No abstract available

Background Bangladesh has made substantial progress in maternal health. However, persistent inequities in service use undermine the achievements at the national level. In 2007, the government introduced a Maternal Health Voucher Scheme (MHVS) to reduce barriers to service utilization. The current study explores the impact of MHVS on reducing distance inequality in utilization across the maternal and newborn continuum of care (MNCoC). Methods A cross-sectional survey was conducted from October’2017 to April’2018 in four selected MHVS sub-districts of Chattogram and Sylhet Divisions of Bangladesh. 2,400 women with at-least one child aged below two years were randomly selected. Both bivariate and multivariate analyses were carried out to explore the absolute and relative influence of the voucher scheme and chi-square test was used for hypothesis testing. Results Nineteen percent of the women were MHVS beneficiaries and 23% of them lived within 5 km of the health facility. Among the beneficiaries no significant differences were observed in the utilization of at-least 4 antenatal visits, skilled-assistance at delivery, postnatal care, and MNCoC between those living closer to the health facility and those living far away. However, a higher facility delivery rate was observed among beneficiary women living closer. By contrast, for non-beneficiaries, a significant difference was found in service use between women living closer to health facilities compared to those living further away. Conclusion The study found the use of MNCoC to be similar for all MHVS beneficiaries irrespective of their distance to health facilities whereas non-beneficiary women living further away had lower utilization rates. MHVS could have potentially reduced distance-related inequality for its beneficiaries. However, despite the provision of transport incentives under MHVS the reduction in inequality in facility delivery was limited. We propose a revision of the transportation incentive adjusting for distance, geographical remoteness, road condition, and transport cost to enhance the impact of MHVS.

BACKGROUND Depression and anxiety were both ranked among the top 25 leading causes of global burden of diseases in 2019 prior to the coronavirus disease 2019 (COVID-19) pandemic. The pandemic affected, and in many cases threatened, the health and lives of millions of people across the globe and within the first year, global prevalence of anxiety and depression increased by 25% with the greatest influx in places highly affected by COVID-19. AIM To explore the psychological impact of the pandemic and resultant restrictions in different countries using an opportunistic sample and online questionnaire in different phases of the pandemic. METHODS A repeated, cross-sectional online international survey of adults, 16 years and above, was carried out in 10 countries (United Kingdom, India, Canada, Bangladesh, Ukraine, Hong Kong, Pakistan, Egypt, Bahrain, Saudi Arabia). The online questionnaire was based on published approaches to understand the psychological impact of COVID-19 and the resultant restrictions. Five standardised measures were included to explore levels of depression [patient health questionnaire (PHQ-9)], anxiety [generalized anxiety disorder (GAD) assessment], impact of trauma [the impact of events scale-revised (IES-R)], loneliness (a brief loneliness scale), and social support (The Multi-dimensional Scale of Perceived Social support).

Background: Pregnant women have self-declared that they have difficulties in estimating nutrient intakes. The Nutrition Information System for Indonesian Pregnant Women (SISFORNUTRIMIL) application was created as a dietary assessment and calorie-counting tool to guide pregnant women to eat the right portion sizes for each meal. Objective: The study aimed to examine the effectiveness of the SISFORNUTRIMIL application in helping users achieve a balanced diet and healthy maternal weight gain in comparison to nonusers in Indonesia. Methods: First-pregnancy women in the second trimester aged 19-30 years (N=112) participated in the randomized controlled trial. Recruited women who were eligible and consented to participate in the study were allocated into the intervention group, or application user (n=56), and the control group, or application nonuser (n=56). The intervention recommended that pregnant women consume at least 5 food groups and calculate a recommended average portion size for 12 weeks. Both groups were self-monitored and recorded their intake in food records for 3 days every week. The dietary diversity consumed, macro- and micronutrient intake, and maternal weight gain were assessed pre- and postintervention. Data were collected three times during the intervention. Diversity food consumption was measured by the Minimum Dietary Diversity for Women of reproductive age. Furthermore, the Indonesian recommended dietary allowances were used to refer to and validate appropriate energy and nutrient amounts. Independent sample t test was used to compare differences between the intervention and control groups.

Despite the progress achieved, approximately one-quarter of all maternal deaths worldwide occur in India. Till now, India monitors maternal mortality in 18 out of its 36 provinces using information from the periodic sample registration system (SRS). The country does not have reliable routine information on maternal deaths for smaller states and districts. And, this has been a major hurdle in local-level health policy and planning to prevent avoidable maternal deaths. For the first time, using triangulation of routine records of maternal deaths under the Health Management Information System (HMIS), Census of India, and SRS, we provide Maternal Mortality Ratio (MMR) for all states and districts of India. Also, we examined socio-demographic and health care correlates of MMR using large-sample and robust statistical tools. The findings suggest that 70% of districts (448 out of 640 districts) in India have reported MMR above 70 deaths—a target set under Sustainable Development Goal-3. According to SRS, only Assam shows MMR of more than 200, while our assessment based on HMIS suggests that about 6-states (and two union territories) and 128-districts have MMR above 200. Thus, the findings highlight the presence of spatial heterogeneity in MMR across districts in the country, with spatial clustering of high MMR in North-eastern, Eastern, and Central regions and low MMR in the Southern and Western regions. Even the better-off states such as Kerala, Tamil Nadu, Andhra Pradesh, Karnataka, and Gujarat have districts of medium-to-high MMR. In order of their importance, fertility levels, the sex ratio at birth, health infrastructure, years of schooling, postnatal care, maternal age and nutrition, and poor economic status have emerged as the significant correlates of MMR. In conclusion, we show that HMIS is a reliable, cost-effective, and routine source of information for monitoring maternal mortality ratio in India and its states and districts.

