Climatic influence on the magnitude of COVID-19 outbreak: a stochastic model-based global analysis

We investigate the climatic influence on COVID-19 transmission risks in 228 cities globally across three climatic zones. The results, based on the application of a Boosted Regression Tree algorithm method, show that average temperature and average relative humidity explain significant variations in COVID-19 transmission across temperate and subtropical regions, whereas in the tropical region, the average diurnal temperature range and temperature seasonality significantly predict the infection outbreak. The number of positive cases showed a decrease sharply above an average temperature of 10°C in the cities of France, Turkey, the US, the UK, and Germany. Among the tropical countries, COVID-19 in Indian cities is most affected by mean diurnal temperature, and those in Brazil by temperature seasonality. The findings have implications on public health interventions, and contribute to the ongoing scientific and policy discourse on the complex interplay of climatic factors determining the risks of COVID-19 transmission.

Breaking the silence about obstetric violence: Body mapping women’s narratives of respect, disrespect and abuse during childbirth in Bihar, India

Background

Evidence on obstetric violence is reported globally. In India, research shows that almost every woman goes through some level of disrespect and abuse during childbirth, more so in states such as Bihar where over 70% of women give birth in hospitals.

Objective

1) To understand how women experience and attach meaning to respect, disrespect and abuse during childbirth; and 2) document women’s expectations of respectful care.

Methods

‘Body mapping’, an arts-based participatory method, was applied. The analysis is based on in-depth interviews with eight women who participated in the body mapping exercise at their homes in urban slums and rural villages. Analysis was guided by feminist relational discourse analysis.

Findings

Women reported their experiences of birthing at home, public facilities, and private hospitals in simple terms of what they felt ‘good’ and ‘bad’. Good experiences included being spoken to nicely, respecting privacy, companion of choice, a bed to rest, timely care, lesser interventions, obtaining consent for vaginal examination and cesarean section, and better communication. Bad experiences included unconsented interventions including multiple vaginal examinations by different care providers, unanesthetized episiotomy, repairs and uterine exploration, verbal, physical, sexual abuse, extortion, detention and lack of privacy.

Discussion

The body maps capturing birth experiences, created through a participatory method, accurately portray women’s respectful and disrespectful births and are useful to understand women’s experience of a sensitive issue in a patriarchal culture. An in-depth understanding of women’s choices, experiences and expectations can inform changes practices in and policies and help to develop a culture of sharing birth experiences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04503-7.

Challenges and needed reforms in midwifery and nursing regulatory systems in India: Implications for education and practice

BACKGROUND

In India, nursing regulation is generally weak, midwifery coexists with nursing, and 88% of nursing and midwifery education is provided by the private health sector. The Indian health system faces major challenges for health care provision due to poor quality, indeterminate regulatory functions and lack of reforms.

METHODS

We undertook a qualitative investigation to understand midwifery and nursing education, and regulatory systems in India, through a review of the regulatory Acts, and an investigation of the perceptions and experiences of senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision in India with an international perspective.

RESULTS

There is a lack of importance accorded to midwifery roles within the nursing system. The councils and Acts do not adequately reflect midwifery practice, and remain a barrier to good quality care provision. The lack of required amendment of Acts, lack of representation of midwives and nurses in key governance positions in councils and committees have restrained and undermined leadership positions, which have also impaired the growth of the professions. A lack of opportunities for professional practice and unfair assessment practices are critical concerns affecting the quality of nursing and midwifery education in private institutions across India. Midwifery and nursing students are generally more vulnerable to discrimination and have less opportunities compared to medical students exacerbated by the gender-based challenges.

CONCLUSIONS

India is on the verge of a major regulatory reform with the National Nursing and Midwifery Commission Bill, 2020 being drafted, which makes this study a crucial and timely contribution. Our findings present the challenges that need to be addressed with regulatory reforms to enable opportunities for direct-entry into the midwifery profession, improving nursing education and practice by empowering midwives and nurses with decision-making powers for nursing and midwifery workforce governance.

Challenges and needed reforms in midwifery and nursing regulatory systems in India: Implications for education and practice

BACKGROUND

In India, nursing regulation is generally weak, midwifery coexists with nursing, and 88% of nursing and midwifery education is provided by the private health sector. The Indian health system faces major challenges for health care provision due to poor quality, indeterminate regulatory functions and lack of reforms.

METHODS

We undertook a qualitative investigation to understand midwifery and nursing education, and regulatory systems in India, through a review of the regulatory Acts, and an investigation of the perceptions and experiences of senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision in India with an international perspective.

RESULTS

There is a lack of importance accorded to midwifery roles within the nursing system. The councils and Acts do not adequately reflect midwifery practice, and remain a barrier to good quality care provision. The lack of required amendment of Acts, lack of representation of midwives and nurses in key governance positions in councils and committees have restrained and undermined leadership positions, which have also impaired the growth of the professions. A lack of opportunities for professional practice and unfair assessment practices are critical concerns affecting the quality of nursing and midwifery education in private institutions across India. Midwifery and nursing students are generally more vulnerable to discrimination and have less opportunities compared to medical students exacerbated by the gender-based challenges.

CONCLUSIONS

India is on the verge of a major regulatory reform with the National Nursing and Midwifery Commission Bill, 2020 being drafted, which makes this study a crucial and timely contribution. Our findings present the challenges that need to be addressed with regulatory reforms to enable opportunities for direct-entry into the midwifery profession, improving nursing education and practice by empowering midwives and nurses with decision-making powers for nursing and midwifery workforce governance.

Forecasting the SARS COVID-19 pandemic and critical care resources threshold in the Gulf Cooperation Council (GCC) countries: population analysis of aggregate data

OBJECTIVE

To generate cross-national forecasts of COVID-19 trajectories and quantify the associated impact on essential critical care resources for disease management in Gulf Cooperation Council (GCC) countries.

DESIGN

Population-level aggregate analysis.

SETTING

Bahrain, Kuwait, Oman, Qatar, United Arab Emirates (UAE) and Saudi Arabia.

METHODS

We applied an extended time-dependent SEICRD compartmental model to predict the flow of people between six states, susceptible-exposed-infected-critical-recovery-death, accounting for community mitigation strategies and the latent period between exposure and infected and contagious states. Then, we used the WHO Adaptt Surge Planning Tool to predict intensive care unit (ICU) and human resources capacity based on predicted daily active and cumulative infections from the SEICRD model.

MAIN OUTCOME MEASURES

Predicted COVID-19 infections, deaths, and ICU and human resources capacity for disease management.

