase 6 and 7 of the Demographic and Health Survey, and we measured women's empowerment using the survey-based women's empowerment (SWPER) index for women's empowerment in Africa. ANC visits as the outcome variable was analyzed as a count variable and the SWPER domains, religion, and marriage type were the key independent variables. We utilised ordinary least square (OLS) and Poisson regression models where appropriate to examine main and interaction effects and analyses were appropriately weighted and key control variables were applied. Statistical significance was established at 95% confidence interval. Findings suggest that being Muslim or in a polygynous household was consistently associated with disempowerment in social independence, attitude toward violence, and decision-making for women. Although less consistent, improved social independence and decision-making for women were associated with the probability of increased ANC visits. Polygyny and Islamic religion were negatively associated with increased number of ANC visits. Decision-making for Muslim women appear to increase the probability of increased number of ANC visits. Improving the conditions that contribute towards women's disempowerment especially for Muslim women and to a lesser extent for those who reside in polygynous households is key towards better uptake of antenatal care services. Furthermore, targeting of interventions and polices that could empower women towards better access to health services should be tailored on existing contextual factors including religion and marriage type.

Socioeconomic and geographical inequalities in using skilled birth attendants during delivery in Bangladesh over two decades

BACKGROUND

Maternal and neonatal mortality is a major public health concern globally. Evidence supports that skilled birth attendants (SBA) can significantly reduce maternal and neonatal mortality. Despite the improvement in SBA use, Bangladesh lacks evidence of equality in SBA use across socioeconomic and geographic regions. Therefore, we aim to estimate the trends and magnitude of inequality in SBA use in Bangladesh over the last two decades.

METHODS

Data from the last 5 rounds of Bangladesh Demographic and Health Surveys (BDHS; 2017-18, 2014, 2011, 2007, and 2004) were used to measure the inequalities in the SBA use utilizing the WHO's Health Equity Assessment Toolkit (HEAT) software. Inequality was assessed by four summary measures, namely, Population Attributable Risk (PAR), Population Attributable Fraction (PAF), Difference (D), and Ratio (R) based on the four equity dimensions: wealth status, education level, place of residence, and subnational regions (divisions). Point estimates and a 95% confidence interval (CI) were reported for each measure.

RESULTS

An increasing trend in the overall prevalence of SBA use was observed (From 15.6% in 2004 to 52.9% in 2017). We found significant inequalities in SBA use in every wave of BDHS (from 2004 to 2017), with the result concentrating on the rich (in 2017, PAF: 57.1; 95% CI: 52.5-61.7), educated (in 2017, PAR: 9.9; 95% CI: 5.2-14.5),  and people from urban areas (in 2017, PAF: 28.0; 95% CI: 26.4-29.5). We also identified geographic disparities in SBA use favoring Khulna and Dhaka divisions (in 2017, PAR: 10.2; 95% CI: 5.7-14.7). Our study also observed inequality in using SBA among Bangladeshi women decreased over time.

CONCLUSION

To increase SBA use and to decrease inequality in all four equity dimensions, disadvantaged sub-groups should be prioritized in policies and planning for program implementation.

How does a pair of near-vision spectacle correction empower older Zanzibari craftswomen?: A qualitative study on perception

BACKGROUND

Studies have shown that correcting presbyopia among women could increase short-term income and quality of life. However, it is unclear whether these short-term outcomes translate to long-term empowerment. This is partly due to women's empowerment being under-studied in the eye health field. Hence, we attempted to understand Zanzibari craftswomen's perception of how near-vision spectacle correction could empower them.

METHODS

Semi-structured interviews were conducted with 24 craftswomen with presbyopia (7 to 21 April 2022), identified from Zanzibari cooperatives using quota and heterogeneity sampling. We included a sample of tailors, beaders/weavers, and potters who were 40 years and older. Directed content analysis was performed on interview transcripts.

RESULTS

Two themes and seven sub-themes emerged from the data. Craftswomen perceived that at the personal level, near-vision spectacle correction could improve their economic empowerment (better income and savings and buying things for themselves), psychological empowerment (more self-confidence and decision-making), political empowerment (taking up leadership roles), and educational empowerment (acquiring new skills). At a relational level, they perceived that near-vision spectacle correction could bring about economic empowerment (ability to buy things for the family), social empowerment (ability to participate in social activities), and educational empowerment (ability to educate other women).

CONCLUSION

Older craftswomen perceived that correcting near vision could empower them at personal and relational levels that encompass economic, psychological, social, political and educational empowerment. The findings laid the foundation for future research into eye health and women's empowerment.

Small vulnerable newborns-big potential for impact

Despite major achievements in child survival, the burden of neonatal mortality has remained high and even increased in some countries since 1990. Currently, most neonatal deaths are attributable to being born preterm, small for gestational age (SGA), or with low birthweight (LBW). Besides neonatal mortality, these conditions are associated with stillbirth and multiple morbidities, with short-term and long-term adverse consequences for the newborn, their families, and society, resulting in a major loss of human capital. Prevention of preterm birth, SGA, and LBW is thus critical for global child health and broader societal development. Progress has, however, been slow, largely because of the global community's failure to agree on the definition and magnitude of newborn vulnerability and best ways to address it, to frame the problem attractively, and to build a broad coalition of actors and a suitable governance structure to implement a change. We propose a new definition and a conceptual framework, bringing preterm birth, SGA, and LBW together under a broader umbrella term of the small vulnerable newborn (SVN). Adoption of the framework and the unified definition can facilitate improved problem definition and improved programming for SVN prevention. Interventions aiming at SVN prevention would result in a healthier start for live-born infants, while also reducing the number of stillbirths, improving maternal health, and contributing to a positive economic and social development in the society.

Measuring women's empowerment during the perinatal period in high income countries: A scoping review of instruments used

Empowerment is acknowledged as a process facilitating those who are less powerful to be engaged in their problem identification, decision making and actions to gain control over their life. This is an important goal for women during the perinatal period in their transition to motherhood. A concept analysis of women's empowerment during the perinatal period found that psychological and social dimensions play a role in women's perinatal empowerment and identified several defining attributes. The aim of this study was to identify robust validated instruments that measure all the attributes of women's empowerment during the perinatal period. We did a scoping review of scientific literature following the methodology of the JBI Reviewer's Manual. We searched the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES and SocINDEX and selected papers meeting the inclusion criteria. Instruments measuring empowerment or related concepts were identified in the selected papers. Two authors independently cross referenced the items of each instrument against the defining attributes for empowerment. Our search resulted in 9771 unique hits of which 36 papers were finally included. Studies were from various countries with a wide variety of aims, demographics of cohorts and timepoints across the perinatal period. Twenty-one different instruments were used to measure empowerment, of which 11 were validated among women during the perinatal period. However, no identified instrument was developed specifically for women during the perinatal period or included all the dimensions of empowerment and the defining attributes. There is a need for a theoretically sound valid and reliable instrument measuring all the dimensions of empowerment of women during the perinatal period. Once developed this instrument needs testing with a broad range of women. Results from such a study will inform the development of appropriate interventions that have a coherent theoretical basis and are empirically informed to enhance women's empowerment during the perinatal period.

Engaging men in maternal, infant and young child nutrition in rural Tanzania: Outcomes from a cluster randomized control trial and qualitative study

There is growing recognition that engaging men in maternal, infant and young child nutrition (MIYCN) interventions can benefit child health and disrupt harmful gender norms. We conducted a cluster-randomized controlled trial in Tanzania, which engaged men and women in behaviour change via mobile messaging (short message service [SMS]) and traditional interpersonal communication (IPC), separately and in combination. Here, we evaluate intervention effects on individual-level men's MIYCN knowledge and discuss barriers to male engagement. Eligible clusters were dispensary catchment areas with >3000 residents. Forty clusters were stratified by population size and randomly allocated to the four study arms, with 10 clusters per arm. Data on knowledge and intervention exposure were collected from 1394 men through baseline and endline surveys (March-April 2018 and July-September 2019). A process evaluation conducted partway through the 15-18-month intervention period included focus group discussions and interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. Male participants in the short message service + interpersonal communication (SMS + IPC) group reported higher exposure to IPC discussions than IPC-only men (43.8% and 21.9%, respectively). Knowledge scores increased significantly across all three intervention groups, with the greatest impact in the SMS + IPC group. Qualitative findings indicated that the main barriers to male participation were a lack of interest in health/nutrition and perceptions that these topics were a woman's responsibility. Other challenges included meeting logistics, prioritizing income-earning activities and insufficient efforts to engage men. The use of a combined approach fusing IPC with SMS is promising, yet countering gender norms and encouraging stronger male engagement may require additional strategies.

Association between women's household decision-making autonomy and health insurance enrollment in sub-saharan Africa

BACKGROUND

Out of pocket payment for healthcare remains a barrier to accessing health care services in sub-Saharan Africa (SSA). Women's decision-making autonomy may be a strategy for healthcare access and utilization in the region. There is a dearth of evidence on the link between women's decision-making autonomy and health insurance enrollment. We, therefore, investigated the association between married women's household decision making autonomy and health insurance enrollment in SSA.

