Deborah Karasek

Women's empowerment and ideal family size: an examination of DHS empowerment measures in Sub-Saharan Africa.

CONTEXT The Demographic and Health Survey (DHS) program collects data on womens empowerment, but little is known about how these measures perform in Sub-Saharan African countries. It is important to understand whether womens empowerment is associated with their ideal number of children and ability to limit fertility to that ideal number in the Sub-Saharan African context. METHODS The analysis used couples data from DHS surveys in four Sub-Saharan African countries: Guinea, Mali, Namibia and Zambia. Womens empowerment was measured by participation in household decision making, attitudes toward wife beating and attitudes toward refusing sex with ones husband. Multivariable linear regression was used to model womens ideal number of children, and multivariable logistic regression was used to model womens odds of having more children than their ideal. RESULTS In Guinea and Zambia, negative attitudes toward wife beating were associated with having a smaller ideal number of children (beta coefficients, -0.5 and -0.3, respectively). Greater household decision making was associated with a smaller ideal number of children only in Guinea (beta coefficient, -0.3). Additionally, household decision making and positive attitudes toward womens right to refuse sex were associated with elevated odds of having more children than desired in Namibia and Zambia, respectively (odds ratios, 2.3 and 1.4); negative attitudes toward wife beating were associated with reduced odds of the outcome in Mali (0.4). CONCLUSIONS Womens empowerment--as assessed using currently available measures--is not consistently associated with a desire for smaller families or the ability to achieve desired fertility in these Sub-Saharan African countries. Further research is needed to determine what measures are most applicable for these contexts.

Lifespan adversity and later adulthood telomere length in the nationally representative US Health and Retirement Study

Significance The gradual aging of the immune system is partly marked by shortened telomeres, the DNA–protein caps at the ends of chromosomes that protect genes from degradation. This study undertakes a lifespan approach to stress and leukocyte telomere length in a nationally representative sample of US residents. By using data from 16 y of the Health and Retirement Study, childhood and adulthood life stressors were examined for their individual and combined associations with increased odds of having short telomeres. Accumulated adverse experiences in childhood significantly predicted an increased likelihood of having short telomeres later in life, suggesting a potential pathway through which childhood experiences have been previously shown to predict adulthood morbidity and mortality. Stress over the lifespan is thought to promote accelerated aging and early disease. Telomere length is a marker of cell aging that appears to be one mediator of this relationship. Telomere length is associated with early adversity and with chronic stressors in adulthood in many studies. Although cumulative lifespan adversity should have bigger impacts than single events, it is also possible that adversity in childhood has larger effects on later life health than adult stressors, as suggested by models of biological embedding in early life. No studies have examined the individual vs. cumulative effects of childhood and adulthood adversities on adult telomere length. Here, we examined the relationship between cumulative childhood and adulthood adversity, adding up a range of severe financial, traumatic, and social exposures, as well as comparing them to each other, in relation to salivary telomere length. We examined 4,598 men and women from the US Health and Retirement Study. Single adversities tended to have nonsignificant relations with telomere length. In adjusted models, lifetime cumulative adversity predicted 6% greater odds of shorter telomere length. This result was mainly due to childhood adversity. In adjusted models for cumulative childhood adversity, the occurrence of each additional childhood event predicted 11% increased odds of having short telomeres. This result appeared mainly because of social/traumatic exposures rather than financial exposures. This study suggests that the shadow of childhood adversity may reach far into later adulthood in part through cellular aging.

Attitudes toward unprotected intercourse and risk of pregnancy among women seeking abortion.

BACKGROUND Despite the high prevalence of unintended pregnancies caused by lack of contraceptive use, little is known about womens reasons for or attitudes toward unprotected intercourse (UI). METHODS We included 562 women seeking pregnancy termination at six U.S. abortion clinics who completed surveys on their experiences and attitudes about UI, knowledge of the risk of conception, and willingness to engage in UI in the future. RESULTS Respondents reported an average of 18 acts of UI leading up to conception. The most commonly reported reasons for UI were thinking one could not get pregnant (42%), difficulties procuring a contraceptive method (40%), and not planning to have sex (38%). When asked about attitudes toward UI, 48% reported that UI feels better or more natural, 36% said it is okay to have UI once in a while or at certain times of the month, and 28% cited partner or relationship benefits as a reason to engage in UI. In addition, 23% said they were somewhat or extremely likely to engage in UI in the next 3 months. Younger women (<20 years), women who named partner or relationship benefits to UI, and women who underestimated the risk of conception were significantly more willing to engage in UI in the next 3 months. CONCLUSIONS Given the prevalence of risk taking and the perceived benefits of UI, contraceptives, particularly long-acting methods, need to be made easy to procure and use. The success of coital specific methods may be limited by women underestimating the risk of conception.