Aims Background: The impact of the pandemic and resultant restrictions on suicidal thoughts may vary across populations, geographical areas, between high and low socio-economic groups and vulnerable populations. Aim: To investigate the psychological impact of COVID-19 and resultant restrictions on suicidal thoughts in the United Kingdom. Methods The study group conducted a cross sectional survey using a questionnaire based on published approaches (Generalised Anxiety Disorder 7, Patient Health Questionnaire 9, Impact of Events Scale-Revised) to understand the psychological impact of COVID-19 and the resultant restrictions on suicidal thoughts. The study was conducted in 3 phases to capture the different phases of the pandemic restrictions: Phase 1: 1st May 2020 to 31st July 2020 Phase 2: 12th November 2020 to 12th February 2021 Phase 3: 1st July 2021 to 30th September 2021 Inclusion: All individuals above 16 years of age who wanted to participate were eligible. Analysis strategy: Descriptive analysis and logistic regression is applied in this study.

This study aimed to assess completeness of antenatal care coverage following implementation of a voucher scheme for maternal health in Bangladesh. The investigation used interview data from a survey conducted in Bangladesh in 2017 of 2400 randomly selected women aged 15-49 with children aged 0-23 months in four geographical areas where voucher scheme implementation was underway. Of these women, 1944 had attended at least one antenatal clinic visit so were included in the analysis. A 'completeness index' for antenatal visits was constructed as an outcome variable based on recall of thirteen elements of care. Bivariate analysis against independent variables of interest was carried out and multivariate linear regression models developed to examine the influence of voucher scheme participation on completeness of antenatal care adjusting for socio-demographic characteristics. Voucher scheme membership was associated with higher 'completeness index' scores, with a mean score of 185.2±101.0 for voucher recipients and 139.6 ± 93.3 for non-recipients (p<0.001). Scheme membership reduced the differentials associated with health facility type and socioeconomic status. Women from the lowest socioeconomic group who were voucher recipients received substantially more components of antenatal care (mean score: 159.6±82.1) compared with non-recipients (mean score: 115.7±83.0). This favourable effect of voucher scheme membership on the most vulnerable socioeconomic group remained significant after adjusting for educational status. The Bangladesh voucher scheme model has the potential to maximize gains in maternal and newborn health through enhancing the completeness of service provision.

Despite the colossal rise in institutional delivery (from 20% in 2005–2006 to 64% in 2015–2016), the state of Bihar shows the poorest performance in the country for utilization of four or more antenatal care services (4 or more ANCs) (14%). In this background, the present paper aims to investigate the factors associated with the low uptake of ANCs in Bihar, India. The study analyses a sample of 16,822 women aged 15–49 in Bihar from the fourth round of the National Family Health Survey (NFHS-4) conducted during 2015–2016. Bivariate and multivariate logistic and linear regression analyses are employed to identify the factors associated with the underutilization of 4 or more ANCs in Bihar. Five out of 38 districts of Bihar have more than 20% uptake of 4 or more ANCs while 13 districts have only 7 to 12% of uptake. However, 79% of women had institutional delivery without having 4 or more ANCs. The results from the logistic regression model suggest that mothers who belonged to the richest wealth index (OR = 3.90; 99% CI: 2.98–5.08) and a higher level of education (OR = 3.35; 99% CI: 2.74–4.08) have a greater likelihood of receiving 4 or more ANCs. In order of their importance, focusing on economic, education, and caste inequalities, awareness of pregnancy registration with MCP cards, and avoiding higher-order births are likely to improve the uptake of 4 or more ANCs in Bihar.

This paper examines the sequential impact of components of maternal and child health care on the continuum of care in India using data from the Indian National Family Health Surveys conducted in 2005–06 and 2015–16. Continuum of care (CoC) for maternal and child health is defined in this paper as the sequential uptake of three key maternal services (antenatal care, institutional delivery and postnatal care for the mother). Women who received all three services were classified as full CoC recipients. Characteristics odd ratios for achieving CoC were estimated by mother’s place of residence, household wealth status, mother’s education, birth order and child full vaccination. Odds ratios were computed to understand the relative impact of each preceding service utilization on the odds of subsequent service uptake. At national level, 30.5% and 55.5% of women achieved full CoC in 2005–06 and 2015–16, respectively, and the overall progress of CoC over the 10-year period was 25.5 percentage points, with significant variation across states and socioeconomic groups. Full CoC improved from 7.5% to 32.4% among the poorest women, whereas among the richest women it improved from 70.5% to 75.1%. Similarly, among uneducated women full CoC improved from 11.7% to 35.9% as against 75.1% to 80.5% among educated mothers over the same period. Furthermore, greater CoC was observed among parity one women. The conditionality between various components of CoC indicated that at national level the odds of having an institutional delivery with antenatal care were 9 times higher in the earlier period as against 4.5 times higher in the more recent period. Furthermore, women who had institutional deliveries complied more with mother’s postnatal care compared with women who did not have institutional deliveries. This again helps increase the likelihood of a child receiving full vaccination.