METHODS

Demographic and Health Survey data of 29 countries in SSA conducted between 2010 and 2020 were analyzed. Both bivariate and multilevel logistic regression analyses were carried out to investigate the relationship between women's household decision-making autonomy and health insurance enrollment among married women. The results were presented as an adjusted odds ratio (AOR) and the 95% confidence interval (CI).

RESULTS

The overall coverage of health insurance among married women was 21.3% (95% CI; 19.9-22.7%), with the highest and lowest coverage in Ghana (66.7%) and Burkina Faso (0.5%), respectively. The odds of health insurance enrollment was higher among women who had household decision-making autonomy (AOR = 1.33, 95% CI; 1.03-1.72) compared to women who had no household decision-making autonomy. Other covariates such as women's age, women's educational level, husband's educational level, wealth status, employment status, media exposure, and community socioeconomic status were found to be significantly associated with health insurance enrollment among married women.

CONCLUSION

Health insurance coverage is commonly low among married women in SSA. Women's household decision-making autonomy was found to be significantly associated with health insurance enrollment. Health-related policies to improve health insurance coverage should emphasize socioeconomic empowerment of married women in SSA.

Gender norms, contraceptive use, and intimate partner violence: A six-country analysis

BACKGROUND

While considerable research has explored associations between gender norms and various sexual and reproductive health behaviors (SRH) with the aim of informing programs, no studies have examined whether couple concordance on specific gender norms is associated with both contraceptive use and reduced intimate partner violence (IPV) experience.

METHODS

This study relies on analysis of Demographic and Health Survey (DHS) couples' datasets from Mali, Nigeria, Nepal, Pakistan, Tanzania, and Zambia that were collected in/after 2015 and include the DHS Domestic Violence Module for female respondents. To examine the associations between couple concordance regarding household decision-making or justification of violence (wife beating) and women's use of modern contraceptives or experience of violence, bivariate and multivariate logistic regression models were fit using Stata15.

RESULTS

Joint decision-making about large household purchases was significantly positively associated with modern contraceptive use in all study countries as well as with reduced odds of IPV experience in adjusted models in Tanzania and Zambia. In Nigeria, women's justification for violence was negatively associated with contraceptive use. Across settings, women in couples where both justified violence had significantly increased odds of reporting IPV experience.

CONCLUSIONS

The evidence suggests that family planning programs should support joint decision-making as it was positively associated with contraceptive use across the six countries and is a proxy for shared economic power within the household. IPV reduction and prevention programs should also consider encouraging joint decision-making given the correlations found in two settings. Programs should enable participants to interrogate attitudes regarding justifying violence against female partners and propose approaches to avoid IPV. Finally, husbands' alcohol consumption, a strong predictor of IPV experience, has too long been overlooked.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 8. Impact on women's empowerment

BACKGROUND

Indigenous Maya women in the rural highlands of Guatemala have traditionally faced constraints to decision-making and participation in community affairs. Anecdotal experiences from previous Curamericas Global projects in Guatemala and Liberia have suggested that interventions using the CBIO+ Approach (which consists of implementing together the Census-Based, Impact-Oriented Approach, the Care Group Approach, and Community Birthing Centers), can be empowering and can facilitate improvements in maternal and child health. This paper, the eighth in a series of 10 papers examining the effectiveness of CBIO+ in improving the health and well-being of mothers and children in an isolated mountainous rural area of the Department of Huehuetenango, explores changes in women's empowerment among mothers of young children associated with the Curamericas/Guatemala Maternal and Child Health Project, 2011-2015.

METHODS

Knowledge, practice, and coverage (KPC) surveys and focus group discussions (FGDs) were used to explore six indicators of women's empowerment focusing on participation in health-related decision-making and participation in community meetings. KPC surveys were conducted at baseline (January 2012) and endline (June 2015) using standard stratified cluster sampling. Seventeen FGDs (9 with women, 3 with men, 2 with mothers-in-law, and 3 with health committees), approximately 120 people in all, were conducted to obtain opinions about changes in empowerment and to identify and assess qualitative factors that facilitate and/or impede women's empowerment.

RESULTS

The KPC surveys revealed statistically significant increases in women's active participation in community meetings. Women also reported statistically significant increases in rates of participation in health-related decision-making. Further, the findings show a dose-response effect for two of the six empowerment indicators. The qualitative findings from FGDs show that the Project accelerated progress in increasing women's empowerment though women still face major barriers in accessing needed health care services for themselves and their children.

CONCLUSION

The Project achieved some notable improvements in women's decision-making autonomy and participation in community activities. These improvements often translated into making decisions to practice recommended health behaviors. Traditional cultural norms and the barriers to accessing needed health services are not easily overcome, even when empowerment strategies are effective.

The Impact of Women's Agency on Accessing and Using Maternal Healthcare Services: A Systematic Review and Meta-Analysis

Agency, defined as the ability to identify one's goals and act upon them, has been recognized as a prominent strategy to access maternal healthcare services (MHS). The purpose of this study was to synthesize evidence of the association between women's agency and MHS utilization. A systematic review was performed on five academic databases, comprising Scopus, PubMed, Web of Science, Embase, and ProQuest. Meta-analysis was performed with a random-effects method using the STATA™ Version 17 software. A total of 82 studies were selected following the PRISMA guidelines. The meta-analysis demonstrated that an increase in women's agency was associated with a 34% increase in the odds of receiving skilled antenatal care (ANC) (OR = 1.34, 95% CI = 1.18-1.52); 7% increase in the odds of initiating the first ANC visit during the first trimester of pregnancy (OR = 1.07, 95% CI = 1.01-1.12); 20% increase in the odds of receiving at least one ANC visit (OR = 1.20, 95% CI = 1.04-1.4); 16% increase in the odds of receiving more than four ANC visits during pregnancy (OR = 1.16, 95% CI = 1.12-1.21); 17% increase in the odds of receiving more than eight ANC visits (OR = 1.17, 95% CI = 1.04-1.32); 13% increase in the odds of facility-based delivery (OR = 1.13, 95% CI = 1.09-1.17); 16% increase in the odds of using skilled birth attendants (OR = 1.16, 95% CI = 1.13-1.19); and 13% increase in the odds of receiving postnatal care (OR = 1.13, 95% CI = 1.08-1.19) compared to low level of agency. Any efforts to improve MHS utilization and reduce maternal morbidity and mortality should include the promotion of women's agency.

Women's multidimensional empowerment index and essential newborn care practice in Bangladesh: The mediating role of skilled antenatal care follow-ups

INTRODUCTION

The World Health Organization recommended a set of five neonatal care practices that are most essential for good health of a newborn. As good essential newborn care (ENC) practice reduces the risk of neonatal morbidity and mortality, this paper focuses how women's multidimensional empowerment index is associated with this practice through the skilled antenatal care. To the best of knowledge, no such study has been conducted yet. The composite index of women's multidimensional empowerments was constructed using family decision, intimate partner violence, social status, healthcare access and economic status of women; and skilled antenatal care was defined if a pregnant woman received eight or more checkups during pregnancy from skilled health professionals.

MATERIALS AND METHODS

Data extracted from Bangladesh Demographic and Health Survey, 2017-18 have been utilized in the study. A total of 2441 mothers have been considered who delivered their last live birth at home within three years preceding the survey. A mediation analysis was performed considering the structural equation modeling to find out the adjusted association of women's empowerment on both skilled antenatal care and good ENC practice, but the unadjusted associations were also checked using a chi-square test. To test the indirect as well as total effect of women's empowerment through skilled antenatal care on good ENC practice, bias-corrected standard errors were estimated using a bootstrapping sampling.

RESULTS

Good ENC practice was considerably low in Bangladesh with 7.6% of newborns receiving the practice. Both adjusted and unadjusted analyses showed the significant association of women's empowerment with both skilled antenatal care and good ENC practice. The study revealed that the indirect effect of high empowerment through skilled antenatal care was greater than its direct effect on good ENC practice.

CONCLUSION

This study explored that the prevalence of good ENC practice can be accelerated through women's empowerment, where skilled antenatal care plays an important mediating role in improving good ENC practice among highly empowered mothers. The study suggests that a woman should follow the latest guidelines recommended by WHO for antenatal care follow-up. Policymakers can modify some of the maternal and child health care interventions based on the research findings.

Women's empowerment and infant mortality in Latin America: evidence from 286 cities

Levels of women's empowerment (WE) can contribute to differences in infant mortality rates (IMRs) across cities. We used a cross-sectional multilevel study to examine associations of WE with IMRs across 286 cities in seven Latin American countries. We estimated IMRs for 2014-2016 period and combined city socioeconomic indicators into factors reflecting living conditions and service provision. WE was operationalized: (1) in cities, by using scores for women's labor force participation (WLFP) and educational attainment among women derived from education and employment indicators disaggregated by sex; (2) in countries, by including a scale of enforcements of laws related to women's rights. We estimated adjusted percent differences in IMRs associated with higher WE scores across all cities and stratified by country GDP. We found substantial heterogeneity in IMRs and WE across cities. Higher WLFP was associated with lower IMRs. Higher women's educational attainment was associated with lower IMRs only in cities from countries with lower GDP. Poorer national enforcement of laws protecting women's rights was associated with higher IMRs in all countries. Women's empowerment could have positive implications for population health. Fostering women's socioeconomic development and girls' education should be part of strategies to reduce IMRs in cities of Global South.