RESULTS

COVID-19 infections vary daily from 498 per million in Bahrain to over 300 per million in UAE and Qatar, to 9 per million in Saudi Arabia. The cumulative number of deaths varies from 302 per million in Oman to 89 in Qatar. UAE attained its first peak as early as 21 April 2020, whereas Oman had its peak on 29 August 2020. In absolute terms, Saudi Arabia is predicted to have the highest COVID-19 mortality burden, followed by UAE and Oman. The predicted maximum number of COVID-19-infected patients in need of oxygen therapy during the peak of emergency admissions varies between 690 in Bahrain, 1440 in Oman and over 10 000 in Saudi Arabia.

CONCLUSION

Although most GCC countries have managed to flatten the epidemiological curve by August 2020, trends since November 2020 show potential increase in new infections. The pandemic is predicted to recede by August 2021, provided the existing infection control measures continue effectively and consistently across all countries. Current health infrastructure including the provision of ICUs and nursing staff seem adequate, but health systems should keep ICUs ready to manage critically ill patients.

Why do some health care providers disrespect and abuse women during childbirth in India?

BACKGROUND

Disrespect and abuse during childbirth can result in fear of childbirth. Consequently, women may be discouraged to seek care, increasing the likelihood for women to choose elective cesarean section in order to avoid humiliation, postnatal depression and even maternal mortality. This study investigates the causes underlying mistreatment of women during childbirth by health care providers in India, where evidence of disrespect and abuse has been reported.

METHODS

Qualitative research was undertaken involving 34 in-depth interviews with midwifery and nursing leaders from India who represent administration, advocacy, education, regulation, research and service provision at state and national levels. Data are analysed thematically with NVivo12. The analysis added value by bringing an international perspective from interviews with midwifery leaders from Switzerland and the United Kingdom.

FINDINGS

The factors leading to disrespect and abuse of women relate to characteristics of both women and their midwives. Relevant woman-related attributes include her age, gender, physical appearance and education, extending to the social environment including her social status, family support, culture of abuse, myths around childbirth and sex-based discrimination. Midwife-related factors include gender, workload, medical hierarchy, bullying and powerlessness.

DISCUSSION

The intersectionality of factors associated with mistreatment during childbirth operate at individual, infrastructural, social and policy levels for both the women and nurse-midwives, and these factors could exacerbate existing gender-based inequalities. Maternal health policies should address the complex interplay of these factors to ensure a positive birthing experience for women in India.

CONCLUSION

Maternal health interventions could improve by integrating women-centred protocols and monitoring measures to ensure respectful and dignified care during childbirth.

Disentangling the effects of reproductive behaviours and fertility preferences on child growth in India

We analysed population data from the 2015-16 National Family Health Survey to disentangle the intricate underlying effects of reproductive behaviours and fertility preferences on child growth. We expected birth interval length to be more strongly associated with stunting than sibsize and these effects to be moderated by whether the child was wanted or unintended (mistimed/unwanted). Regression analyses showed strong and equal effects of short birth interval and sibsize on stunting, when adjusted for potential confounders and unobserved between-mother heterogeneity. There were no statistical associations between stunting and mistiming/unwantedness of index children, suggesting the absence of discrimination against such children. We conclude that while fertility preferences have no effect, reproductive behaviours exert significant influence on child growth. Sibsize has been falling for many years in India but birth interval lengths have remained largely unchanged. The results underscore the need for strengthening uptake of reversible contraceptives to enable longer birth intervals.

Social inequalities in low birthweight outcomes in Sri Lanka: evidence from the Demographic and Health Survey 2016

OBJECTIVE

To investigate social inequalities underlying low birthweight (LBW) outcomes in Sri Lanka.

DESIGN

Cross-sectional study.

SETTING

This study used the Sri Lanka Demographic and Health Survey 2016, the first such survey to cover the entire country since the Civil War ended in 2001.

PARTICIPANTS

Birthweight data extracted from the child health development records available for 7713 babies born between January 2011 and the date of interview in 2016.

OUTCOME MEASURES

The main outcome variable was birth weight, classified as LBW (≤2500 g) and normal.

METHODS

We applied random intercept three-level logistic regression to examine the association between LBW and maternal, socioeconomic and geographic variables. Concentration indices were estimated for different population subgroups.

RESULTS

The population-level prevalence of LBW was 16.9% but was significantly higher in the estate sector (28.4%) compared with rural (16.6%) and urban (13.6%) areas. Negative concentration indices suggest a relatively higher concentration of LBW in poor households in rural areas and the estate sector. Results from fixed effects logistic regression models confirmed our hypothesis of significantly higher risk of LBW outcomes across poorer households and Indian Tamil communities (AOR 1.70, 95% CI 1.02 to 2.83, p<0.05). Results from random intercept models confirmed there was substantial unobserved variation in LBW outcomes at the mother level. The effect of maternal biological variables was larger than that of socioeconomic factors.

CONCLUSION

LBW rates are significantly higher among babies born in poorer households and Indian Tamil communities. The findings highlight the need for nutrition interventions targeting pregnant women of Indian Tamil ethnicity and those living in economically deprived households.

Power relations and negotiations in contraceptive decision-making when husbands oppose family planning: analysis of ethnographic vignette couple data in Southwest Nigeria

Contraceptive use in Nigeria has remained low at less than 15% for over two decades. Although husbands' opposition is acknowledged as one of the factors impeding women's contraceptive use, little is known about how wives negotiate when their husbands oppose family planning. We addressed this research gap by conducting thematic analyses of qualitative data from 30 interviews of married couples. We employed thematic analysis to identify relevant themes from the transcribed data. The findings clearly demonstrate attitudes highlighting an imbalance in power relations and contraceptive decision-making within marital relationships. By initially complying with the husband's wish as a 'sign of honour', and then making further attempts at convincing him about family planning use, a woman can achieve her contraceptive target, or through the involvement of a third party. Wives are less empowered to overtly use contraceptives when their husbands oppose family planning. However, there are accepted justifications for covert use. The findings underscore the need to strengthen family planning interventions to enable behavioural change among Nigerian men, promote gender and reproductive health rights, and empower women with better negotiation skills.

Recurrent child mortality risks and parity transition in Nigeria

BACKGROUND

Fertility rates remain persistently high in Nigeria, with little difference across socioeconomic groups. While the desire for large family size is culturally rooted, there is little understanding of how repeated child mortality experiences influence fertility behaviour and parity transition in Nigeria.