Do macroeconomic contractions induce or ‘harvest’ suicides? A test of competing hypotheses

Background Researchers often invoke a mortality displacement or ‘harvesting’ mechanism to explain mortality patterns, such that those with underlying health vulnerabilities die sooner than expected in response to environmental phenomena, such as heat waves, cold spells and air pollution. It is unclear if this displacement mechanism might also explain observed increases in suicide following economic contraction, or if suicides are induced in persons otherwise unlikely to engage in self-destructive behaviour. Here, we test two competing hypotheses explaining an observed increase in suicides following unemployment—induction or displacement. Methods We apply time series methods to monthly suicide and unemployment data from Sweden for the years 2000–2011. Tests are conducted separately for working age (20–64 years old) men and women as well as older (aged 65 years and older) men and women. Results Displacement appeared among older men and women; an unexpected rise in unemployment predicted an increase in suicides 6 months later, followed by a significant decrease 8 months later. Induction appeared among working age men, but not among working age women; an unexpected rise in unemployment predicted an increase in suicides 4–6 months later. Conclusions Displacement and induction both appear to have operated following unexpected labour market contractions in Sweden, though with different population segments.

Timing of birth: Parsimony favors strategic over dysregulated parturition

The “dysregulated parturition” narrative posits that the human stress response includes a cascade of hormones that “dysregulates” and accelerates parturition but provides questionable utility as a guide to understand or prevent preterm birth. We offer and test a “strategic parturition” narrative that not only predicts the excess preterm births that dysregulated parturition predicts but also makes testable, sex‐specific predictions of the effect of stressful environments on the timing of birth among term pregnancies.

Twins less frequent than expected among male births in risk averse populations.

Male twin gestations exhibit higher incidence of fetal morbidity and mortality than singleton gestations. From an evolutionary perspective, the relatively high rates of infant and child mortality among male twins born into threatening environments reduce the fitness of these gestations, making them more vulnerable to fetal loss. Women do not perceive choosing to spontaneously abort gestations although the outcome may result from estimates, made without awareness, of the risks of continuing a pregnancy. Here, we examine whether the non-conscious decisional biology of gestation can be linked to conscious risk aversion. We test this speculation by measuring the association between household surveys in Sweden that gauge financial risk aversion in the population and the frequency of twins among live male births. We used time-series regression methods to estimate our suspected associations and Box-Jenkins modeling to ensure that autocorrelation did not confound the estimation or reduce its efficiency. We found, consistent with theory, that financial risk aversion in the population correlates inversely with the odds of a twin among Swedish males born two months later. The odds of a twin among males fell by approximately 3.5% two months after unexpectedly great risk aversion in the population. This work implies that shocks that affect population risk aversion carry implications for fetal loss in vulnerable twin pregnancies.

Racial/ethnic differences in the role of childhood adversities for mental disorders among a nationally representative sample of adolescents

Background: Childhood adversities may play a key role in the onset of mental disorders and influence patterns by race/ethnicity. We examined the relations between childhood adversities and mental disorders by race/ethnicity in the National Comorbidity Survey-Adolescent Supplement. Methods: Using targeted maximum likelihood estimation, a rigorous and flexible estimation procedure, we estimated the relationship of each adversity with mental disorders (behavior, distress, fear, and substance use), and estimated the distribution of disorders by race/ethnicity in the absence of adversities. Targeted maximum likelihood estimation addresses the challenge of a multidimensional exposure such as a set of adversities because it facilitates “learning” from the data the strength of the relationships between each adversity and outcome, incorporating any interactions or nonlinearity, specific to each racial/ethnic group. Cross-validation is used to select the best model without over fitting. Results: Among adversities, physical abuse, emotional abuse, and sexual abuse had the strongest associations with mental disorders. Of all outcomes, behavior disorders were most strongly associated with adversities. Our comparisons of observed prevalences of mental disorders to estimates in the absence of adversities suggest lower prevalences of behavior disorders across all racial/ethnic groups. Estimates for distress disorders and substance use disorders varied in magnitude among groups, but some estimates were imprecise. Interestingly, results suggest that the adversities examined here do not play a major role in patterns of racial/ethnic differences in mental disorders. Conclusions: Although causal interpretation relies on assumptions, growing work on this topic suggests childhood adversities play an important role in mental disorder development in adolescents.