Association between women's empowerment and diarrhoea in children under five years: evidence from the 2017/18 Benin Demographic and Health Survey

Globally, diarrhoea is the third leading cause of death for under five-children. Women's empowerment can significantly reduce under-five mortality due to diarrhoea. This study investigated the association between women's empowerment and childhood diarrhoea in Benin using data from the 2017/18 Benin Demographic and Health Survey. A total of 7979 currently married women were included in the study. A logistic regression model was used to control for possible confounders. The prevalence of diarrhoea among children under five years of age was 13.6%. About 36.3% of the currently married women decided either alone or together with their husband on their own health, purchase of large household items and visiting family/relatives. Close to 65.4% of currently married women disagreed with all five reasons to justify wife-beating. The children of mothers who had decision-making power were less likely to have diarrhoea (aOR = 0.74, 95% CI: 0.57-0.96) than the children of mothers who had no decision-making power. Moreover, the children of mothers who disagreed with all five reasons to justify wife-beating (aOR = 0.79, 95% CI: 0.65-0.96) were less likely to have diarrhoea than the children of mothers who accepted wife-beating as a part of life. Women's age, educational level, wealth index and region were associated with childhood diarrhoea in Benin. The role of women's empowerment, as determined by decision-making power and wife-beating attitude, was found to be significantly associated with the risk of childhood diarrhoea in Benin, after adjusting for other variables. Therefore, it is essential for policymakers in Benin to reinforce strategies and interventions focusing on women's empowerment to avert childhood mortality caused by diarrhoea. This includes improving household economic status, women's education and decision-making power and enhancing awareness of women's human and democratic rights.

Internal migration and utilization of reproductive and maternity care among women in Pakistan: evidence from a recent National Survey

Background

During the last decades, migratory behavior has had a key role in population growth and redistribution in Pakistan. Migration has far-reaching socioeconomic implications for individuals and society at large that could influence the health integrity of Pakistani women. This study aimed to describe the migration patterns and drivers as well as their association with adequate access to reproductive and maternal care among married Pakistani women aged 15-49.

Methods

The data from the 2017-18 Pakistan Demographic Health Survey (PDHS) was used to extract the information on the explanatory (sociodemographic and migration backgrounds) and outcome variables (unmet needs for family planning, adequate antenatal care, and delivery at health facilities). Bivariate and multivariate logistic regression analyses were employed to examine the relationship between these explanatory and outcome variables before and after adjustment for sociodemographic inequalities.

Results

In unadjusted models, the odds of having adequate ANC and delivery at health facilities were approximately 2 to 4 times higher in those living (urban non-migrant), moving to (urban to urban, rural to urban), or leaving the urban areas (rural to urban) as compared to rural non-migrants; likewise, the odds of the unmet needs for family planning was about 20-50% lower in the same migration streams compared to rural non-migrant. However, after adjustment for sociodemographic inequalities, most of these associations attenuated and only the association of urban to urban migration with unmet needs for family planning and the association of urban non-migrant with delivery at health facilities remained significant.

Conclusion

Although the findings suggest that Internal migration flows, particularly those to urban areas (urban to urban and rural to urban), could be associated with better access to reproductive and maternity care among married Pakistani women aged 15-49 years; adjustment for sociodemographic inequalities, particularly education and wealth, nullified this association to a great extent. This has important implications for current policies and interventions in Pakistan and calls for policy reform and women's rights advocacy to enhance the literacy level of young Pakistani girls through well-tailored interventions, maintaining them at school.

Factors that determine women's autonomy to make decisions about sexual and reproductive health and rights in Nepal: A cross-sectional study

Women's autonomy on sexual and reproductive health issues is critical to women's health and well-being. Women have the right to decide on their fertility and sexuality, be free from coercion and violence, and achieve well-being. This study has identified women's autonomy regarding decision and exercise of their sexual reproductive health and rights and its association with determining factors in Nepal. Descriptive and analytical statistics such as bivariate and multivariate regression analysis were performed using data from Nepal Demographic and Health Survey 2016. The survey collected data from 12,862 women of reproductive age groups i.e. 15-49 years. However, for this study, we analyzed the data of only ever-married women and they were 9,875 in total. The analysis showed that women's autonomy in exercising their sexual reproductive health rights is highly associated with media exposure after controlling demographic variables. The frequency of exposure to media (i. less than a week: adjusted odds ratio (AOR):1.383; confidence interval (CI):1.145-1.670, p<0.001, ii. at least once a week: AOR:1.657; CI:1.359-2.021, p<0.001) is positively associated with women's autonomy. Furthermore, factors like women from Janajati (AOR:1.298; CI:1.071-1.576, p<0.01) and other Terai ethnic groups (AOR:1.471; CI:1.160-1.866, p<0.01), higher education attainment (AOR:1.482; CI:1.164-1.888, p<0.01), richest wealth quintile (AOR:1.527; CI:1.151-2.026, p<0.01), paid work (AOR:1.277; CI:1.045-1.561, p<0.05) and living in Lumbini Province (AOR:0.622; CI:0.486-0.797, p<0.001) and Sudur Paschim Province (AOR:0.723; CI:0.554-0.944, p<0.05) were found to be significantly associated with women's autonomy in sexual and reproductive health decision making. Similarly, women's autonomy is also increased with their increased age. In conclusion, women's exposure to media, improved socio-economic status and increased age influence their autonomy to make decisions about sexual and reproductive health rights in Nepal. Therefore, this study underscores the need to address socio-economic barriers and improve women's exposure to the media to enhance their autonomy further.

Introducing the Power In Nepali Girls (PING) empowerment scale

The multi-dimensional concept of empowerment is context specific, uniquely defined in various cultures, and challenging to measure. The aim of this study was to develop a scale for measuring empowerment among adolescent girls in Nepal. Twenty-nine items related to empowerment were drawn from formative, participatory research conducted in southern Nepal to comprise a draft empowerment scale. A case/control survey among 300 adolescent Nepali girls was then conducted to refine the scale. Factor analysis determined the most parsimonious scale and identified the underlying structure of items, resulting in the The Power In Nepali Girls (PING), a two-factor, 16-item empowerment scale. Factor 1 items address decision-making power and treatment in family and society. Factor 2 items address knowledge, education, and skills development. We used the 16-item scale to assess the impact of a social and financial skills program on empowerment among adolescent girls residing in southern Nepal. The PING scale is a culturally- and population-specific measure that can be used to quantify the impact of empowerment programs in Nepal among adolescent girls. The methods used also serve as a template for future work aiming to design context-specific measures of empowerment using community-engaged approaches.

Association of spousal violence and women's empowerment status among the rural women of sub-Saharan Africa

Spousal violence (SV) is a global problem for women and its elimination is one of the prime targets of Sustainable Development Goal-5. Data from the Demographic and Health Surveys of seventeen countries, representing two sub-Saharan Africa (SSA) regions (East and Southern Africa [ESA] and West and Central Africa [WCA]), were used to examine the relationship between all types of SV and women's empowerment status among rural married women aged 15-49 years. Multivariate logistic regression analysis was used to explore adjusted associations, and a relative index of inequality (RII) and slope index of inequality (SII) were used to measure the inequality in experiencing SV by rural women based on their overall empowerment position. Within the period 2015-2019, the reported rate of SV was higher in the ESA (physical SV: 33.55%; sexual SV: 16.96%; any type of SV: 46.14%) than the WCA countries (physical SV: 27.80%; sexual SV: 7.63%; any type of SV: 40.83%), except for emotional SV (WCA: 31.28% vs ESA: 29.35%). In terms of overall empowerment status, rural WCA women were slightly ahead of their counterparts in the ESA region (46.09% and 44.64%, respectively). For both ESA and WCA countries, women who didn't justify violence and who had access to health care (except physical SV in WCA) showed negative but significant association with all types of SV in the adjusted analysis. Conversely, economic empowerment significantly increased the odds of experiencing physical and any type of SV in both regions. The significant risk ratios obtained from RII, for any SV were 0.83 and 1.09, and the β-coefficients from SII were -0.082 and 0.037 units, respectively, in ESA and WCA. Multi-sectoral microfinance-based intervening programmes and policies should be implemented regionally to empower women, especially in the economic, socio-culture, health care accessibility dimensions, and this will eventually reduce all types of spousal violence in rural SSA.

Socioecological predictors of breastfeeding practices in rural eastern Ethiopia

BACKGROUND

Estimates by the World Health Organization indicate that over 800,000 global neonatal deaths each year are attributed to deviations from recommended best practices in infant feeding. Identifying factors promoting ideal breastfeeding practices may facilitate efforts to decrease neonatal and infant death rates and progress towards achieving the Sustainable Development Goals set for 2030. Though numerous studies have identified the benefits of breastfeeding in reducing the risk of childhood undernutrition, infection and illness, and mortality in low- and middle-income countries, no studies have explored predictors of breastfeeding practices in rural eastern Ethiopia, where undernutrition is widespread. The aim of this study is to examine predictors of infant feeding practices in Haramaya, Ethiopia, using a multi-level conceptual framework.