METHODS

Using birth history data from the 2013 Nigeria Demographic and Health Survey (NDHS), we applied life table techniques and proportional-hazard regression model to explore the effect of child survival experience on parity transitions. We hypothesize that a woman with one or more child death experience is at elevated risk of progressing towards higher parities.

RESULTS

Our findings show that child mortality is concentrated among mothers living in deprived conditions especially in rural areas of the northern part of Nigeria and among those with little or no education and, among those belonging to Hausa/Fulani ethnicity and Islam religion. Mothers with repeated experience of child deaths were significantly at a higher rate of progressing to higher parities than their counterparts (HR: 1.45; 95% CI: 1.31-1.61), when adjusted for relevant biological and socio-demographic characteristics.

CONCLUSION

Recurrent experience of child deaths exacerbates the risks to higher parity transition. Interventions aimed at reducing fertility in Nigeria should target promoting child survival and family planning concurrently.

Socio-economic differentials in minimum dietary diversity among young children in South-East Asia: evidence from Demographic and Health Surveys

OBJECTIVE

To investigate the socio-economic differentials underlying minimum dietary diversity (MDD) among children aged 6-23 months in three economically diverse South-East Asian countries.

DESIGN

The outcome variable MDD was defined as the proportion of children aged 6-23 months who received foods from four of the seven recommended food groups within the 24 h prior to interview. The association between socio-economic factors and MDD, adjusting for relevant characteristics, was examined using logistic regression.

SETTING

We used cross-sectional population data from recent Demographic and Health Surveys from Cambodia (2014), Myanmar (2015-16) and Indonesia (2012).

SUBJECTS

Total of 8364 children aged 6-23 months.

RESULTS

Approximately half of all children met the MDD, varying from 47·7 % in Cambodia (n 1023) to 58·2 % in Indonesia (n 2907) and 24·6 % in Myanmar (n 301). The likelihood (adjusted OR; 95 % CI) of meeting MDD increased for children in the richest households (Cambodia: 2·4; 1·7, 3·4; Myanmar: 1·8; 1·1, 3·0; Indonesia: 2·0; 1·6, 2·5) and those residing in urban areas (Cambodia: 1·4; 1·1, 1·9; Myanmar: 1·7; 1·2, 2·4; Indonesia: 1·7; 1·5, 1·9). MDD deprivation was most severe among children from the poorest households in rural areas. The association between mother's labour force participation and MDD was positive in all three countries but reached significance only in Indonesia (1·3; 1·1, 1·5).

CONCLUSIONS

MDD deprivation among young children was significantly high in socio-economically disadvantaged families in all three study settings. MDD requirements are not being met for approximately half of young children in these three South-East Asian countries.

Interventions to improve immigrant health. A scoping review

Background: Disparities in health between immigrants and their host populations have been described across countries and continents. Hence, interventions for improving health targeting general populations are not necessarily effective for immigrants. Aims: To conduct a systematic search of the literature evaluating health interventions for immigrants; to map the characteristics of identified studies including range of interventions, immigrant populations and their host countries, clinical areas targeted and reported evaluations, challenges and limitations of the interventions identified. Following the results, to develop recommendations for research in the field. Methods: A scoping review approach was chosen to provide an overview of the type, extent and quantity of research available. Studies were included if they empirically evaluated health interventions targeting immigrants and/or their descendants, included a control group, and were published in English (PubMed and Embase from 1990 to 2015). Results: Most of the 83 studies included were conducted in the USA, encompassed few immigrant groups and used a randomized controlled trial (RCT) or cluster RCT design. Most interventions addressed chronic and non-communicable diseases and attendance at cancer screening services, used individual targeted approaches, targeted adult women and recruited participants from health centres. Outcome measures were often subjective, with the exception of interventions for cardiovascular risk and diabetes. Generally, authors claimed that interventions were beneficial, despite a number of reported limitations. Conclusions: Recommendations for enhancing interventions to improve immigrant health are provided to help researchers, funders and health care commissioners when deciding upon the scope, nature and design of future research in this area.

Impact of men's perception on family planning demand and uptake in Nigeria

OBJECTIVE

Evidence from the last three Demographic and Health Surveys (DHS) in Nigeria shows slow progress in family planning (FP) uptake, despite programmatic interventions. While socioeconomic and religious barriers continue to exist, psychosocial factors such as negative contraceptive perceptions by male partners may influence both spousal FP demand and use. Therefore, this research investigates the influence of male partners' contraceptive perceptions on spousal FP demand and use.

METHODS

We analysed the couple dataset from the 2013 Nigeria DHS.

RESULTS

One in five men held the perception that contraceptive use is women's business whereas two in five men reported that women who use family planning may become promiscuous, especially older men, those with no formal education, Muslims and residents in rural areas and northern region. Results from regression models, controlling for relevant sociodemographic characteristics, show that men's perception that contraception is women's business did not significantly influence FP demand. However, their fear that women who use family planning may become promiscuous was associated with lower odds of FP demand (AOR: 0.86; 95% CI: 0.76-0.97) and increased the odds of traditional methods use (AOR: 1.34; 95% CI: 1.01-1.79).

CONCLUSION

The findings direct the need to adopt targeted approach focusing on couples, and reorient policy and program efforts for FP counselling and behavioural changes in men.

Disentangling age-gender interactions associated with risks of fatal and non-fatal road traffic injuries in the Sultanate of Oman

Objective

Road traffic injuries (RTIs) are the leading cause of disability-adjusted life years lost in Oman, Saudi Arabia and United Arab Emirates. Injury prevention strategies often overlook the interaction of individual and behavioural risk factors in assessing the severity of RTI outcomes. We conducted a systematic investigation of the underlying interactive effects of age and gender on the severity of fatal and non-fatal RTI outcomes in the Sultanate of Oman.

Methods

We used the Royal Oman Police national database of road traffic crashes for the period 2010–2014. Our study was based on 35 785 registered incidents: of these, 10.2% fatal injuries, 6.2% serious, 27.3% moderate, 37.3% mild injuries and 19% only vehicle damage but no human injuries. We applied a generalised ordered logit regression to estimate the effect of age and gender on RTI severity, controlling for risk behaviours, personal characteristics, vehicle, road, traffic, environment conditions and geographical location.

Results

The most dominant group at risk of all types of RTIs was young male drivers. The probability of severe incapacitating injuries was the highest for drivers aged 25–29 (26.6%) years, whereas the probability of fatal injuries was the highest for those aged 20–24 (26.9%) years. Analysis of three-way interactions of age, gender and causes of crash show that overspeeding was the primary cause of different types of RTIs. In particular, the probability of fatal injuries among male drivers attributed to overspeeding ranged from 3%–6% for those aged 35 years and above to 13.4% and 17.7% for those aged 25–29 years and 20–24 years, respectively.