Stroke-attributable death among older persons during the great recession.

Epidemiological evidence indicates an elevated risk for stroke among stressed persons, in general, and among individuals who have lost their job, in particular. We, therefore, tested the hypothesis that stroke accounted for a larger fraction of deaths during the Great Recession than expected from other deaths and from trends, cycles, and other forms of autocorrelation. Based on vital statistics death data from California spanning 132 months from January 2000 through December 2010, we found support for the hypothesis. These findings appear attributable to non-Hispanic white men, who experienced a 5% increase in their monthly odds of stroke-attributable death. Total mortality in this group, however, did not increase. Findings suggest that 879 deaths among older white men shifted from other causes to stroke during the 36 months following the start of the Great Recession. We infer the Great Recession may have affected social, biologic, and behavioral risk factors that altered the life histories of older white men in ways that shifted mortality risk toward stroke.

Delayed pregnancy testing and second-trimester abortion: can public health interventions assist with earlier detection of unintended pregnancy?

BACKGROUND Delayed pregnancy testing has been associated with presentation for abortion in the second trimester. Little is known about acceptability of potential interventions to hasten pregnancy recognition. STUDY DESIGN A total of 592 women presenting for abortion at six clinics in the United States completed surveys on contraceptive use, risk behavior, timing of first pregnancy test and interest in interventions to speed pregnancy recognition and testing. RESULTS Forty-eight percent of women presenting for second-trimester abortion delayed testing until at least 8 weeks. In multivariate analysis, women who often spotted between periods had higher odds of delaying pregnancy testing [odds ratio (OR) 2.7, 95% confidence interval (CI) 1.04-6.94]. Women who often missed periods had higher odds of second-trimester abortion (OR 2.1, 95% CI 1.34-3.13). The majority (64%) of women were not aware of a fertile time in the menstrual cycle; these women had higher odds of second-trimester abortion (OR 2.0, 95% CI 1.21-3.37). Ninety-four percent of women expressed interest in at least one potential intervention to help recognize pregnancy earlier. CONCLUSIONS While there was near-universal interest in earlier pregnancy recognition, no single proposed intervention or scenario was endorsed by the majority. Improving sexual health awareness is an important consideration in future efforts to expedite pregnancy testing. IMPLICATIONS We found near-universal interest in earlier pregnancy recognition, though no single proposed intervention or scenario garnered majority support. Based on our findings, the concept of improving sexual health awareness through education should be incorporated in the development of future strategies to hasten recognition of unintended pregnancy.

Cohort Variation in Selection During Pregnancy and Risk of Selected Birth Defects Among Males

Background: The literature theorizes, but does not test, that variation over time in selective loss in utero affects the observed count of live-born birth defects cases. We test the hypothesis that the risk of birth defects among live-born males varies inversely with the strength of selection against males in utero. Methods: We identified a subset of six birth defect phenotypes among males from the California Birth Defects Monitoring Program, an active surveillance system for over 490,000 male singletons born in eight California counties from 1986 to 2004. We assigned each birth defect case infant to a monthly conception cohort at risk of selection in utero. We used the monthly sex ratio at birth (M:F), derived from each conception cohort, as the indicator of selection against males. We analyzed the odds ratio of birth defects with both individual-level logistic regression and aggregate time-series methods. Results: Consistent with selection in utero, male infants from conception cohorts with low outlying sex ratios (i.e., stronger selectivity) exhibit fewer than expected birth defects (adjusted odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.76, 0.98). Aggregate time-series tests also yield similar findings (OR = 0.81; 95% CI = 0.71, 0.90). Conclusions: Our findings among males indicate that variation in the strength of selectivity in utero accounts for a portion of observed cohort differences in morbidity due to birth defects. These findings suggest that “revealed prevalence” of morbidity across birth cohorts varies, at least in part, from selective loss in utero. See video abstract at, http://links.lww.com/EDE/B209.