The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countries

Background Coverage levels for essential interventions aimed at reducing deaths of mothers and children are increasing steadily in most low-income and middle-income countries. We assessed how much poor and rural populations in these countries are benefiting from national-level progress. Methods We analysed trends in a composite coverage indicator (CCI) based on eight reproductive, maternal, newborn, and child health interventions in 209 national surveys in 64 countries, from Jan 1, 1994, to Dec 31, 2014. Trends by wealth quintile and urban or rural residence were fitted with multilevel modelling. We used an approach akin to the calculation of population attributable risk to quantify the contribution of poor and rural populations to national trends. Findings From 1994 to 2014, the CCI increased by 0·82 percent points a year across all countries; households in the two poorest quintiles had an increase of 0·99 percent points a year, which was faster than that for the three wealthiest quintiles (0·68 percent points). Gains among poor populations were faster in lower-middle-income and uppermiddle- income countries than in low-income countries. Globally, national level increases in CCI were 17·5% faster than they would have been without the contribution of the two poorest quintiles. Coverage increased more rapidly annually in rural (0·93 percent points) than urban (0·52 percent points) areas. Interpretation National coverage gains were accelerated by important increases among poor and rural mothers and children. Despite progress, important inequalities persist, and need to be addressed to achieve the Sustainable Development Goals

Who are the women having non-institutional deliveries in Brazil and who attends them? An analysis of 13.7 million births (2018-2022)

Objective: Over 13 million pregnancies in Brazil were analyzed to identify groups of women more likely to have deliveries outside health facilities, applying an equity approach to assess social determinants. Additionally, the types of professionals attending these deliveries were examined. Methods: Data from the Live Birth Information System (SINASC) from 2018 to 2022, were used to investigate non-institutional deliveries according to the region of residence, ethnicity/skin color, schooling, and age, as well as the intersections of these factors. The proportion of births attended by doctors, nurses/midwives, traditional birth attendants, and others was also analyzed, comparing institutional and non-institutional deliveries. Results: The overall prevalence of non-institutional deliveries was 1.0%. Higher proportions were observed in the North region (4.0%), among Indigenous women (26.3%), adolescent mothers (1.4%), and those with less than four years of schooling (8.3%). The proportion of non-institutional delivery rose to 67.6% among low-educated, Indigenous women from the North region. Indigenous women with less than 4 years of schooling and having a non-institutional delivery presented the highest proportion of delivery without a qualified professional (95.2%). Conclusions: Cultural norms and barriers to accessing maternity services, combined with broader social inequalities and organizational challenges faced by Indigenous populations, may contribute to the high proportion of these deliveries observed among these women. Culturally sensitive strategies to expand access and empower Indigenous women are crucial to ensuring their survival as well as their children’s

Age, class and race discrimination: their interactions and associations with mental health among Brazilian university students

Although research on discrimination and health has progressed significantly, it has tended to focus on racial discrimination and US populations. This study explored different types of discrimination, their interactions and associations with common mental disorders among Brazilian university students, in Rio de Janeiro in 2010. Associations between discrimination and common mental disorders were examined using multiple logistic regression models, adjusted for confounders. Interactions between discrimination and socio-demographics were tested. Discrimination attributed to age, class and skin color/race were the most frequently reported. In a fully adjusted model, discrimination attributed to skin color/race and class were both independently associated with increased odds of common mental disorders. The simultaneous reporting of skin color/race, class and age discrimination was associated with the highest odds ratio. No significant interactions were found. Skin color/race and class discrimination were important, but their simultaneous reporting, in conjunction with age discrimination, were associated with the highest occurrence of common mental disorders

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

Background: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to deter- mine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). Methods: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15–24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW’s beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. Results: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater pro- portion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disap- proved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). Conclusion: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries sug- gesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV

The SWPER index for women's empowerment in Africa:development and validation of an index based on survey data

Background The Sustainable Development Goals strongly focus on equity. Goal 5 explicitly aims to empower all women and girls, reinforcing the need to have a reliable indicator to track progress. Our objective was to develop a novel women's empowerment indicator from widely available data sources, broadening opportunities for monitoring and research on women's empowerment. Methods We used Demographic and Health Survey data from 34 African countries, targeting currently partnered women. We identified items related to women's empowerment present in most surveys, and used principal component analysis to extract the components. We carried out a convergent validation process using coverage of three health interventions as outcomes; and an external validation process by analysing correlations with the Gender Development Index. Findings 15 items related to women's empowerment were selected. We retained three components (50% of total variation) which, after rotation, were identified as three dimensions of empowerment: attitude to violence, social independence, and decision making. All dimensions had moderate to high correlation with the Gender Development Index. Social independence was associated with higher coverage of maternal and child interventions; attitude to violence and decision making were more consistently associated with the use of modern contraception.Interpretation The index, named Survey-based Women's emPowERment index (SWPER), has potential to widen the research on women's empowerment and to give a better estimate of its effect on health interventions and outcomes. It allows within-country and between-country comparison, as well as time trend analysis, which no other survey-based index provides. Funding Bill & Melinda Gates Foundation