BACKGROUND Pandemic mitigation policies, such as lockdown, are known to impact on mental health of individuals. Compulsory face covering under relaxed lockdown restrictions gives assurance of less transmission of airborne infection and has the potential to improve mental health of individuals affected by restrictions. AIM To examine the association of the lockdown relaxation and the implementation of the face covering policy on the mental health of the general population and sub-groups in the United Kingdom using interrupted time series model. METHODS Using a web-based cross-sectional survey of 28890 United Kingdom adults carried out during May 1, 2020 to July 31, 2020, changes in mental health status using generalised anxiety disorder (GAD-7), and impact of events scale-revised (IES-R) scales are examined, at the dates of the first lockdown relaxation (July 4, 2020) and the subsequent introduction of face covering (July 24, 2020) in United Kingdom. A sharp regression discontinuity design is used to check discontinuities in mental health outcomes at policy-change dates. RESULTS Average GAD-7 scores of participants were 5.6, 5.6 and 4.3 during the lockdown period, the lockdown relaxation phase and the phase of compulsory face covering, respectively, with lower scores indicating lower anxiety levels. Corresponding scores for IES-R were 17.3, 16.8 and 13.4, with lower scores indicating less distress. Easing lockdown measures and subsequent introduction of face covering, on average, reduced GAD-7 by 0.513 (95%CI: 0.913-0.112) and 1.148 (95%CI: 1.800-0.496), respectively. Corresponding reductions in IES-R were 2.620 (95%CI: 4.279-0.961) and 3.449 (95%CI: 5.725-1.172). These imply that both lockdown relaxation and compulsory face-covering have a positive association with mental health scores (GAD-7 and IES-R). CONCLUSION The differential impact of lockdown and relaxation on the mental health of population sub-groups is evident in this study with future implications for policy. Introduction of face covering in public places had a stronger positive association with mental health than lockdown relaxation.

Background The Indian Government launched a demand-side financing program, ‘Janani Suraksha Yojana’ (JSY) in 2005 with the aim of reducing maternal and neonatal mortality through increased access to institutional delivery care service. This paper analyses the effects of the JSY on the uptake of maternal and child health (MNCH) care services intending to understand the overall impact of the program on the continuum of care. Methods Using the 2013-14 round of the District-level Household Survey (DLHS) surveyed in high performing states, the average treatment effect on the treated (ATT) was estimated by using the Propensity Score Matching (PSM). Results are reported regarding both ATTs and deviations from the theoretical continuum of care line, which represents 100% uptake, i.e., all women availing all the MNCH services. Results Overall, JSY effects on MNCH components ranged between 0.7% and 12%. As expected, the highest impact of the JSY was on institutional delivery (ATT: 0.12; 95% CI: 0.104-0.131) and the lowest for breastfeeding more than six months (ATT: 0.007; 95% CI: -0.014-0.027). Deviation from the complete continuum of care line ranged from 2.3% to 80.9%. The highest deviation was for three or more Tetanus Toxoid (100%-19.1%=80.9%) injections and the lowest for Polio given at any time (100%-97.7%=2.3%). Conclusions The program had high effects on those MNCH care services, the uptakes of which were already high without the program (low deviations from the continuum of care line), and the program had low effects on those MNCH care services, which had low uptakes in the absence of the program (high deviations from the continuum of care line). The program should also incentivize the utilization of those MNCH care services, which have low uptakes in the absence of the program.

Background/objectives: Anaemia accounts for a significant proportion of pre- and post-partum morbidity and mortality in low-income countries with sequelae, including an increased risk of infection. Factors contributing to anaemia need to be addressed through the introduction of evidence-based measures to control and prevent the disease. We aimed to determine the prevalence of anaemia in women of child-bearing age in the Democratic Republic of Congo (DRC) and investigate the associated individual, household and community level factors. Subjects/methods: Cross sectional representative population data from the 2013-2014 DRC Demographic and Health Survey (DHS) was used. The primary outcome was anaemia in women, stratified according to pregnancy in those of child-bearing age. A haemoglobin level of below 11 g/dl for pregnant women and 12 g/dl for non-pregnant women was used as the indicator of anaemia. Using a three-level random intercept model this study explored risk factors at individual, household and community levels and quantified the observed and unobserved variations between households and communities. Results: Thirty-eight percent of women in the DRC are anaemic. Anaemia is significantly higher in younger, pregnant and underweight women, as well as those with comorbidities, including HIV and malaria who are living in the capital city Kinshasa. Anaemia varies within and between households and communities in the DRC. Conclusions: Integrated approaches to reduce anaemia in settings with high malaria and HIV prevalence such as the DRC should target households.

Background In Portsmouth, the prevalence of long-term conditions and presence of modifiable risk factors are often higher than in England as a whole. It has been identified that most adults presenting to an urgent treatment centre (UTC) in Portsmouth have one or more of the following risk factors: smoking, being overweight or obese, and alcohol overuse. Opportunistic health promotion may be beneficial in addressing these risk factors, but there has been little research on its use in UTCs. Aim To determine the efficacy and effectiveness of using an opportunistic brief health promotion intervention – including advice on smoking cessation, weight management and alcohol intervention as appropriate – with adult patients presenting to Portsmouth’s UTC. Method A total of 204 participants were recruited to a randomised controlled trial (RCT). Half of the participants (n=102) received the brief health promotion intervention at initial consultation within 20 minutes of their arrival at the UTC (Arm A). The other half of the participants (n=102) received the brief health promotion intervention at full consultation, between 20 minutes and four hours later (Arm B). The primary outcome measure was the number of referrals to the local well-being service for further support with behaviour change. The secondary outcome measures were the acceptability of the intervention and the time taken by the intervention. Results Participants were generally receptive to the brief health promotion intervention. Of the 204 participants, 64% (n=130) accepted the support provided at the UTC, which indicates that a brief health promotion intervention is acceptable to most patients presenting to the UTC. The same number of referrals to the local well-being service was made in Arm A and Arm B (n=11 in each, n=22 in total), indicating that the timing of the intervention did not affect participants’ decisions to accept or reject referral. Conclusion An opportunistic brief health promotion intervention with patients presenting to UTCs is feasible and potentially effective. Nurses practising in UTCs and primary care settings generally need to use every opportunity to engage patients in health promotion as part of their routine consultations. Adequate training, support and policies are required to assist nurses in integrating health promotion into their practice.