Conclusions

The high burden of severe and fatal RTIs in Oman was primarily attributed to overspeed driving behaviour of young male drivers in the 20–29 years age range. Our findings highlight the critical need for designing early gender-sensitive road safety interventions targeting young male and female drivers.

Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis

Background

Total domestic and international funding for malaria is inadequate to achieve WHO global targets in burden reduction by 2030. We describe the trends of investments in malaria-related research in sub-Saharan Africa and compare investment with national disease burden to identify areas of funding strength and potentially neglected populations. We also considered funding for malaria control.

Methods

Research funding data related to malaria for 1997–2013 were sourced from existing datasets, from 13 major public and philanthropic global health funders, and from funding databases. Investments (reported in US$) were considered by geographical area and compared with data on parasite prevalence and populations at risk in sub-Saharan Africa. 45 sub-Saharan African countries were ranked by amount of research funding received.

Findings

We found 333 research awards totalling US$814·4 million. Public health research covered $308·1 million (37·8%) and clinical trials covered $275·2 million (33·8%). Tanzania ($107·8 million [13·2%]), Uganda ($97·9 million [12·0%]), and Kenya ($92·9 million [11·4%]) received the highest sum of research investment and the most research awards. Malawi, Tanzania, and Uganda remained highly ranked after adjusting for national gross domestic product. Countries with a reasonably high malaria burden that received little research investment or funding for malaria control included Central African Republic (ranked 40th) and Sierra Leone (ranked 35th). Congo (Brazzaville) and Guinea had reasonably high malaria mortality, yet Congo (Brazzaville) ranked 38th and Guinea ranked 25th, thus receiving little investment.

Interpretation

Some countries receive reasonably large investments in malaria-related research (Tanzania, Kenya, Uganda), whereas others receive little or no investments (Sierra Leone, Central African Republic). Research investments are typically highest in countries where funding for malaria control is also high. Investment strategies should consider more equitable research and operational investments across countries to include currently neglected and susceptible populations.

Funding

Royal Society of Tropical Medicine and Hygiene and Bill & Melinda Gates Foundation.

Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?

OBJECTIVE

To investigate, the impact of maternity-related fee payment policies on the uptake of skilled birth care amongst the poor in Ghana.

METHODS

Population data representing 12 288 births between November 1990 and October 2008 from four consecutive rounds of the Ghana demographic and health surveys were used to examine the impact of four major maternity-related payment policies: the full-cost recovery 'cash and carry' scheme; 'antenatal care fee exemption'; 'delivery care fee exemption' and the 'National Health Insurance Scheme (NHIS)'. Concentration curves were used to analyse the rich-poor gap in the use of skilled birth care by the four policy interventions. Multilevel logistic regression was used to examine the effect of the policies on the uptake of skilled birth care, adjusting for relevant predictors and clustering within communities and districts.

FINDINGS

The uptake of skilled birth care over the policy periods for the poorest women was trivial when compared with their non-poor counterparts. The rich-poor gap in skilled birth care use was highly pronounced during the 'cash and carry' and 'free antenatal care' policies period. The benefits during the 'free delivery care' and ' NHIS' policy periods accrued more for the rich than the poor. There exist significant differences in skilled birth care use between and within communities and districts, even after adjusting for policy effects and other relevant predictors.

CONCLUSIONS

The maternal care fee exemption policies specifically targeted towards the poorest women had limited impact on the uptake of skilled birth care.

Contraceptive confidence and timing of first birth in Moldova: an event history analysis of retrospective data

OBJECTIVES

To test the contraceptive confidence hypothesis in a modern context. The hypothesis is that women using effective or modern contraceptive methods have increased contraceptive confidence and hence a shorter interval between marriage and first birth than users of ineffective or traditional methods. We extend the hypothesis to incorporate the role of abortion, arguing that it acts as a substitute for contraception in the study context.

SETTING

Moldova, a country in South-East Europe. Moldova exhibits high use of traditional contraceptive methods and abortion compared with other European countries.

PARTICIPANTS

Data are from a secondary analysis of the 2005 Moldovan Demographic and Health Survey, a nationally representative sample survey. 5377 unmarried women were selected.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measure was the interval between marriage and first birth. This was modelled using a piecewise-constant hazard regression, with abortion and contraceptive method types as primary variables along with relevant sociodemographic controls.

RESULTS

Women with high contraceptive confidence (modern method users) have a higher cumulative hazard of first birth 36 months following marriage (0.88 (0.87 to 0.89)) compared with women with low contraceptive confidence (traditional method users, cumulative hazard: 0.85 (0.84 to 0.85)). This is consistent with the contraceptive confidence hypothesis. There is a higher cumulative hazard of first birth among women with low (0.80 (0.79 to 0.80)) and moderate abortion propensities (0.76 (0.75 to 0.77)) than women with no abortion propensity (0.73 (0.72 to 0.74)) 24 months after marriage.

CONCLUSIONS

Effective contraceptive use tends to increase contraceptive confidence and is associated with a shorter interval between marriage and first birth. Increased use of abortion also tends to increase contraceptive confidence and shorten birth duration, although this effect is non-linear-women with a very high use of abortion tend to have lengthy intervals between marriage and first birth.

Contraceptive behavior among women after abortion in Nepal

OBJECTIVE

To investigate the timing of contraceptive use and estimate the discontinuation rates of temporary methods among women after abortion, or a live birth or stillbirth.

METHODS

A sample of married women with detailed pregnancy and contraceptive histories was analyzed in a population-based cross-sectional study based on calendar data extracted from the 2011 Nepal Demographic and Health Survey. Kaplan-Meier cumulative and discrete-time hazard models were used to estimate the timing of contraceptive use and discontinuation rates among users of temporary methods.

RESULTS

The final analysis sample included 3190 women. Of 684 women who had had an abortion, 298 (43.6%) had not initiated any contraceptive use in the 12 months afterwards. Women initiated contraceptive use significantly earlier after abortion (hazard ratio [HR] 2.25; 95% CI, 1.96-2.59; P<0.001). The rate of discontinuation among contraceptive users was significantly higher in the postabortion group (HR 1.32; 95% CI, 1.05-1.65; P<0.05). Women who were educated, wealthier, had used contraceptives before the index pregnancy, had two sons and had autonomy initiated contraceptive use significantly earlier in the post-abortion period than their counterparts.

