On the Compression of Reproductive Spans: the case of Andhra Pradesh in India

Many women in Andhra Pradesh marry early, have two or three children and accept voluntary sterilization at very early ages. The state has recently succeeded in reducing fertility to near replacement levels. Data from the second round of the National Family Health Survey are used to examine the duration between first marriage and sterility by distinguishing different marriage cohorts of the 4,032 ever-married women aged 15-49 years. Life table and hazard models are used to understand the cohort effects on the time spend in the effective reproductive span. The cohort effects remain highly significant when controlling for other demographic, social and reproductive attitude characteristics. Sterilization acceptance among younger women explains the compression trends in reproductive spans. Women’s position as mothers is undergoing transition in Andhra Pradesh and they seem to make familial decisions much faster than the older generations did

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

The correlates of natural method use in Moldova: is natural method use associated with poverty and isolation?

Natural method use is often associated with high levels of unwanted births and induced abortions. This study investigates the correlates of natural method use in Moldova, a country with one of the highest proportions of natural contraceptive users in Europe. We hypothesize that economic and spatial disadvantage increase the reliance on natural methods whereas exposure to FP programs decreases the probability of natural method use. The analysis considers a sub-sample of 5860 sexually-active women from the 2005 Demographic and Health Survey. Results from multilevel multinomial models, controlling for relevant characteristics and data structure, show that economic disadvantage increases the probability of natural method use; but the overall effect is small. Higher FP media exposure reduces natural method use; however this effect attenuates with age. We conclude that FP efforts directed towards the poorest may have limited impact, but interventions targeted at older women could reduce the burden of unwanted pregnancies

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

BackgroundAlthough 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 FindingsThe 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.ConclusionsThere 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

Disentangling the complex association between female genital cutting and HIV among Kenyan women

Female genital cutting (FGC) is a widespread cultural practice in Africa and the Middle East, with a number of potential adverse health consequences for women. It was hypothesised by Kun (1997) that FGC increases the risk of HIV transmission through a number of different mechanisms. Using the 2003 data from the Kenyan Demographic and Health Survey (KDHS), this study investigates the potential association between FGC and HIV. The 2003 KDHS provides a unique opportunity to link the HIV test results with a large number of demographic, social, economic and behavioural characteristics of women, including women’s FGC status. It is hypothesised that FGC increases the risk of HIV infection if HIV/AIDS is present in the community. A multilevel binary logistic regression technique is used to model the HIV status of women, controlling for selected individual characteristics of women and interaction effects. The results demonstrate evidence of a statistically significant association between FGC and HIV, after controlling for the hierarchical structure of the data, potential confounding factors, and interaction effects. The results show that women who had had FGC and a younger or the same age first union partner have higher odds of being HIV positive than women with a younger or same age first union partner but without FGC; whereas women who had had FGC and an older first union partner have lower odds of being HIV positive than women with an older first union partner but without FGC. The findings suggest the behavioural pathway of association between FGC and HIV as well as an underlying complex interplay of bio-behavioural and social variables being important in disentangling the association between FGC and HIV

Does early childbearing and a sterilization-focused family planning programme in India fuel population growth?

Recent stagnation in the reduction of infant mortality in India can arguably be attributed to early child bearing practices and the lack of progress in lengthening birth intervals. Meanwhile, family planning efforts have been particularly successful in the southern states such as Andhra Pradesh, although family limitation is almost exclusively by means of sterilisation at increasingly younger ages. This paper examines the population impact of the unprecedented convergence of early childbearing trajectories in India and quantifies the potential implications stemming from the neglect of strategies that encourage delaying and spacing of births. The effects of adopting a ‘later, longer and fewer’ family planning strategy are compared with the continuation of fertility concentrated in the younger age groups. Results from the cohort component population projections suggest that a policy encouraging later marriage and birth spacing would achieve a future total population which is about 52 million less in 2050 than if the current early fertility trajectory is continued.census, family planning, fertility, India, National Family Health Surveys, population policies, population projections, Sample Registration Systems, sterilisation

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$275·2 million (33·8%). Tanzania ($107·8 million [13·2$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

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