METHODS

This study uses data collected from household questionnaires during the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) project among 102 households in the Haramaya woreda, Eastern Hararghe Zone, Eastern Ethiopia, and investigates factors influencing breastfeeding practices: early initiation, prelacteal feeding, and untimely complementary feeding.

RESULTS

Nearly half (47.9%) of infants in this study were non-exclusively breastfed (n = 96). Generalized liner mixed effects models of breastfeeding practices revealed that prelacteal feeding may be a common practice in the region (43.9%, n = 98) and characterized by gender differences (p = .03). No factors evaluated were statistically significantly predictive of early initiation and untimely complementary feeding (82% and 14%, respectively). Severely food insecure mothers had more than 72% lower odds of early breastfeeding initiation, and participants who self-reported as being illiterate had 1.53 times greater odds of untimely complementary feeding (95% CI, [0.30,7.69]) followed by male children having 1.45 greater odds of being untimely complementary fed compared to female (95% CI,[0.40,5.37]).

CONCLUSIONS

This study found high rates of prelacteal feeding and low prevalence of exclusive breastfeeding, with girls more likely to be exclusively breastfed. While no predictors evaluated in this multi-level framework were associated with prevalence of early initiation or complementary feeding, rates may be clinically meaningful in a region burdened by undernutrition. Findings raise questions about gendered breastfeeding norms, the under-examined role of khat consumption on infant feeding, and the complex factors that affect breastfeeding practices in this region. This information may be used to guide future research questions and inform intervention strategies.

Afghan women's empowerment and antenatal care utilization: a population-based cross-sectional study

BACKGROUND

Although antenatal care (ANC) offers a unique opportunity to diagnose and prevent complications by mitigating modifiable risk, 38.2% of women did not complete any ANC visits in Afghanistan in 2015. Women empowerment is associated with increased use of ANC; however, there is no evidence of the effect of women empowerment on ANC in the country. Addressing this gap, we aimed to evaluate the association between women's empowerment and ANC utilization based on the conceptual framework of women's empowerment.

METHODS

We analyzed data from the 2015 Afghanistan Demographic and Health Survey for 11,056 women. The association between four domains of women's empowerment, including capability, access to resources, security, and decision-making and power, and at least four ANC visits was analyzed using a multivariable logistic regression.

RESULTS

After adjusting for covariates, access to information (AOR 1.38, 95%CI 1.24, 1.54) and decision-making (AOR 1.16, 95%CI 1.08, 1.24) were positively associated with four or more ANC visits. Compared to those without any education, women with primary education (AOR 1.67, 95%CI 1.02, 2.72), secondary education (AOR 2.43, 95%CI 1.25, 4.70), and higher education (AOR 3.03, 95%CI 1.30, 7.07) had higher odds of least four ANC visits. However, asset ownership was negatively associated with ANC visits (AOR 0.72, 95%CI 0.56, 0.92). Variables related to security and literacy were not associated with the minimum ANC visits.

CONCLUSIONS

The mixed results of the study highlight the complex natures of women's empowerment, warranting a more nuanced understanding of women's empowerment in the context and future research that capture multidimensionality of women's empowerment. Also, efforts to empower women, particularly those with no education and had less decision-making power and access to health information, could be an effective strategy to enhance ANC use in Afghanistan.

Identifying Predictors for Minimum Dietary Diversity and Minimum Meal Frequency in Children Aged 6-23 Months in Uganda

Adequate complementary foods contribute to good health and growth in young children. However, many countries are still off-track in achieving critical complementary feeding indicators, such as minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD). In this study, we used the 2016 Ugandan Demographic Health Survey (UDHS) data to assess child feeding practices in young children aged 6-23 months. We assess and describe complementary feeding indicators (MMF, MDD and MAD) for Uganda, considering geographic variation. We construct multivariable logistic regression models-stratified by age-to evaluate four theorized predictors of MMF and MDD: health status, vaccination status, household wealth and female empowerment. Our findings show an improvement of complementary feeding practice indicators in Uganda compared to the past, although the MAD threshold was reached by only 22% of children. Children who did not achieve 1 or more complementary feeding indicators are primarily based in the northern regions of Uganda. Cereals and roots were the foods most consumed daily by young children (80%), while eggs were rarely eaten. Consistent with our hypotheses, we found that health status, vaccination status and wealth were significantly positively associated with MDD and MMF, while female empowerment was not. Improving nutrition in infant and young children is a priority. Urgent nutritional policies and acceptable interventions are needed to guarantee nutritious and age-appropriate complementary foods to each Ugandan child in the first years of life.

Women's empowerment indicators and short- and long-acting contraceptive method use: evidence from DHS from 11 countries

BACKGROUND

With a population of about 1.1 billion, sub-Saharan Africa is projected to overtake Eastern, Southern and Central Asia to become the most populous region by 2060. One effective approach for slowing this rapid population growth is the use of modern contraception and this may be short-acting or long acting. Previous studies have explored the association between women empowerment indicators contraception use, however, there is limited evidence on how women empowerment indicators associate with type of contraception. Hence the present study investigated the association between women empowerment indicators and type of contraception used by women in 11 sub-Saharan African countries.

METHODS

We utilised Demographic and Health Survey data of 22,637 women from 11 countries, collected between 2018 and 2021. The outcome variable was type of contraception used. Descriptive and inferential analyses were executed. The descriptive analysis reflected women empowerment indicators and the proportion of women using contraceptives. Multinomial logistic regression was considered for the inferential analysis. The results for the multinomial logistic regression were presented as adjusted odds ratios (aORs) along with the respective 95% confidence intervals (CIs) signifying precision. The sample weight (wt) was used to account for the complex survey (svy) design. All the analyses were done with Stata version 13 and SPSS version 25.

RESULTS

The study showed that on the average, 15.95% of the women do not use modern contraceptives, whilst 30.67% and 53.38% use long-acting and short-acting contraceptives respectively. The adjusted models showed that women who were working had higher odds of using long-acting (aOR = 1.44, CI 1.28-1.62) and short-acting (aOR = 2.00, CI 1.79-2.24) methods compared with those who were not working. The analysis revealed higher likelihood of long-acting method use among women with high decision-making capacity (aOR = 1.27, CI 1.09-1.47) compared with women with low decision-making capacity. Women with medium knowledge level had a higher likelihood (aOR = 1.54, 1.09-2.17) of using long-acting methods than their counterparts with low knowledge level.

CONCLUSION

Our findings show that most women in the 11 countries use modern contraceptives, however, different empowerment indicators align with different contraceptive type. It therefore behoves governments of the studied countries to review current interventions and embrace new ones that are more responsive to the peculiar contraception needs of empowered and non-empowered women.

Women empowerment indicators and uptake of child health services in sub-Saharan Africa: a multilevel analysis using cross-sectional data from 26 countries

BACKGROUND

The sustainable development goal 3, target 2, seeks to reduce under-five mortality to as low as 25 deaths per 1000 live births by 2030. As such, seeking child health services has become a priority concern for all countries, particularly those in sub-Saharan Africa (SSA). Evidence suggests that empowered women are more likely to seek child health services. Hence, this study examined the association between women empowerment indicators and uptake of child health services in SSA.

METHODS

The study used data from the Demographic and Health Surveys of 26 SSA countries, which were conducted between 2010 and 2019. Two different samples were considered in the study: a total of 12 961 children within the vaccination age of 12-23, and 9489 children under age 5 with diarrhoea symptoms in the last 2 weeks before the survey. Women empowerment indicators comprised disagreement with reasons to justify wife beating, decision-making power and knowledge level, while child health services constituted complete vaccination uptake and seeking diarrhoea treatment. Frequencies, percentages and multivariable, multilevel binary logistic regression models were employed.

RESULTS

The study shows that women with high decision-making power [adjusted odds ratio (AOR) = 1.20, 95% confidence interval (CI) = 1.07, 1.35] had higher odds of seeking treatment for childhood diarrhoea compared to those with low decision-making power. It was also observed that among children aged 12-23 months [AOR = 1.28, 95% CI = 1.14, 1.43], mothers had higher odds of seeking diarrhoea treatment for them compared to those who were aged less than 12 months. Children whose mothers had medium decision-making power [AOR = 1.30, 95% CI = 1.19, 1.41] were more likely to seek complete immunization for their children compared to those with low decision-making power. Also, those with medium [AOR = 1.19, 95% CI = 1.07, 1.31] and high knowledge [AOR = 1.25, 95% CI = 1.10, 1.42] had higher odds of completing immunization for their children compared to those with low knowledge. Women with medium acceptance had lower odds [AOR = 0.76, 95% CI = 0.67, 0.83] of completing immunization for their children compared with those with low acceptance of wife beating.