Background: Despite decent progress in Children Full Immunisation (CFI) in India during the last decade, surprisingly, Gujarat, an economically more developed state, had the second-lowest coverage of CFI (50%) in the country, lower than economically less developed states such as Bihar (62%). Further, the proportion of children with no immunisation in Gujarat has risen from 5% in 2005 to 9% in 2016. This paper investigated factors associated with the low level of CFI coverage in Gujarat. Methods: The study used two types of datasets: (1) the information on immunisation from 7730 children aged 12-23 months and their mothers from the fourth round of the Gujarat chapter of National Family Health Survey (NFHS 2015-16). (2) A macro (district) level data on both supply and demand-side factors of CFI are compiled from multiple sources. Bivariate and multivariate linear and logistic regression techniques were employed to identify the factors associated with CFI coverage. Results: In Gujarat, during 2015-2016, 50% of children aged 12-23 months did not receive full immunisation. The odds of receiving CFI was higher among children whose mothers had a Maternal and Child Protection (MCP) card (OR: 1.97, 95% CI 1.48-2.60) and those who received "high" maternal health services utilisation (OR: 1.59, 95% CI 1.10-2.26) compared to their counterparts. The odds of receiving CFI was about three times higher among the richest households (OR: 6.50, 95% CI 3.75-11.55) compared to their counterparts in the poorer households. Macro-level analyses suggest that poverty, maternal health care, and higher-order births are defining factors of CFI coverage in Gujarat. Conclusions: In order of importance, focusing on poverty, economic inequalities, pregnancy registration, and maternal health care services utilisation are likely to improve receiving CFI uptake in Gujarat. The disadvantageous position of urban areas and non-scheduled tribes in CFI coverage needs further investigation.

Tuberculosis (TB) is a globally widespread disease, with approximately a quarter of the world's population currently infected (WHO, 2018). Some risk factors, such as HIV status, nutrition and body mass index, have already been thoroughly investigated. However, little attention has been given to behavioural and/or psychological risk factors such as stress and education level. This study investigated the risk factors for TB diagnosis by statistical analyses of publicly available data from the most recent wave of the Indonesian Family Life survey (IFLS-5) conducted in 2015. Out of 34,249 respondents there were 328 who reported having TB. For comparison and completeness, variables were divided into levels: individual-, household- and community-level variables. The most prominent and interesting variables found to influence TB diagnosis status (on each level) were investigated, and a logistic regression was subsequently developed to understand the extent to which each risk factor acts as a predictor for being diagnosed with TB. Age, health benefit or insurance, stress at work and living in a rural area all showed significant association with TB diagnosis status. This study's findings suggest that suitable control measures, such as schemes for improving mental health/stress reduction and improved access to health care in rural areas should be implemented in Indonesia to address each of the key factors identified.

Background The psychological impact of COVID-19, resultant measures and future consequences to life will be unveiled in time. Aim To investigate the psychological impact of COVID-19, resultant restrictions, impact on behaviours and mental wellbeing globally. This early analysis, explores positive and adverse factors and behaviours with focus on healthcare professionals. Methods This is a cross-sectional survey, using a questionnaire based on published approaches to understand the psychological impact of COVID-19. The survey will be repeated at 6 months because of rapidly changing situation. Results We have presented results from first 3 weeks of the survey. Conclusions may change as more individuals take part over time. 7,917 participants completed the survey in the first 3 weeks; 7,271 are from the United Kingdom. 49.7% of the participants are healthcare professionals. There is high representation of female participants. Participants reporting suicidal thoughts is 32%. Healthcare professionals have reported mild depression and anxiety in higher proportions. Increasing age and female gender report higher compliance with government advice on COVID 19 whereas higher education, homeowners, key worker status, high alcohol, drug use and participants with pre-existing suicidal thoughts reported low compliance with government advice. Participants who reported suicidal thoughts pre-COVID are less likely to communicate with friends and family, or engage in coping strategies. Conclusions Evidence has shown an adverse psychological impact of previous pandemics on the population, especially wellbeing of healthcare professionals. Research should focus on identifying the need, preparing services and determining the factors that enhance and build resilience. Funding This survey is linked to a MRC global health research program of the Portsmouth-Brawijaya center for Global Health, Population, and Policy, (MR/N006267/1), University of Portsmouth.

We exploit the difference in means of postnatal hospital stays between beneficiary mothers of Janani Suraksha Yojana (JSY) and control mothers to estimate causal effects of postnatal hospital stay on postdischarge complications of a mother and her newborn. We argue that JSY increases the demand for institutional deliveries in those hospitals, which are assigned by the government to provide such services to the JSY recipients. Given the limited supply of beds, health professionals and other facilities, an excess demand for institutional deliveries in those hospitals forces JSY recipients to stay for a shorter time after birth compared with nonrecipients of JSY who are free to deliver in any hospital. Thus, the dummy for JSY becomes a suitable instrument for postnatal hospital stay. Using instrumental variables (IV) regressions, we find that postnatal hospital stay has statistically significant negative causal effects on half of the available postdischarge complications in the data, including abdominal pain, vaginal discharge, convulsion and severe headache of a mother and fever or cold of the newborn.

Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest.Objective: The current paper reports the effect of vouchers on the use of continuum of maternal care.Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0-23 months. Using Cluster analysis utilisation groups for antenatal care, facility delivery and postnatal care were formed. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders.Results: Four clusters with varying levels of utilisation were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%).Conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programmes that improve access to quality healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.

Janani Suraksha Yojana (safe motherhood scheme, or JSY) provides cash incentives to marginal pregnant women in India conditional on having mainly institutional delivery. Using the fourth round of district level household survey (DLHS-4), we have estimated its effects on both intended and unintended outcomes. Our estimates of average treatment effect on the treated (ATT) from propensity score matching are remarkably higher than those found in previous prominent studies using the second and third rounds of the survey (DLHS-2 and DLHS-3). When we apply fuzzy regression discontinuity design exploiting the second birth order, our estimates of local average treatment effect (LATE) are much higher than that of ATT. For example, due to JSY, institutional delivery increases by around 16 percentage points according to ATT estimate but about 23 percentage points according to LATE estimate.

The objective of this article is to examine the impact of international female labor migration on left-behind parents by taking into consideration the daughters' marital status. Data were taken from in-depth interviews with 37 left-behind parents of migrant women in East Java Province. The study showed that left-behind parents had limited access to the remittances sent by married daughters, except when they carried out childcare responsibilities. Parents of unmarried daughters had some access to remittances, but this varied according to the economic conditions of the family. Left-behind parents were concerned about the safety of their daughters overseas, the marriage prospects of unmarried daughters, the stability of their daughters' marriages and the welfare of left-behind grandchildren. Because the migration of married and unmarried daughters has diverse impacts on left-behind parents, this should be considered in programs that aim to mitigate potential negative impacts of women's migration.

Although share of older population, an indicator of population ageing, is relatively low in most African countries, the number of older people has been steadily increasing across the region. The UN projections show that by 2050, the percentage of population aged 60+ currently estimated at 5% will reach 9% on average in Africa, and the number of older people will be almost three times higher. These trends clearly highlight the need to systematically monitor population ageing in Africa, and the Madrid International Plan of Action on Ageing (MIPAA) has offered a unique policy framework for this purpose. Moreover, the distortions in economic growth suggest that African populations might become old before getting affluent. The MIPAA strategy adopted in 2002 and implemented globally, covers three priority areas for investment in older people: development; health and wellbeing; and supportive environment. This article provides a summary of an extensive review of literature and data from national and international sources to assess the progress and gaps in the implementation of MIPAA in East and Southern Africa (ESA) of UNFPA, with a focus on six countries: Ethiopia, Kenya, Mauritius, Mozambique, Tanzania and Uganda. These countries represent diverse demographic, economic, social, cultural, political and geographic characteristics. Although there are some key developments in terms of new legislations and policies on older people since 2002, it was difficult to evaluate the impact and effectiveness of these measures due to lack of appropriate comparable data. We conclude that while many of these countries have included policies for older people, institutional and governance structures, data collection systems, target setting and programme implementation strategies remain weak, and poverty remains widespread amongst older people in low-income settings across the ESA region.

No abstract available

This paper examines the impact of low fertility and early age at sterilisation on women’s formal education and skill development in South India. Multilevel ordered-logit modelling of pseudo-cohort data re-organised from the three rounds of National Family Health Survey, and thematic analysis of qualitative data collected from Tamil Nadu and Kerala states showed no evidence of women’s resumption of formal education or uptake of skill development training in the post-sterilisation and post-childcare period. While resuming formal education in the post-sterilisation and post-childcare period is harder to achieve for various individual, household, community and policy reasons, there is greater preparedness and support for women to undertake skill development training. As low fertility and early age at sterilisation are widely regarded as the emerging reproductive norm in India, post-sterilisation and -childcare women will be a significant population group both in number and in proportional terms. No government policies or programs have so far recognised this group. India’s new government should consider targeted skill development programs for post-sterilisation and -childcare women appropriate to their social, economic and educational levels. An important contribution of the family planning program, particularly female sterilisation, for the economic and social development of the family and the wider society will otherwise be lost.

Background & objectives: The age at which menopause naturally occurs may reflect nutritional and environmental circumstances as well as genetic factors. In this study we examined natural menopause as a marker of women's health at the population level in India and in some major States. Methods: Data from the Indian District Level Household Survey (DLHS) carried out during 2007-2008 covering 643,944 ever-married women aged 15-49 yr were used; women of older ages were not included in this survey. Since not all women in this age group had achieved natural menopause at the time of survey, Cox proportional hazard regression models were employed to obtain the median age of women reporting a natural menopause, excluding those who underwent hysterectomy. Hazard ratios (HRs) were estimated for key socio-economic and reproductive variables that could potentially affect the age at natural menopause <40 yr. Results: Overall, menopause prior to age 40 was reported by approximately 1.5 per cent of women. In the national data set, significant associations with age at natural menopause were identified with marriage breakdown or widowhood, poverty, Muslim religious affiliation, ‘scheduled caste’ status, not having received schooling, rural residence, having never used contraceptive pills, not been sterilized or had an abortion, low parity and residence in the western region. Within data from five selected States examined separately, the strength of these associations varied. Interpretation & conclusions: Associations of natural menopause with sociocultural, family planning and demographic variables were noted. Most importantly, there was an association with poverty that would require further investigation as to causality. The proportion of women experiencing early menopause may represent a useful overall indicator of women's health. The data are reassuring with regard to possible late effects of sterilization on ovarian function.