CONCLUSION

Postabortion contraceptive use is low in Nepal. Postabortion family-planning counseling and related services should be strengthened with systematic monitoring and follow-up interventions.

Dominance of sterilization and alternative choices of contraception in India: an appraisal of the socioeconomic impact

Background

The recent decline in fertility in India has been unprecedented especially in southern India, where fertility is almost exclusively controlled by means of permanent contraceptive methods, mainly female sterilization, which constitutes about two-thirds of overall contraceptive use. Many Indian women undergo sterilization at relatively young ages as a consequence of early marriage and childbearing in short birth intervals. This research aims to investigate the socioeconomic factors determining the choices for alternative contraceptive choices against the dominant preference for sterilization among married women in India.

Methods

Data for this study are drawn from the 2005–06 National Family Health Surveys focusing on a sample of married women who reported having used a method of contraception in the five years preceding the survey. A multilevel multinomial logit regression is used to estimate the impact of socioeconomic factors on contraceptive choices, differentiating temporary modern or traditional methods versus sterilization.

Findings

Religious affiliation, women's education and occupation had overarching influence on method choices amongst recent users. Muslim women were at higher odds of choosing a traditional or modern temporary method than sterilization. Higher level of women's education increased the odds of modern temporary method choices but the education effect on traditional method choices was only marginally significant. Recent users belonging to wealthier households had higher odds of choosing modern methods over sterilization. Exposure to family planning messages through radio had a positive effect on modern and traditional method choices. Community variations in method choices were highly significant.

Conclusion

The persistent dominance of sterilization in the Indian family planning programme is largely determined by socioeconomic conditions. Reproductive health programmes should address the socioeconomic barriers and consider multiple cost-effective strategies such as mass media to promote awareness of modern temporary methods.

Are women deciding against home births in low and middle income countries?

BACKGROUND

Although there is evidence to tracking progress towards facility births within the UN Millennium Development Goals framework, we do not know whether women are deciding against home birth over their reproductive lives. Using Demographic and Health Surveys (DHS) data from 44 countries, this study aims to investigate the patterns and shifts in childbirth locations and to determine whether these shifts are in favour of home or health settings.

METHODS AND FINDINGS

The analyses considered 108,777 women who had at least two births in the five years preceding the most recent DHS over the period 2000-2010. The vast majority of women opted for the same place of childbirth for their successive births. However, about 14% did switch their place and not all these decisions favoured health facility over home setting. In 24 of the 44 countries analysed, a higher proportion of women switched from a health facility to home. Multilevel regression analyses show significantly higher odds of switching from home to a facility for high parity women, those with frequent antenatal visits and more wealth. However, in countries with high infant mortality rates, low parity women had an increased probability of switching from home to a health facility.

CONCLUSIONS

There is clear evidence that women do change their childbirth locations over successive births in low and middle income countries. After two decades of efforts to improve maternal health, it might be expected that a higher proportion of women will be deciding against home births in favour of facility births. The results from this analysis show that is not the case.

A health promotion logic model to review progress in HIV prevention in China

Using the theory and concepts of health promotion, this paper proposes a logic model for HIV/AIDS prevention and control which provides a structure for describing planned actions and predicted impacts/outcomes from comprehensive HIV prevention interventions. The potential usefulness of the model is examined by reviewing the evolution of HIV prevention and management in China, drawing on evidence from interventions reported from a mixture of study designs and formats. It reports that HIV interventions in China can be considered in two distinctive phases, before and after 2003 when China commenced its 'official' response to the HIV epidemic. The logic model was useful in comparing actions taken over these two periods highlighting the importance of political leadership in distinguishing between the two phases, and the continuing importance of systematic and broadly based public education and communication. We conclude that the logic model can not only be used as a planning model, but can also be applied retrospectively to assess successes and failures in national and local responses to HIV in complex social settings.

Socio-economic inequalities in the use of postnatal care in India

OBJECTIVES

First, our objective was to estimate socio-economic inequalities in the use of postnatal care (PNC) compared with those in the use of care at birth and antenatal care. Second, we wanted to compare inequalities in the use of PNC between facility births and home births and to determine inequalities in the use of PNC among mothers with high-risk births.

METHODS AND FINDINGS

Rich-poor ratios and concentration indices for maternity care were estimated using the third round of the District Level Household Survey conducted in India in 2007-08. Binary logistic regression models were used to examine the socio-economic inequalities associated with use of PNC after adjusting for relevant socio-economic and demographic characteristics. PNC for both mothers and newborns was substantially lower than the care received during pregnancy and child birth. Only 44% of mothers in India at the time of survey received any care within 48 hours after birth. Likewise, only 45% of newborns received check-up within 24 hours of birth. Mothers who had home births were significantly less likely to have received PNC than those who had facility births, with significant differences across the socio-economic strata. Moreover, the rich-poor gap in PNC use was significantly wider for mothers with birth complications.

CONCLUSIONS

PNC use has been unacceptably low in India given the risks of mortality for mothers and babies shortly after birth. However, there is evidence to suggest that effective use of pregnancy and childbirth care in health facilities led to better PNC. There are also significant socio-economic inequalities in access to PNC even for those accessing facility-based care. The coverage of essential PNC is inadequate, especially for mothers from economically disadvantaged households. The findings suggest the need for strengthening PNC services to keep pace with advances in coverage for care at birth and prenatal services in India through targeted policy interventions.

Estimating unmet need for contraception by district within Ghana: an application of small-area estimation techniques

The importance of meeting the unmet need for contraception is nowhere more urgent than in the countries of sub-Saharan Africa, where the fertility decline is stalling and total unmet need exceeds 30 per cent among married women. In Ghana, where fertility levels vary considerably, demographic information at sub-national level is essential for building effective family planning programmes. We used small-area estimation techniques, linking data from the 2003 Ghana Demographic and Health Survey to the 2000 Ghana Population and Housing Census, to derive district-level estimates of contraceptive use and unmet need for contraception. The results show considerable variation between districts in contraceptive use and unmet need. The prevalence of contraceptive use varies from 4.1 to 41.7 per cent, while that of the use of modern methods varies from 4.0 to 34.8 per cent. The findings identify districts where family planning programmes need to be strengthened.

Postabortion contraceptive use and method continuation in India

OBJECTIVE

To investigate the patterns and determinants of postabortion contraceptive use and the rates of method continuation in India.

METHODS

Population-level retrospective calendar data on 5135 married women who had their last abortion during the 60 months preceding the survey were drawn from 2005-2006 Indian National Family Health Surveys. Multinomial logistic regression was used to model the factors associated with postabortion method choices. Method discontinuation rates were estimated using proportional hazard models.