CONCLUSIONS

This study has demonstrated a strong association between women empowerment indicators and the uptake of child health services. Therefore, efforts should be made to seek policy tools to empower women to help improve the well-being of women and the children they care for.

The human right to safely give birth: data from 193 countries show that gender equality does affect maternal mortality

BACKGROUND

While a reduction in the global maternal mortality ratio (MMR) has slowed, newer strategies are needed to achieve an ongoing and sustainable reduction of the MMR. Previous studies have investigated the association between health system-related factors such as wealth inequalities, healthcare access and use on maternal mortality. However, a women's rights-based approach to address MMR has not been studied, excluding the health system-related factors. This study aimed to analyse the association between gender equality and MMR globally.

METHODS

Using structural equation modelling (SEM), secondary and open access data from the United Nations and other international agencies from 193 countries were analysed using structural equation modelling (SEM). Gender-sensitive variables that represented the theoretical, conceptual framework of the study were selected. The association between latent variable gender equality and the outcome, MMR, was examined in the SEM. A second SEM model (n = 158) was designed to include two variables related to gender-based violence.

FINDINGS

The latent variable, gender equality, was negatively associated with MMR (p < 0‧001, Z = -6‧96, 95% CI: - 6508.98 to - 3141.89 for Model 1 and p < 0‧001, Z = -7‧23, 95% CI: - 6045.356 to - 3467.515 for Model 2).

INTERPRETATION

Gender equality was significantly associated with maternal mortality. Investing in higher education for women, improving their paid employment opportunities, increasing participation in leadership roles and politics, reducing intimate partner violence (IPV) and ending child marriage can significantly reduce maternal mortality.

Reducing Psychological Impacts on Children with Chronic Disease via Family Empowerment: A Scoping Review

Chronic diseases cause physical and psychological impacts on sufferers. In dealing with illness, the family is not involved in the treatment of chronic diseases. Children also do not receive support from their families in dealing with their illness. Family empowerment is an important thing to implement in treating children with chronic diseases. The purpose of this study was to explore family empowerment interventions as potential methods to reduce the impact of chronic disease. This study used the scoping review method. A literature review was conducted via CINAHL, PubMed, and ProQuest databases. The keywords used in English were "family empowerment OR family center empowerment" AND "child OR children" AND "chronic disease". The criteria for articles in this study were full text, free access, randomized control trial or quasi-experiment research design, English language, population and samples of chronic disease, and the publication period of the last 10 years (2013-2022). We found nine articles that used a family empowerment intervention in an effort to reduce the impact of chronic disease on children. Most of the study designs were randomized control trial and quasi-experiment. Some of the benefits of family empowerment interventions were quality of life, family care, and self-ability. The interventions helped the families to be empowered and actively participate in caring for children with chronic diseases. There were nine articles that discussed family empowerment interventions that have an impact in dealing with the impact of chronic disease on children, namely improving quality of life, family care, and self-ability.

The associations between women's empowerment measures, child growth and dietary diversity: Findings from an analysis of demographic and health surveys of seven countries in Eastern Africa

Evidence on the efficacy of women's empowerment to improve child growth and minimum dietary diversity (MDD) in the Eastern Africa (EA) region is limited. This cross‐sectional study used recent Demographic and Health Survey data of mother–child dyads from seven countries in EA to examine the associations between women's empowerment measures, child growth and MDD. Length‐for‐age z‐scores, weight‐for‐length z‐scores and weight‐for‐age z‐scores were used to categorize growth indicators of 6–23 months old children. Multivariable logistic regression was used to identify significant associations. Among all countries, 32%–59% of children experienced growth failure. Children meeting MDD were 18%–45%. Women having self‐esteem were associated with lower odds of stunting (adjusted odds ratio [AOR] = 0.62 in Rwanda), wasting (AOR = 0.38 in Uganda), underweight (AORs = 0.60 and 0.57 in Tanzania and Uganda, respectively) and growth failure (AOR = 0.64 in Rwanda). Having health decision control in Burundi was associated with lower odds of stunting (AOR = 0.49) and child growth failure (AOR = 0.52) and higher odds of meeting MDD (AOR = 2.50). Having Legal empowerment among women increased the odds of stunting (AOR = 1.79 in Burundi), underweight (AOR = 1.77 in Uganda) and growth failure (AOR = 1.87 in Burundi). Economic empowerment showed mixed associations with child growth and MDD among some countries. Women's self‐esteem and health decision control were associated with better child growth and MDD for some countries in EA. Nutrition‐sensitive interventions aimed at improving child growth and MDD should consider local contexts when addressing women's empowerment.

Understanding the associations between women's empowerment, child growth and child dietary diversity is important for most nutrition‐sensitive interventions seeking to improve child feeding practices and growth by targeting mothers.

In this study, for women to have self‐esteem and health decision control was consistently beneficial for child growth and minimum dietary diversity (MDD). Mixed associations existed among other women's empowerment measures, child growth and MDD across the seven East African countries investigated.

For improved child growth and better child dietary diversity, targeting specific women's empowerment measures based on local context may be beneficial in the East African region.

How women's empowerment influences fertility-related outcomes and contraceptive practices: A cross-sectional study in Mozambique

Women's empowerment could be a crucial step for tackling gender inequality and improve women's reproductive health and rights in Mozambique. This study aims to examine how different domains of women's empowerment influence fertility-related outcomes and contraceptive practices in Mozambique. We used the 2015 Demographic Health Survey (DHS) conducted in Mozambique from which a sample of 2072 women aged 15 to 49 years were selected and included in this analysis. A principal component analysis was performed, and the components retained were identified as the domains of empowerment. These were: Beliefs about violence against women, Decision-making, and Control over sexuality and safe sex. A multinomial logistic regression was run to estimate the association between levels of empowerment for each domain and the study outcomes. Crude and adjusted odds ratio (OR) were calculated, with 95% confidence intervals (95% CI). Beliefs about violence against women and Control over sexuality and safe sex were positively associated with having 1 to 4 children. Control over sexuality and safe sex also increased likelihood of women wanting to space childbearing over more than 2 years. Decision-making increased the odds of women not wanting more children. Middle to high empowerment levels for Control over sexuality and safe sex also increased the chances of using any type of contraceptive method and using it for longer periods. All domains, from the middle to high levels of empowerment, decreased the chances of women not wanting to use contraception. Our study confirmed the multidimensional nature of empowerment showing that each domain had a different effect over specific fertility and contraceptive outcomes and reinforced the importance of a domain approach for estimating and understanding empowerment. It also revealed the critical role of Control over sexuality and safe sex domain for improving women's ability to decide over fertility and contraceptive practices in Mozambique.

Association between receipt of nutritional counseling during antenatal care visits and anemia: A cross-sectional study

BACKGROUND

Anemia during pregnancy is associated with premature births, low birth weight and increased susceptibility to infection. Nearly a quarter (24.34%) of Ethiopian pregnant women suffer from anemia. Nutritional counseling during antenatal care (ANC) visits may encourage pregnant women to take a more iron-rich diet and prevent anemia. This study examines the association between nutritional counseling during ANC and anemia among Ethiopian women.

METHODS

This cross-sectional study uses the 2016 Ethiopia Demographic and Health Survey (EDHS) data (n=4, 384). The outcome of interest was anemia, measured objectively by blood hemoglobin level. The main independent variable was the receipt of nutritional counseling during ANC visits. Univariate, bivariate, and multivariable analyses were performed using SAS 9.4.

RESULTS

Overall, 25.8% of the participants were anemic and 65.7% received nutritional counseling during ANC visits. Compared to women who received nutritional counseling during ANC visits, a significantly higher proportion of women who did not receive nutritional counseling were anemic (23.1% vs. 30.8%; p<0.001). In the multivariable model, compared to women who received nutritional counseling during their ANC visits, the odds of being anemic were higher among women who did not receive nutritional counseling during their ANC visits AOR 1.34 (95% CI) = (1.07-1.67; p=0.010).

CONCLUSION

In a representative sample of Ethiopian women, exposure to nutritional counseling during ANC visits is associated with a lower likelihood of anemia, independent of potential confounders. Focused ANC counseling that includes nutritional counseling programs during ANC visits can be an effective strategy to prevent and control anemia. This article is protected by copyright. All rights reserved.

Association of women's empowerment with anaemia and haemoglobin concentration in children in sub-Saharan Africa: A multilevel analysis

We assessed the associations between women's empowerment and anaemia and haemoglobin concentration among children (6-59 months) in 31 sub-Saharan African (SSA) countries. We included 72,032 mother-child pairs from Demographic and Health Surveys conducted between 2006 and 2019. A three-dimensional women's empowerment index (attitude towards violence, decision making and social independence) was constructed using principal components analysis, and associations between the index and any anaemia and Hb concentration were assessed using multilevel regression. The mean (standard deviation) haemoglobin concentration was 102.3 (16.0 g/L) and 65.8% of the children were anaemic. The odds of anaemia reduced with increasing empowerment in the dimensions of attitude towards violence [quintile (Q5) versus Q1, OR 0.77; 95% confidence interval [CI] 0.65-0.89, p_trend  = 0.006], decision making (Q5 vs. Q1, OR 0.72; 95% CI 0.61-0.84, p_trend  < 0.001) and social independence (Q5 vs. Q1, OR 0.86; 95% CI 0.76-0.97, p_trend  = 0.015). The mean Hb concentration increased with increasing women's empowerment in the dimensions of attitude towards violence (Q5 vs. Q1, mean difference [MD] 1.40 g/L; 95% CI 0.63-2.17, p_trend  < 0.001) and social independence (Q5 vs. Q1, MD 1.32 g/L; 95% CI 0.36-2.28, p_trend  = 0.001). There was no evidence for a linear trend in the association between decision making and haemoglobin concentration (p_trend  = 0.051). Women's empowerment was associated with reduced odds of any anaemia and higher haemoglobin concentration in children. The promotion of women's empowerment may play a role in reducing the burden of childhood anaemia in SSA.