This study examined the post-sterilization autonomy of women in south India in the context of early sterilization and low fertility. Quantitative data were taken from the third round of the National Family Health Survey (NFHS-3) carried out in 2005-06, and qualitative data from one village each in Kerala and Tamil Nadu during 2010-11. The incident rate ratios and thematic analysis showed that among currently married women under the age of 30 years, those who had been sterilized had significantly higher autonomy in household decision-making and freedom of mobility compared with women who had never used any modern family planning method. Early age at sterilization and low fertility enables women to achieve the social status that is generally attained at later stages in the life-cycle. Policies to capitalize on women's autonomy and free time resulting from early sterilization and low fertility should be adopted in south India.

Although antenatal care (ANC) interventions have been in place for a long time, there is hardly any systematic evidence on the association between ANC interventions and neonatal mortality in India. The present study attempts to investigate the association between ANC interventions and neonatal mortality in India using data from the District Level Household Survey conducted in India during 2007-8. The ANC interventions included in the analysis are at least four antenatal visits, consumption of 90 or more iron-folic acid (IFA) tablets, and uptake of two or more tetanus toxoid (TT) injections. We have used discrete-time logistic regression models to investigate the association between ANC interventions and neonatal mortality. Risk of neonatal mortality was significantly lower for infants of mothers who availed four or more antenatal visits [odds ratio (OR): 0.69; 95% confidence interval (CI): 0.60-0.81], consumed 90 or more IFA tablets (OR: 0.85; 95% CI: 0.73-0.99), received two or more TT injections (OR: 0.73; 95% CI: 0.63-0.83). When we analysed different combinations of antenatal visits, IFA supplementation and TT injections, TT injections provided the main protective effect-the risk of neonatal mortality was significantly lower in newborns of women who received two or more TT injections but did not consume 90 or more IFA tablets (OR: 0.69; 95% CI: 0.60-0.78), or who received two or more TT injections but did not avail four or more antenatal visits (OR: 0.75; 95% CI: 0.66-0.86). In the statistical model, 6% (95% CI: 4-8%) of the neonatal deaths in India could be attributed to a lack of at least two TT injections during pregnancy. Indian public health programmes must ensure that every pregnant woman receives two or more TT injections during antenatal visits.

Using data from the ‘Youth in India: Situation and Needs’ survey, this article provides perhaps the first estimates of inequality of opportunity in schooling outcomes for males and females separately for six Indian states. The inequality of educational opportunity in completion of primary (and secondary) schooling among females is more than twice (and nearly twice) that among males. Further, among females, only 20 per cent of total schooling opportunities needed for universal completion of secondary schooling are available and equitably distributed, a figure substantially lower than that for males (35 per cent). We also find stark inter-state variations in gender differential in inequality of educational opportunities.

This paper examines the extent of inequalities in human resource provision at India's Heath Sub-Centres (HSC)—first level of service provision in the public health system. ‘Within state’ inequality explained about 71% and ‘between state’ inequality explained the remaining 29% of the overall inter-HSC inequality. The Northern states had a lower health worker share relative to the extent of their HSC provision. Contextual factors that contributed to ‘between’ and ‘within’ district inequalities were the percentages of villages connected with all-weather roads and having primary schools. Analysis demonstrates a policy and programming need to address ‘within State’ inequalities as a priority.

This article presents new knowledge on the link between dowry and instances of abuse against newly married women. It draws on data collected during structured and in-depth interviews and focus groups involving 60 women in Kerala. The data argue that despite decades of campaigning by women's groups' dowry is still widely practised. Furthermore, the links between dowry, harassment and violence remain. The qualitative analysis of the data reveals how most people hold complex and seemingly contradictory views on dowry. Placing these views along a continuum with ‘dowry is a problem’ and ‘dowry is necessary’ at each end enables a picture to emerge of why dowry remains hard to eradicate. Most informants were clear that dowry represents a key problem for women; they also said they would continue to give dowry because it was the only way to secure a ‘good’ marriage. The data did reveal cracks in the patriarchal system; young women were direct identifying dowry as the main problem they faced. Also, indifferent views were voiced by younger men suggesting they may not forcefully act to maintain the system. Opportunities do exist to push wider holes in the system which could in turn spark the transformation still needed.

In the bid to explain reproductive health outcomes in most developing countries, men have often been seen as the cause of the problem. However, no systematic attempt has been made to examine men's perception of their own social and health needs, including how ideologies of masculinity impact men's social and physical health. This study examines the Igbo context and shows how men understand and interpret masculinity and the consequences of this for social and health behaviours. Data from adolescent and adult Igbo men aged 15-75 were collected using both quantitative survey interviews (n = 1372) and qualitative techniques such as focus-group discussion (n = 20), in-depth interviews (n = 10) and key informant interviews (n = 10) in selected areas of south-eastern Nigeria. We collected data on gender role ideologies and sexuality issues and practices. Our analysis shows that there are social and health costs associated with adherence to masculine ideologies and a strong association between masculine ideologies and men's health, risk-taking and health-seeking behaviours in the study population. We conclude that all sexual and reproductive health programmes should include services that address the specific needs of men and those negative aspects of masculinity that tend to expose men to adverse health outcomes.