RESULTS

Overall, 70.4% of women reported not using any method following abortion, and the levels varied considerably across states. Significant differences were observed in the type of method adopted by women living in large cities, small towns, and rural areas. Poor and socially excluded women were less likely to use any method after abortion, particularly modern reversible methods. Method discontinuation rates were considerably higher among socially disadvantaged groups.

CONCLUSION

Postabortion contraceptive adoption is exceptionally low in India. Reproductive health interventions should urgently consider implementing comprehensive postabortion care policies, integrating family planning with sexual and reproductive healthcare services, and in particular targeting women from disadvantaged communities.

Measuring birth weight in developing countries: does the method of reporting in retrospective surveys matter?

This study investigates the patterns of recording birth weight data in retrospective surveys and their influence on birth weight estimates in less developed countries. We hypothesise that the method of reporting birth weight in surveys influences the classification of infants in the low birth weight category. Population-level data from Demographic and Health Surveys conducted in six selected countries representing different regions of the world were used. Birth weight data were reported in the survey from either an official health card or from mother's memory. Birth weight distributions were examined in detail and revised low birth weight estimates were calculated accounting for potential heaping and data inconsistencies. There were substantial differences in the distribution of birth weights by method of reporting. The percentage of infants with low birth weight was higher in all six countries for birth weight recalled from memory than when reported from a health card. Health cards displayed less clustering on certain digits than memory recalled weights, but were still highly heaped in certain countries. Heaping of birth weight data on multiples of 500 g was also observed irrespective of any differences in method of reporting. The study concludes that the method of recording birth weight data can affect birth weight estimates in developing countries. Health systems in poor countries should initiate efforts to systematically monitor the recording of birth weight data ensuring for both quality and comparability at the international levels.

A multilevel analysis of the effects of a reproductive health programme that encouraged informed choice of contraceptive method rather than use of officially preferred methods, China 2003-2005

Historically, the Chinese government's family planning (FP) policy has emphasized post-partum IUD use after first birth and sterilization after subsequent births. Was the influence of this policy-driven programme on women's contraceptive choices weakened by a reproductive health intervention programme based on the idea of enabling and encouraging clients to make an informed choice? Multilevel analyses of cross-sectional data from baseline (2003) and endline (2005) surveys conducted as part of the evaluation of a large-scale UNFPA RH/FP programme show significant reductions in the uptake of methods emphasized by official policy between the two surveys. But county-level effects are highly significant, suggesting the continuation of a strong exogenous influence on women's choices. The results suggest that, while the intervention had the effect of weakening the top-down approach towards promoting methods, family planning workers continued to be influential in promoting sterilization for women at higher parities.

Orphanhood and vulnerability: a conduit to poor child health outcomes in Rwanda

The HIV epidemic in sub-Saharan Africa has caused many children to become orphaned and vulnerable. Recent studies show that orphaned and vulnerable children (OVC) lack the basic necessities for survival and development. These children are particularly at high risk of poor health and poverty. Although the poor health outcomes of these children are well documented, the complexities of the factors that mediate their health outcomes have not been systematically studied. The aim of this paper is to examine how the complex relationships between and within the proximate and socio-economic determinants mediate the poor health outcomes of children through their OVC status. The analyses considered graphical chain modelling of morbidity data from a sample of 3745 children aged below five years from the 2005 Rwandan Demographic and Health Survey. The results show that OVC status influences the risk of childhood morbidity both directly and indirectly and also as a conduit through which other significant proximate factors and socio-economic factors operate.

On the spatial inequalities of institutional versus home births in Ghana: a multilevel analysis

Spatial inequalities related to the choice of delivery care have not been studied systematically in Sub-Saharan Africa where maternal and perinatal health outcomes continue to worsen despite a range of safe motherhood interventions. Using retrospective data from the 1998 and 2003 Demographic and Health Surveys, this paper investigates the extent of changes in spatial inequalities associated with type of delivery care in Ghana with a focus on rural-urban differentials within and across the three ecological zones (Savannah, Forest and Coastal). More than one-half of births in Ghana continue to occur outside health institutions without any skilled obstetric care. While this is already known, we present evidence from multilevel analyses that there exist considerable and growing inequalities, with regard to birth settings between communities, within rural and urban areas and across the ecological zones. The results show evidence of poor and disproportionate use of institutional care at birth; the inequalities remained high and unchanged in both urban and rural communities within the Savannah zone and widening in urban communities of the Forest and Coastal zones. The key policy challenges in Ghana, therefore, include both increasing the uptake of institutional delivery care and ensuring equity in access to both public and private health institutions.

Fertility-limiting behavior and contraceptive choice among men in Nepal

CONTEXT

Contraceptive choices among men who want no more children have been little explored in South Asia, particularly in Nepal, where fertility rates have remained high over the last few decades.

METHODS

Using the 2001 Nepal Demographic and Health Survey couple data set, multinomial logistic regression analyses were conducted for 1,041 married men aged 20 or older who had at least one living child and wanted no more children. Regression models examined relationships between selected characteristics and men's reported contraceptive use, and predicted probabilities were estimated to assess interactions between ecological zone, family composition and method choice. The primary goal was to determine whether the number and sex of living children influenced contraceptive use.

RESULTS

Twenty-four percent of men who wanted no more children were not using any contraceptive method at the time of the survey, 30% reported that their wives were sterilized, 12% had had a vasectomy, 7% were using condoms and 27% used other temporary methods. The probability of relying on permanent methods was highest among men who had at least two living sons and lowest among those who had only daughters, while the probability of using no method was highest among those who had only daughters.

CONCLUSION

In Nepal, men who report a desire to have no more children are likely to choose permanent methods only after they have two living sons.

Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries

Caesarean section rates have risen dramatically in several developing countries, especially in Latin America and South Asia. This raises a range of concerns about the use of caesarean section for non-emergency cases, not least the progressive shift of resources to non-essential medical interventions in resource-poor settings and additional health risks to mothers and newborns following a caesarean section. There are only a few studies that have systematically examined the factors influencing the recent increase in caesarean rates. In particular, it is not clear whether high elective caesarean rates are driven by medical, institutional or individual and family decisions. Where a woman's decisions predominate her interaction with peers and significant others have an impact on her caesarean section choices. Using random intercept logistic regression analyses, this paper analyses the institutional, socio-economic and community factors that influence caesarean section in six countries: Bangladesh, Colombia, Dominican Republic, Egypt, Morocco and Vietnam. The analyses, based on data from over 20,000 births, show that women of higher socio-economic background, who had better access to antenatal services are the most likely to undergo a caesarean section. Women who exchange reproductive health information with friends and family are less likely to experience a caesarean section than their counterparts. The study concludes that there is a need to pursue community-based approaches for curbing rising caesarean section rates in resource-poor settings.