Skilled maternal healthcare and good essential newborn care practice in rural Bangladesh: A cross-sectional study

Background and Aims

Essential newborn care (ENC) practices play an important role in reducing the risk of infant mortality and morbidity. Therefore, more studies are needed on ENC practices. Skilled maternal healthcare can be a good strategy to increase the practice. Learn about the independent and joint effects of skilled maternal healthcare during pregnancy and childbirth on newborn care practices.

Methods

The study used a cross-sectional data obtained from Bangladesh Multiple Indicator Cluster Survey, 2019. To investigate the association between maternal healthcare utilization and good ENC practice (cord care, delayed bathing, and immediate breast-feeding), χ 2 test and t-test in bivariate and binary logistic regression analysis, respectively have been performed after taking into account complex survey design.

Results

Only about 24% (95% confidence interval [CI]: 22.95%-25.89%) women given birth at home in rural Bangladesh followed good newborn care practice. The results obtained from adjusted regression analysis showed that a woman was 24%, 49%, and 75% more likely of having good ENC practice if she received four or more skilled checkups during antenatal period only (adjusted odds ratios [AOR]: 1.24, 95% CI: 0.97, 1.60), received assistance from SBA during delivery only (AOR: 1.49, 95% CI 1.12, 1.97) and received skilled healthcare in both pregnancy and delivery (AOR: 1.75, 95% CI 1.13, 2.71), respectively compared to a woman who did not get an opportunity to receive skilled healthcare during pregnancy and delivery. Among the selected confounders, maternal age at birth, birth order, education of household heads and religion showed a significant association with good ENC practice.

Conclusion

The study revealed that proper maternal healthcare during pregnancy and childbirth from skilled health personnel can improve the rate of ENC practices. For this, more training programs should be started, especially at the community level, and health promotion activities are needed to create awareness about efficient maternal healthcare practices.

A non-linear decomposition analysis of children's dietary diversity scores: explaining rural-urban inequality

Sufficient and nourishing foods during the early years of a child's life are essential for optimal growth and healthy life. The existing disparities among rural-urban populations also affect the dietary pattern as well. Therefore, this study aims to identify the factors that contribute towards the rural-urban disparity in children's dietary diversity (CDD) and quantify their importance for the reduction of rural-urban disparities in achieving a minimum dietary diversity level. Using Pakistan Demographic and Health Survey (PDHS) data, version 2017-18, a non-linear decomposition analysis was performed. Eighty-one (81%) of the gap in CDD between rural-urban areas is attributed to the differences in the observed factors (endowments) and of these most of the difference is explained by three factors i.e. number of antenatal care visits (45%), maternal education (18%) and type of toilet facility (15%). There is a need to explore maternal education-related interventions to decrease the rural-urban gap regarding CDD as maternal education may affect CDD through different dimensions. Moreover, such programs should be initiated that may be helpful to enhance women's role in society, such as skilled education, well-paid job opportunities and better health facilities.

Does maternal empowerment improve dietary diversity of children? Evidence from Pakistan demographic and health survey 2017-18

The role of maternal empowerment (ME) to improve child nutrition in patriarchal societies of developing countries remains ambiguous. This study provides empirical evidence about the impact of ME and some other factors selected under United Nations International Children's Emergency Fund theoretical framework, on dietary diversity of children (under 5 years age) in Pakistan. Partial proportional odds model is estimated to obtain varying estimates of the parameters by using data of Pakistan Demographic and Health Survey 2017-18. Significant positive role of empowered mothers to improve child dietary diversity (CDD) is explored (OR = 1.135; Confidence Interval [CI] = 1.001-1.288). Moreover, positive association of maternal higher education on CDD (OR = 1.329; 95% CI = 1.085-1.628) supports the productive and allocative efficiency hypotheses of health economics. Maternal agricultural employment, paternal education, and paternal employment were not significantly associated with CDD. This requires further exploration. Positive association of household socioeconomic status with CDD (OR = 1.768; 95% CI = 1.314-2.380) and significance of some demographic variables call for social welfare programs. Positive association of mother's age and CDD demands for amendment in Child Marriage Restraint Act. The observed adverse association of family size with CDD induces effective family planning to control high birth rate in Pakistan. It may be concluded that ME and creation of awareness about nutrition security through maternal education are the important factors to overcome child malnutrition in Pakistan. Since, socioeconomic and cultural environment in South Asian countries is homogeneous, the analysis in this study might be relevant to the South Asian region. Moreover, the study provides evidence informing the debate on the role of ME to improve child nutrition in patriarchal societies.

Determinants and Trends of Health Facility Delivery in Bangladesh: A Hierarchical Modeling Approach

Background

Most maternal deaths occur during childbirth and after childbirth. This study was aimed at determining the trends of health facilities during delivery in Bangladesh, as well as their influencing factors.

Methods

This study used secondary data from three Bangladesh Multiple Indicator Cluster Surveys (MICSs) in 2006, 2012–13, and 2019. The study's target sample was those women who gave birth in the last two years of the survey. A two-level logistic regression was applied to determine the effects on health facility delivery separately in these two survey points (MICSs 2012–13 and 2019).

Results

The results show that the delivery of health facilities has increased by almost 37.4% in Bangladesh, from 16% in 2006 to 53.4% in 2019. The results of two-level logistic regression show that the total variation in health facility delivery across the community has decreased over recent years. After adding community variables, various individual-level factors such as women with secondary education (OR = 0.55 in 2012-13 vs. OR =0.60 in 2019), women from middle wealth status (OR = 0.49 in 2012-13 vs. OR = 0.65 in 2019), religion, and child ever born showed a strong relationship with health facility delivery in both survey years. At the community level, residents showed significant association only in the 2012-13 survey and indicated a 43% (OR = 1.43 for 2012-13) greater availability of health facilities in urban residences than in rural residences. Using media showed a highly significant connection with health facility delivery in both years as well as an increasing trend over the years in Bangladesh (OR = 1.19 in 2012-13 vs. OR = 1.38 in 2019). However, division, prenatal care, and skilled services all contribute greatly to increasing the delivery of health facilities in Bangladesh.

Conclusions

The results of this study suggest that policymakers need to pay attention to individual and community-level factors, especially women's education, poverty reduction, and adequate prenatal care provided by well-trained caregivers.

Gender and sociocultural factors in animal source foods (ASFs) access and consumption in lower-income households in urban informal settings of Nairobi, Kenya

BACKGROUND

Gender shapes household decision-making and access for nutritious diets, including animal source foods (ASFs) that impact on child health and nutrition status. However, research shows that the poorest households in the urban informal settlements of Nairobi have low ASFs consumption. This study was conducted to explore further from a qualitative perspective the gender, sociocultural factors affecting household ASF consumption this study.

METHODS

To explore further on the topic of study, an exploratory qualitative study was carried out to establish the factors that influence access, allocation and consumption of animal source foods (ASFs) by households in urban informal settings of Nairobi. Nineteen focus group discussions with men and women were conducted to enable in-depth exploration of ASFs consumption.

RESULTS

Gender influences decision-making of household ASFs dietary intake. Gendered power dynamics prevail with men as breadwinners and household heads often determining the food access and consumption of ASFs. Women are increasingly accessing short-term waged-based incomes in urban informal settings and now play a role in food and nutrition security for their households. This enforces the idea that women's decision-making autonomy is an important aspect of women empowerment, as it relates to women's dietary diversity and subsequently, better household nutritional status. As evidenced in this study, if a woman has bargaining power based on accessing incomes to support their household food needs, she will not jeopardize food security. The mobile digital money platform was key in enabling access to resources to access food. Use of trust to access food on credit and purchasing smaller packaged quantities of food were also enablers to access of food/ASFs.

Childhood maltreatment and decision-making autonomy in adulthood: The mediating roles of self-esteem and social support

BACKGROUND

Childhood maltreatment (CM) is connected with a large number of maladaptive long-term outcomes. Effective prevention and intervention hinges partly on our understanding of the key mediating mechanisms that help account for the relationship between child maltreatment and its long-term consequences. We know the consequences of CM can extend into adulthood, including the intergenerational transmission of violence, re-victimization, high-risk behavior, and persisting mental health problems. We argue that CM also likely affects decision-making autonomy in adulthood, limiting their independence and exaggerating their risk for other poor outcomes. We suggest that the effects of CM on self-esteem and access to social support mediate this relationship, helping to explain how and why CM impacts autonomy in the long term.