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Objectives: Studies have widely documented the socioeconomic inequalities in maternal and child health related outcomes in developing countries including India. However, there is limited research on the inequalities in advice provided by public health workers on maternal and child health during antenatal visits. This paper investigates the inequalities in advice provided by public health workers to women during antenatal visits in rural India. Methods and findings: The District Level Household Survey (2007-08) was used to compute rich-poor ratios and concentration indices. Binary logistic regressions were used to investigate inequalities in advice provided by public health workers. The dependent variables comprised the advice provided on seven essential components of maternal and child health care. A significant proportion of pregnant women who attended at least four ANC sessions were not advised on these components during their antenatal sessions. Only 51%-72% of the pregnant women were advised on at least one of the components. Moreover, socioeconomic inequalities in providing advice were significant and the provision of advice concentrated disproportionately among the rich. Inequalities were highest in the case of advice on family planning methods. Advice on breastfeeding was least unequal. Public health workers working in lower level health facilities were significantly less likely than their counterparts in the higher level health facilities to provide specific advice. Conclusion: A significant proportion of women were not advised on recommended components of maternal and child health in rural India. Moreover, there were enormous socioeconomic inequalities. The findings of this study raise questions about the capacity of the public health care system in providing equitable services in India. The Government of India must focus on training and capacity building of the public health workers in communication skills so that they can deliver appropriate and recommended advice to all clients, irrespective of their socioeconomic status.

Context: In India, female sterilization accounts for 66% of contraceptive use, and age at sterilization is declining. It is likely that some women regret having been sterilized, but data on the prevalence of, and the social and economic correlates of, regret at the national level are insufficient. Methods: Data for analysis came from 30,999 sterilized women aged 15-49 interviewed in the 2005-2006 Indian National Family Health Survey. Logistic regression analyses and Wald tests were used to identify the social and demographic characteristics associated with sterilization regret. Results: Nationally, 5% of sterilized women aged 15-49 reported sterilization regret. Women sterilized at age 30 or older were less likely than women sterilized before age 25 to express regret (odds ratio, 0.8). Compared with women having only sons, those who had only daughters were more likely to express regret (1.3), while those having both sons and daughters were less likely to express regret (0.8). Women who had experienced child loss had higher odds of reporting regret than women who had not (for one child lost, 1.6; for two or more children lost, 2.0). Conclusions: Given the large proportion of women undergoing sterilization, the potential numbers experiencing regret are considerable. If age at sterilization continues to decline, sterilization regret is likely to increase. Encouraging couples to delay sterilization and increasing the availability of highly effective reversible contraceptives are options that India may consider to avert sterilization regret.

Objectives: Studies have widely documented the socioeconomic inequalities in maternal and child health related outcomes in developing countries including India. However, there is limited research on the inequalities in advice provided by public health workers on maternal and child health during antenatal visits. This paper investigates the inequalities in advice provided by public health workers to women during antenatal visits in rural India. Methods and findings: The District Level Household Survey (2007-08) was used to compute rich-poor ratios and concentration indices. Binary logistic regressions were used to investigate inequalities in advice provided by public health workers. The dependent variables comprised the advice provided on seven essential components of maternal and child health care. A significant proportion of pregnant women who attended at least four ANC sessions were not advised on these components during their antenatal sessions. Only 51%-72% of the pregnant women were advised on at least one of the components. Moreover, socioeconomic inequalities in providing advice were significant and the provision of advice concentrated disproportionately among the rich. Inequalities were highest in the case of advice on family planning methods. Advice on breastfeeding was least unequal. Public health workers working in lower level health facilities were significantly less likely than their counterparts in the higher level health facilities to provide specific advice. Conclusion: A significant proportion of women were not advised on recommended components of maternal and child health in rural India. Moreover, there were enormous socioeconomic inequalities. The findings of this study raise questions about the capacity of the public health care system in providing equitable services in India. The Government of India must focus on training and capacity building of the public health workers in communication skills so that they can deliver appropriate and recommended advice to all clients, irrespective of their socioeconomic status.

No abstract available

No abstract available

This study estimated birth order-specific miscarriage rates and characterized the influence of maternal age using the complete birth history of 90,303 ever-married women from the 1998-2000 Indian National Family Health Survey. Rates of miscarriage in India were low in association with early childbearing, whereas birth order as well as age substantially influenced miscarriage risk.

Sources of AIDS awareness among rural and urban Indian women were analysed using data from the National Family and Health Survey (1998–2000). Two measures were developed to study the impact each source had on knowledge. ‘Effectiveness’ was defined as the proportion of women who had heard of AIDS from only one source, from among women who had heard of AIDS from that particular source and other sources. ‘Independent effect’ was the proportion who had heard of AIDS from only one source in relation to all women who had heard of AIDS. Television was the most effective medium, and also had the highest independent effect. Radio and print had very low effectiveness and independent effect. Although television and print audiences are growing in India, it is likely a sub-group of women will continue to lack media access. There is an urgent need to disseminate AIDS awareness to this ‘media underclass’. Since the media will not reach this group, other sources including health workers, community level activities such as adult education programmes, and networks of friends and relatives need to be explored.