Delivery settings and caesarean section rates in China

OBJECTIVE

To quantify the influence of increasing use of health-care services on rising rates of caesarean section in China.

METHODS

We used data from a population-based survey conducted by the United Nations Population Fund during September 2003 in 30 selected counties in three regions of China. The study sample (derived from birth history schedule) consisted of 3803 births to mothers aged less than 40 years between 1993 and 2002. Multiple logistic regression models were used to estimate the effect of health-care factors on the odds of a caesarean section, controlling for time and selected variables.

FINDINGS

Institutional births increased from 53.5% in 1993-1994 to 82.2% in 2001-2002, while the corresponding increase in births by caesarean section was from 8.9% to 24.8%, respectively. Decomposition analysis showed that 69% of the increase in rates of caesarean section was driven by the increase in births within institutions. The adjusted odds of a caesarean section were 4.6 times (95% confidence interval, CI: 3.4-11.8) higher for recent births. The adjusted odds were also significantly higher for mothers who had at least one antenatal ultrasound test. Rates of caesarean section in secondary-level facilities markedly increased over the last decade to the same levels as in major hospitals (P < 0.001).

CONCLUSION

The upsurge in rates of births by caesarean section in this population cannot be fully explained by increases in institutional births alone, but is likely to be driven by medical practice within secondary-level hospitals and women's demand for the procedure.

Maternal health during pregnancy and perinatal mortality in Bangladesh: evidence from a large-scale community-based clinical trial

Perinatal mortality is very high in Bangladesh. In this setting, few community-level studies have assessed the influence of underlying maternal health factors on perinatal outcomes. We used the data from a community-based clinical controlled trial conducted between 1994 and 1997 in the catchment areas of a large MCH/FP hospital located in Mirpur, a suburban area of Dhaka in Bangladesh, to investigate the levels of perinatal mortality and its associated maternal health factors during pregnancy. A total of 2007 women were followed after recruitment up to delivery, maternal death, or until they dropped out of the study. Of these, 1584 who gave birth formed our study subjects. The stillbirth rate was 39.1 per 1000 births [95% confidence interval (CI) 39.0, 39.3] and the perinatal mortality rate (up to 3 days) was 54.3 per 1000 births [95% CI 54.0, 54.6] among the study population. In the fully adjusted logistic regression model, the risk of perinatal mortality was as high as 2.7 times [95% CI 1.5, 4.9] more likely for women with hypertensive disorders, 5.0 times [95% CI 2.3, 10.8] as high for women who had antepartum haemorrhage and 2.6 times [95% CI 1.2, 5.8] as high for women who had higher haemoglobin levels in pregnancy when compared with their counterparts. The inclusion of potential confounding variables such as poor obstetric history, sociodemographic characteristics and preterm delivery influenced only marginally the net effect of important maternal health factors associated with perinatal mortality. Perinatal mortality in the study setting was significantly associated with poor maternal health conditions during pregnancy. The results of this study point towards the urgent need for monitoring complications in high-risk pregnancies, calling for the specific components of the safe motherhood programme interventions that are designed to manage these complications of pregnancy.

Dyspareunia, urinary sensory symptoms, and incontinence among young Chinese women

This study examined the prevalence of dyspareunia, urinary sensory symptoms, and urinary incontinence and explored their associations among sexually active Chinese women aged 15-34 years. Data from 3,150 women were analyzed from a survey undertaken during 2003 in 30 counties in China as part of the United Nations Population Fund Country Program. The overall prevalence of dyspareunia was 4.7%. Urinary pain, burning or frequency was reported by 8.5%, 6.2% reported urinary incontinence, and 2.3% reported both sets of urinary symptoms. The prevalence of urinary incontinence, both alone and in combination with sensory symptoms, increased in a linear manner with age. Dyspareunia was associated with early sexual debut, primary level of education, and membership of minority ethnic communities. Urinary sensory symptoms and incontinence were more common among those reporting early sexual debut, those with less schooling, and women engaged in agricultural and manual unskilled occupations. Urinary incontinence was more common among women who had had a previous vaginal delivery compared to nulliparous women. Dyspareunia was strongly associated with the presence of urinary symptoms, particularly among those with both sensory symptoms and incontinence (26.8%). Nearly a quarter of women who had dyspareunia had sought treatment but fewer had done so for urinary incontinence. Dyspareunia and urinary symptoms show distinct but overlapping patterns of association with demographic variables. The findings indicate unmet need for assessment and advice about these symptoms in women's reproductive health programs.

Disentangling women's responses on complex dietary intake patterns from an Indian cross-sectional survey: a latent class analysis

OBJECTIVE

To investigate the degree of individual heterogeneity related to complex dietary behaviour and to further examine the associations of different dietary compositions with selected characteristics.

DESIGN

Latent class analysis was applied to data from the recent cross-sectional National Family Health Survey that collected information on the intake frequency of selected foods. Different responses regarding intake frequency were condensed into a set of five meaningful latent clusters representing different dietary patterns and these clusters were then labelled based on the reported degree of diet mixing.

SETTING

Indian states. Subjects In total, 90,180 women aged 15-49 years.

RESULTS

Three clusters were predominantly non-vegetarian and two were vegetarian. A very high or high mixed-diet pattern was observed particularly in the southern and a few north-eastern states. Many women in the very high mixed-diet cluster consumed mostly non-green/leafy vegetables on a daily basis, and fruits and other non-vegetarian diet on a weekly basis. In contrast, those in the low mixed-diet cluster consumed more than three-fifths of the major vegetarian diet ingredients alone on a daily basis. The affluent group that represented the low mixed-diet cluster were primarily vegetarians and those who represented the very high mixed-diet cluster were mostly non-vegetarians. The significant interrelationships of different characteristics highlight not only socio-economic, spatial and cultural disparities related to dietary practices, but also the substantial heterogeneity in diet mixing behaviour.

CONCLUSIONS

The results of this study confirmed our hypothesis of heterogeneous dietary behaviour of Indian women and yielded useful policy-oriented results which might be difficult to establish otherwise.

Contraceptive awareness among men in Bangladesh

OBJECTIVE

A considerable gap exists between contraceptive awareness and use. Traditional approaches to measuring awareness are inadequate to properly understand the linkages between awareness and use. The objective of this study was to examine the degree of men's modern contraceptive awareness in Bangladesh and the associated determinants and further testing of a hypothesis that current contraceptive use confers a high degree of method awareness.