OBJECTIVE

This study aimed to examine these relationships using a cross-sectional sample of currently married women of Bangladesh aged 15-49 years (N = 426).

METHOD

A multi-stage random sampling technique was employed for data collection and a multivariate logistic regression technique was applied for data analysis.

RESULTS

Results from the multivariate logistic regression model revealed a direct effect of a history of CM on limited decision-making autonomy in adulthood and a full mediating effect of self-esteem and social support on the associations between CM and decision-making autonomy in women, even after adjusting for theoretically and empirically relevant covariates.

CONCLUSIONS

The study findings provide insight into the mechanisms by which early childhood experiences impact autonomous decision-making. However, causality cannot be determined because of the cross-sectional design. Finally, our findings suggest that the influence of CM on autonomy could be augmented by self-esteem recovery through social support from family, friends, and peers.

Consistencies and contradictions: Revisiting the relationship between women's education and infant mortality from a distributional perspective

The connection between women's education and infant mortality is one of the most consistent and powerful relationships established in public health. A large body of cross-national research highlights the benefits of women's access to education, especially for improving population health in developing countries. However, most of this literature assumes the relationship is uniform across cases. In this study, we revisit the education-health link using a distributional approach. To do so, we conduct a series of unconditional quantile regression analyses that estimate the impact of female secondary school enrollment on infant mortality rates across 153 countries from 1970 to 2016. This technique allows for the possibility that the relationship between education and health may vary across the distribution of mortality. Indeed, results show that the education advantage is distribution-specific. We find that the expected benefits of women's education are limited to the middle of the distribution where infant mortality rates range from about 11 to 55 deaths per 1000 live births. However, we find no significant effect where mortality is comparatively low or high. Both consistent with and contradictory to prior research, these findings provide a more nuanced picture of how women's access to education relates to global health inequalities.

Gender-Related Inequality in Childhood Immunization Coverage: A Cross-Sectional Analysis of DTP3 Coverage and Zero-Dose DTP Prevalence in 52 Countries Using the SWPER Global Index

Gender-related barriers to immunization are key targets to improve immunization coverage and equity. We used individual-level demographic and health survey data from 52 low- and middle-income countries to examine the relationship between women’s social independence (measured by the Survey-based Women’s emPowERment (SWPER) Global Index) and childhood immunization. The primary outcome was receipt of three doses of the diphtheria-tetanus-pertussis vaccine (DTP3) among children aged 12–35 months; we secondarily examined failure to receive any doses of DTP-containing vaccines. We summarized immunization coverage indicators by social independence tertile and estimated crude and adjusted summary measures of absolute and relative inequality. We conducted all analyses at the country level using individual data; median results across the 52 examined countries are also presented. In crude comparisons, median DTP3 coverage was 12.3 (95% CI 7.9; 16.3) percentage points higher among children of women with the highest social independence compared with children of women with the lowest. Thirty countries (58%) had a difference in coverage between those with the highest and lowest social independence of at least 10 percentage points. In adjusted models, the median coverage was 7.4 (95% CI 5.0; 9.1) percentage points higher among children of women with the highest social independence. Most countries (41, 79%) had statistically significant relative inequality in DTP3 coverage by social independence. The findings suggest that greater social independence for women was associated with better childhood immunization outcomes, adding evidence in support of gender-transformative strategies to reduce childhood immunization inequities.

Identifying the association of women’s empowerment with reproductive and maternal health practices using a cross-sectional study in the context of self-help groups in rural India

Background: Globally, women’s empowerment is captured through different combinations of indicators related to their collective and individual empowerment. In this paper, the association of diverse domains related to women’s collective and individual empowerment on their reproductive and maternal health practices were assessed. Collective empowerment referred to a cluster of indicators measuring mutual support, rights, and access to services women received, as a result of membership in self-help groups (SHGs) focused on micro-finance activities. Women’s individual empowerment was measured through their perception to make decisions on their own, be mobile, financially self-reliant, self-confident in expressing themselves, having self-esteem and being free from spousal violence. Methods: Cross-sectional data were collected in 2017 from 2,197 SHG members across 57 administrative blocks of Uttar Pradesh, India. Using exploratory and confirmatory factor analysis, the sub-domains of individual and collective empowerment were developed. The reproductive and maternal health indicators included antenatal care, delivery preparedness, postnatal care and current contraceptive use. Bivariate and multivariate analyses, using logistic regression, were carried out to measure the association of sub-domains of women’s empowerment with health practices. Results: Collective and individual empowerment were independently and jointly associated with correct health practices. Women with greater empowerment through independent mobility, high self-esteem, access to financial resources, and confidence in interacting with a frontline worker, were more likely to access antenatal care. Similarly, delivery preparedness—which entailed deciding on the place of delivery, arranging for transportation during labor, and managing expenses for the delivery—was positively influenced by collective support from fellow SHG members. Receiving postnatal care was positively associated with self-confidence and financial autonomy, and current family planning method use was positively associated with self-confidence, lower spousal violence and confidence in support from the group. Conclusions: Women’s collective and individual empowerment were independently and jointly positively associated with health outcomes among SHG members.

A simplified measure of nutritional empowerment: Using machine learning to abbreviate the Women's Empowerment in Nutrition Index (WENI)

Measuring empowerment is both complicated and time consuming. A number of recent efforts have focused on how to better measure this complex multidimensional concept such that it is easy to implement. In this paper, we use machine learning techniques, specifically LASSO, using survey data from five Indian states to abbreviate a recently developed measure of nutritional empowerment, the Women's Empowerment in Nutrition Index (WENI) that has 33 distinct indicators. Our preferred Abridged Women's Empowerment in Nutrition Index (A-WENI) consists of 20 indicators. We validate the A-WENI via a field survey from a new context, the western Indian state of Maharashtra. We find that the 20-indicator A-WENI is both capable of reproducing well the empowerment scores and status generated by the 33-indicator WENI and predicting nutritional outcomes such as BMI and dietary diversity. Using this index, we find that in our Maharashtra sample, on average, only 35.9% of mothers of children under the age of 5 years are nutritionally empowered, whereas 77.2% of their spouses are nutritionally empowered. We also find that only 14.6% of the elderly women are nutritionally empowered. These estimates are broadly consistent with those based on the 33-indicator WENI. The A-WENI will reduce the time burden on respondents and can be incorporated in any general purpose survey conducted in rural contexts. Many of the indicators in A-WENI are often collected routinely in contemporary household surveys. Hence, capturing nutritional empowerment does not entail significant additional burden. Developing A-WENI can thus aid in an expansion of efforts to measure nutritional empowerment; this is key to understanding better the barriers and challenges women face and help identify ways in which women can improve their nutritional well-being in meaningful ways.

National and subnational variations in gender relations and the utilization of maternal healthcare services in Nigeria

Introduction

poor maternal health outcomes remain a major public health issue in Nigeria. These have been shown to be affected by the low level of utilization of maternal healthcare services. This study investigates the levels of gender relations (GR) among Nigerian women and how these influence their utilization of maternal healthcare services. The relations are conceptualized as feminine (FGR), masculine (MGR) and egalitarian.

Methods

data on household decision-making, antenatal care (ANC) visits, health facility delivery, and associated sociodemographic variables, were extracted from the 2018 Nigeria Demographic and Health Survey for 29,992 parous women aged 15-49 for a cross-sectional study. Associations were investigated using Chi-Square and regression analyses.

Results

women with FGR constituted 5.7% of the population at the national level, while subnational variations ranged from 1.8% in the North-East to 12.8% in the South-South regions. The prevalence rates of the recommended minimum ANC visits (RMANC) and health facility delivery were 42.1% and 30.0% at the national level and were lowest in the northern regions. At both the unadjusted and adjusted levels, FGR was not significantly associated with RMANC and health facility delivery at the national level and in all the regions except the South-West. MGR was however significantly associated with increased odds of RMANC (OR: 2.235, CI: 2.043-2.444) and health facility delivery (OR: 2.571, CI: 2.369-2.791) at national level. Significant subnational variations in the association between gender relations and the utilization of maternal healthcare services were also recorded.

Conclusion

sub-national variations in GR and their varying impacts on the utilization of maternal healthcare services in Nigeria suggest that gender-related policies to improve maternal health outcomes should be location-specific, rather than general. As FGR did not affect maternal healthcare services utilization, educating men on the benefits of supporting their wives to scale-up utilization is recommended.

The relationship between health literacy and empowerment in pregnant women: a cross-sectional study

Background

Maternal health literacy is defined as the acquisition of required cognitive and social skills to enable women to access, understand, appraise, and use the information needed to maintain and enhance their health conditions. The World Health Organization (WHO) proposes health literacy and women empowerment as two pivotal components of maternal health improvement programs. In this regard, providing women with education and training in various fields is a key factor for their empowerment, prosperity, and well-being. Therefore, the present study aimed to determine the relationship between health literacy and empowerment during pregnancy.