This study aimed to identify socio-cultural and reproductive health correlates of knowledge about AIDS among rural women using multivariate analysis of 1998-1999 National Family Health Survey (NFHS) data from two Indian states, Maharashtra and Tamil Nadu, where the urban HIV prevalence is relatively high. Analysis using multiple logistic regression was undertaken, modelling women's knowledge of AIDS, of whether the disease can be avoided, and of effective means of protection. Although 47% of all rural women in Maharashtra were aware of AIDS only about 28% knew that one can avoid it, and only about 16% possessed correct knowledge about its transmission. In Tamil Nadu, where overall 82% of rural women had awareness of AIDS, about 71% knew that one can avoid the disease but only about 31% possessed correct knowledge about its transmission. In both states, women from socially and economically backward groups had lower odds both of having awareness of AIDS and knowledge of ways to avoid getting the disease. Associations with socio-cultural and reproductive variables and the impact of contact with family planning services differed in the two states. The spread of the epidemic to rural areas presents a need actively to disseminate AIDS related knowledge for health protection rather than waiting for knowledge to follow the appearance of the disease in communities. Approaches to health promotion that do not consider differing contextual factors are unlikely to succeed. In particular, innovative strategies to disseminate knowledge among disadvantaged population groups are needed.

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children's care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations.

Kerala is famous for the speed with which its fertility has fallen over the decades. During the fertility transition Kerala's GDP per head and industrialisation have remained low, even compared with the rest of India. In general, explanations for this fertility decline have regarded Kerala as a homogeneous society and paid little attention to internal differences. However, fertility is low among the most socially and economically disadvantaged group in Kerala society, the scheduled castes, the former 'untouchables' of the traditional caste system. Thus, not only is fertility in Kerala low (1.96), but for scheduled castes it is even lower (1.52). This reversal of normal expectations is studied in the context of a scheduled caste community, the Vettuvans. The most important reason for the reversal of fertility was caste-system change triggered by land reform, Gulf migration, and democratisation of education in the state.

This paper identifies sociocultural and reproductive health correlates of knowledge about HIV among ever-married women using 1998–99 National Family Health Survey data from two low HIV prevalence Indian states, Madhya Pradesh (MP) and Uttar Pradesh (UP). Logistic regressions were undertaken modelling women’s awareness of HIV, of whether the disease can be avoided and of effective means of protection. In MP 22.7 per cent women were aware of HIV; 56.4 per cent (of 22.7 per cent) knew that the disease can be avoided; and 47.5 per cent (of 56.4 per cent) possessed correct knowledge about effective means of protection. In UP 20.7 per cent women had awareness of HIV; 59.2 per cent (of 20.7 per cent) knew that the disease can be avoided; and 45.7 per cent (of 59.2 per cent) were informed about effective means of protection. In both states older, uneducated, rural, poor, those not exposed to television, and those who had never used a modern family planning method were less likely to possess HIV awareness. However, for women who were aware of HIV, acquisition of further knowledge about it had fewer socioeconomic barriers. These barriers were state specific so interventions to overcome them need to be highly focused.

The objectives of this paper are to examine factors associated with use of antenatal care in rural areas of north India, to investigate access to specific critical components of care and to study differences in the pattern of services received via health facilities versus home visits. We used the 1998-1999 Indian National Family Health Survey of ever-married women in the reproductive age group and analysed data from the states of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh (n = 11,369). Overall, about three-fifths of rural women did not receive any antenatal check-up during their last pregnancy. Services actually received were predominantly provision of tetanus toxoid vaccination and supply of iron and folic acid tablets. Only about 13% of pregnant women had their blood pressure checked and a blood test done at least once. Women visited by health workers received fewer services compared to women who visited a health facility. Home visits were biased towards households with a better standard of living. There was significant under-utilisation of nurse/midwives in the provision of antenatal services and doctors were often the lead providers. The average number of antenatal visits reported in this study was 2.4 and most visits were in the second trimester. Higher social and economic status was associated with increased chances of receiving an antenatal check-up, and of receiving specific components including blood pressure measurement, a blood test and urine testing but not the obstetric physical examination, which was however linked to ever-use of family planning and the education of women and their husbands. Thus, pregnant women from poor and uneducated backgrounds with at least one child were the least likely to receive antenatal check-ups and services in the four large north Indian states. Basic antenatal care components are effective means to prevent a range of pregnancy complications and reduce maternal mortality. The findings indicate substantial limitations of the health services in overcoming socio-economic and cultural barriers to access.

Bangladesh initiated the Maternal Health Voucher Scheme (MHVS) in 2007 to improve maternal and child health practices and bring equity to the mainstream of health systems by reducing financial and institutional barriers. In this study, we investigated whether the MHVS has an association with immunization coverage in a rural area of Bangladesh. Between 30 October 2016 and 15 June 2017, we carried out a cross-sectional survey in two low performing areas in terms of immunization coverage- Chattogram (erstwhile Chittagong division) and Sylhet division of Bangladesh. We calculated the coverage of fully immunized children (FIC) for 1151 children aged 12–23 months of age. We compared the coverage of FIC between children whose mothers enrolled in MHVS and children whose mother did not. We analyzed immunization coverage using crude odds ratio (OR) and adjusted OR (aOR) from binary logistic regression models. The overall coverage of FIC was 86%. Ninety-three percent children whose mothers were MHVS members were fully immunized whereas the percentage was 84% for the children of mothers who were not enrolled in MHVS. Multivariate analysis also shows that FIC coverage was higher for children whose mothers enrolled in MHVS compared to those children whose mothers did not; the aOR was 2.03 (95% confidence interval 1.11–3.71). MHVS provides a window for non-targeted benefits of childhood vaccination. Providing health education to pregnant mothers during prenatal care may motivate them to immunize their children. Programmes targeted for mothers during pregnancy, childbirth and post-natal may further increase utilization of priority health services such as childhood immunization.