METHODS

This study used the couple data set from the Bangladesh Demographic and Health Survey (1999-2000). A two-level, multinomial logistic regression was used with the degree of contraceptive awareness as the dependent variable. The degree of awareness was measured by the reported number of modern contraceptive methods known among men aged 15-59 years. Men's responses on method awareness were classified according to those reported spontaneously and probed.

RESULTS

Nearly 100% of the study participants reported having heard of at least one method and about half reported awareness of at least eight different methods of contraception. Multinomial logistic regression analyses showed that older and educated men were more likely to have reported a high degree of awareness. The findings confirmed our hypothesis that current contraceptive use is likely to confer a high degree of modern method awareness among men (p<0.001), after controlling for other important characteristics.

CONCLUSIONS

Men who had a low degree of contraceptive awareness seem not properly informed of the wide range of contraceptive options. It is imperative that family planning intervention strategies in Bangladesh should focus on the degree and functional knowledge of contraceptive methods to improve the uptake of especially male-based modern methods.

Dyspareunia and Urinary Sensory Symptoms in India: Population‐Based Study

INTRODUCTION

Population level estimates of sexual dysfunction in less developed settings where sexuality is not openly discussed or is culturally constrained are lacking.

AIM

To determine the prevalence of dyspareunia and identify associated symptoms and sociocultural factors.

METHODS

Data from a population-based national level family health sample survey conducted in Indian states from 1998 to 1999 which collected sexual and reproductive health information from 84,644 currently married women. The main outcome measure was dyspareunia.

RESULTS

The overall prevalence of dyspareunia was 12.6%, with a higher prevalence in the central region, among newly married and younger women, among Muslims, rural residents, and among nonusers or traditional contraceptive method users. Dyspareunia was significantly more common among respondents who had urinary sensory symptoms when compared with their counterparts (adjusted odds ratio: 6.57, 95% confidence interval: 6.28, 6.87).

CONCLUSION

Dyspareunia prevalence and the associated symptoms reported in this analysis could be underestimates because of possible underreporting. There is a substantial hidden burden of sexual health problems especially affecting younger women.

MEN’S APPROVAL OF FAMILY PLANNING IN BANGLADESH

This article attempts to evaluate men’s approval of family planning in Bangladesh using the couple data set from the recent Bangladesh Demographic and Health Survey (BDHS), 1999–2000. Family planning approval is addressed both from individual and couple perspectives. Analysis of BDHS data shows that about 85% of the wives report that their husbands approve of family planning, which is lower than the wives’ own approval rate (95%). Using the couple data set, husbands’ characteristics were matched to the wives’ responses on family planning approval. Regression analyses show that age, education, access to TV, inter-spousal communication, current use of family planning and the number of living children significantly determine family planning approval among both men as well as couples. Family planning approval was found to be much lower in Sylhet than in the other administrative divisions. Multilevel modelling analysis suggests almost negligible variation at the community level. The findings indicate the need for careful evaluation of the DHS questions in order to measure appropriately men’s family planning attitudes.

DIVERSITY IN FAMILY PLANNING USE AMONG ETHNIC GROUPS IN GUATEMALA

This study investigates the ethnic differentials in contraceptive use in the north-eastern Ch’orti area of Guatemala, a region dominated by the Ladino culture. Data come from a household survey and in-depth interviews with service providers carried out in 2001 in the town of Jocotán, and a survey carried out in 1994 in two nearby indigenous villages (aldeas). Descriptive analysis and logistic regression are used to explore the data. Previous DHS surveys have used dress and language to classify ethnic groups. In this paper, an alternative approach based on self-identification is adopted. The results reveal significant differences in contraceptive behaviour among different ethnic groups within the same town and region. The results show that self-identified Ladino women who represented the minority of the population had contraceptive behaviour similar to their counterparts elsewhere in Latin America. The extremely low levels of contraceptive use among indigenous women from the aldeas suggest that the corresponding DHS figures in this region are probably overestimated.

Compression of Women's Reproductive Spans In Andhra Pradesh, India

CONTEXT

The total fertility rate in Andhra Pradesh, India, has recently decreased to near-replacement level; however, the reasons for the fertility decline are unknown.

METHODS

Data from the second round of the National Family Health Survey were used to examine the reproductive span-the duration between first marriage and menopause or sterilization-among 4,032 ever-married women aged 15-49 living in Andhra Pradesh in 1998-1999.

RESULTS

Between 1992-1993 and 1998-1999, the median age at which women married remained at 15.1, whereas the age at which they adopted sterilization decreased from 24.5 to 23.6. In life-table analyses, reproductive spans of successive cohorts of women decreased-from 22 years among those who married during the 1960s to 15 years among those who married in the 1970s, 10 years among those who married in the 1980s and five years among those who married in 1990-1996. Proportional hazards regression analyses that controlled for demographic and social characteristics, as well as reproductive attitudes, confirmed this cohort effect (hazard ratios, 1.5-2.6).

CONCLUSIONS

These findings suggest that women are making the decision to end childbearing faster than older generations did. The gradual compression in reproductive spans is attributable mainly to sterilization acceptance among younger women.

Weaning initiation patterns and subsequent linear growth progression among children aged 2-4 years in India

BACKGROUND

Reliance on full breastfeeding alone for a longer time could have deleterious nutritional and health implications at later stages of children's lives. About 47% of children are weaned at age >or=6 months and more than 50% of children in India under 4 years are stunted. We investigated the association between timing of weaning and stunting of children in India, using the data from National Family Health Survey, 1992-1993.

METHODS

Logistic analyses were employed on pooled data comprising one state each from six regions of India (N = 6285) with height status of children aged 2-4 years as the dependent variable. Timing of weaning was considered as the main control variable in the regression models.

RESULTS

Children weaned at age 6 months (odds ratio [OR] = 1.57) and after 6 months (OR = 1.88) were more likely to be stunted at later age compared with those weaned before 6 months (P < 0.001). Stunting appeared to be considerably lower for children weaned at age 3 months and showed an upward trend thereafter. The effect of age at weaning on stunting attenuated but persisted with statistical significance after controlling for important demographic, health, social and region variables. The likelihood of stunting was 77% for children weaned at age >6 months who had not received full immunization in the first year and had lived in poor conditions.

CONCLUSIONS

Timing of weaning is significantly associated with stunting among children in India. The underlying causal associations between weaning behaviour and growth retardation need to be further examined by using longitudinal data.