Methods

This descriptive-analytical cross-sectional study examined 355 pregnant women, presented to different health centers in Sanandaj, Iran, in 2021. The cluster technique was used for sampling. For data collection, the socio-demographic and obstetrics characteristics, health literacy, and pregnant women's empowerment questionnaires were completed by interviewing research subjects. Data analysis was done using t-test, one-way ANOVA, Pearson correlation coefficient, and multivariate linear regression in STATA13.

Results

The mean and standard deviation of health literacy and empowerment were 80.03 ± 12.79 (0–100) and 80.30 ± 8.14 (27–108), respectively. In terms of empowerment, the highest (19.50) and the lowest (12.92) scores were, respectively, observed in subdomains of “self-efficacy” and “the joy of an addition to the family.” With respect to health literacy, the highest (88.52) and lowest (73.78) mean scores were, respectively, observed in the subdomains of “understanding” and “access.” Pearson correlation test suggested that there was a significant direct correlation between the overall health literacy (r = 0.26; p < 0.001) and access (r = 0.18; p = 0.001), understanding (r = 0.11; p = 0.038), evaluation (r = 0.18; p = 0.001), and decision-making (r = 0.33; p < 0.001) with empowerment during pregnancy. Based on the multivariate linear regression model, empowerment during pregnancy improved with increasing health literacy (B = 0.16, 95% CI = 0.09 to 0.23; p < 0.001).

Conclusion

The results show a direct relationship between health literacy and its dimensions with empowerment during pregnancy. Therefore, it is recommended to improve the health literacy of all women of reproductive age.

Perinatal considerations for care of transgender and nonbinary people: a narrative review

PURPOSE OF REVIEW

The visibility of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities, specifically the transgender and nonbinary (TGNB) communities, continues to grow. However, there is little description, much less guidance toward optimizing, the pregnancy-related care of TGNB people. The overarching goal of this paper is to provide guidance that aids in reimagining obstetrics to include people of all genders.

RECENT FINDINGS

This article will review current literature and provide recommendations specific to the hospital birthing environment to help address the lack of knowledge regarding pregnancy-related care of TGNB individuals. This care is further divided into three main times: (1) preconception, antepartum care, and triage, (2) intrapartum, and (3) postpartum. We also discuss considerations for the general medical care of TGNB individuals.

SUMMARY

Understanding facilitators and barriers to gender affirming pregnancy-related care of TGNB individuals are first steps toward providing a respectful, affirming, and evidence-based environment for all patients, especially TGNB individuals. Here we provide context, discussion, and resources for providers and TGNB patients navigating pregnancy-related care. Lastly, this review challenges researchers and clinicians with future directions for the care of TGNB individuals in this continually expanding field.

Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys

Background

To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women’s empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys.

Methods

We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women’s empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women’s empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries.

Results

In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level.

Conclusions

Our country-level and individual-level analyses support the importance of women’s empowerment for child vaccination, especially in countries with weaker routine immunisation programs.

Empowerment in pregnancy: ART adherence among women living with HIV in Cape Town, South Africa

RATIONALE

Adherence to antiretroviral therapy (ART) is a global concern among pregnant and postpartum women living with HIV (WLHIV). Research focusing on peripartum WLHIV and how they balance adherence, engaging in HIV care, and other forms of self-care is limited. Women's empowerment theories have been applied to myriad health behaviors to understand patterns, establish mechanisms, and develop interventions; yet empowerment theory as applied to ART is under-researched.

OBJECTIVE

Seeking deeper insight into peripartum health behaviors, we examine these factors using Naila Kabeer's (1999) women's empowerment theory, which denotes resources, agency, and achievements as three primary and interrelated components of empowerment.

METHODS

Data were collected in Gugulethu, South Africa, between March and July 2018. Thirty in-depth interviews were conducted with WLHIV at 32-35 weeks of pregnancy, with topics including experiences related to ART adherence and meanings of empowerment in motherhood. Analyses had two phases: (1) inductive open-coding for emergent themes; and (2) classifying themes into Kabeer's empowerment theory.

RESULTS

Participants expressed that resources play a critical role in adherence, ranging from practical support to motivational support provided by both family and partners. Agency is experienced as a desire to be an independent mother in the often-expected event that partners withdraw support. Participants described achievements as time-oriented goals, ranging from having a baby born without HIV to living a long and productive life.

CONCLUSIONS

These findings suggest that a promising and innovative approach to improving ART adherence across the peripartum transition would focus on understanding resources as an enabling environment, build on existing feelings of agency, and highlight the lifelong goals achievable with high levels of adherence. A better understanding of how women's empowerment evolves over the course of pregnancy and into the postpartum period will support intervention development aimed at improving ART adherence and potentially additional peripartum health behaviors.

Exploring a theory of change: Are increases in parental empowerment associated with healthier weight-related parenting practices?

INTRODUCTION

Parent health-related empowerment is defined as the process by which parents realize control over their life situation and take action to promote a healthier lifestyle. For decades, researchers have described the theoretical potential of empowerment in health promotion efforts, though few have empirically examined this hypothesized relationship. This study is one of the first to examine the relationship between parental empowerment and healthy weight parenting practices (i.e., food, physical activity, sleep, and media parenting), as a mechanism for early childhood health promotion in community settings.

METHODS

Low-income parents of preschool-aged children attending Head Start in Greater Boston between fall 2017 and spring 2019 were invited to complete a survey in the fall and spring of each academic school year (n = 578 with two surveys and n = 45 with four). Parental empowerment and healthy weight parenting practices were assessed using validated surveys. We used a multilevel difference-in-difference approach to estimate changes in healthy weight parenting practices score by changes in parental empowerment score.

RESULTS

Out of a possible score of four, the unadjusted mean (SD) score in fall was 3.20 (0.40) for empowerment and 3.01 (0.40) for parenting. An increase in parental empowerment was associated with an increase in healthier parenting practices (b = 0.14; 95% CI = 0.08, 0.20; p < 0.0001).

CONCLUSIONS

Parent empowerment may be an important target in interventions to prevent obesity in low-income children.

Protocol for development and validation of instruments to measure women's empowerment in urban sanitation across countries in South Asia and Sub-Saharan Africa: the Agency, Resources and Institutional Structures for Sanitation-related Empowerment (ARISE) scales

INTRODUCTION

Despite an increasing emphasis on gender and empowerment in water, sanitation and hygiene (WaSH) programmes, no rigorously validated survey instruments exist for measuring empowerment within the WaSH sector. Our objective is to develop and validate quantitative survey instruments to measure women's empowerment in relation to sanitation in urban areas of low-income and middle-income countries.

METHODS AND ANALYSIS

We are developing the Agency, Resources and Institutional Structures for Sanitation-related Empowerment scales through a process that involves three phases: item development; scale development and initial validation and scale evaluation and further validation. The first phase includes domain specification, item generation, face validity and content validity assessment and item refinement. The second phase involves a second round of face validity and content validity assessment, followed by survey implementation in two cities (Tiruchirappalli, India and Kampala, Uganda) and data analysis involving factor analysis and item response theory approaches as well as reliability and validity testing. The third phase involves a final round of face validity and content validity assessment, followed by survey implementation in three additional cities (Narsapur and Warangal, India and Lusaka, Zambia) and statistical analysis using similar approaches as in phase 2 for further validation.

ETHICS AND DISSEMINATION

Ethics approvals have been received from the Emory University Institutional Review Board (USA); Azim Premji University and Indian Institute of Health Management Research Institutional Review Boards (India); Makerere University School of Health Sciences Research and Ethics Committee (Uganda); and ERES Converge Institutional Review Board (Zambia). The study team will share findings with key stakeholders to inform programming activities and will publish results in peer-reviewed journals.

Single motherhood, social independence and non-communicable disease (NCD) outcomes among young females (15-24 years old) in South Africa

Background: Non-communicable diseases (NCDs) acquired during youth follow into and affect adulthood. The association between young mother’s social independence and NCD status is of policy interest due to its effect on economic and social development. This study aimed to determine the causal relationship between social independence and NCD outcomes among young, single mothers in South Africa. Methods: Data from the South African National Income Dynamics Survey (NIDS) in 2008 and 2017 was used to determine if single mothers developed hypertension, diabetes or asthma by various indicators of social independence, including highest level of education and employment status. The sample was initially made-up of unmarried females (15-24 years old) without any children in 2008. Both fertility and social independence was followed-up to 2017. Results: In total, 66 young females developed an NCD by 2017 and 87% (n=57) of these women had a child in the interim period. Employment of young females increased from 4.78% in 2008 to 37.79% in 2017, but completion of secondary or tertiary education declined from 67.94% in 2008 to 56.01% in 2017. In addition, half (50.88%) of the young females were partially independent by 2017, with only 11.03% being fully independent at this time. Finally, logistic regression results showed that the likelihood of developing an NCD increased if young females with children were not socially independent. Conclusions: The relationship between social independence and NCDs suggest that policies and programmes in South Africa need to incorporate socioeconomic status as a determinant of disease and in particular, need to address socioeconomic indicators as additive measures and not autonomous indicators.