Jasmine Fledderjohann

‘Zero is not good for me’: implications of infertility in Ghana

BACKGROUND Given the high value placed on children in sub-Saharan Africa, previous research suggests that infertility increases the risk of psychological distress and marital conflict, encourages risky sexual behavior and deprives infertile individuals and couples of an important source of economic and social capital. This paper explores the implications of infertility for women in Ghana, West Africa. METHODS Semi-structured interview data collected from 107 women (aged 21-48 years, mean 33 years) seeking treatment in gynecological and obstetric clinics in Accra, Ghana, are analyzed. Based on iterative open coding of the interviews, the focus of the analysis is on mental health, marital instability, social interaction and gendered experiences. RESULTS Infertile women report facing severe social stigma, marital strain and a range of mental health difficulties. Many women feel that they shoulder a disproportionate share of the blame for infertility and, by extension, face greater social consequences than male partners for difficulties conceiving. Women who do not self-identify as infertile corroborate these findings, asserting that the social consequences of infertility are severe, particularly for women. CONCLUSIONS Infertility in Ghana has important consequences for social interactions, marital stability and mental health. These consequences are not perceived to be shared equally by Ghanaian men.

Revisiting "her" infertility: medicalized embodiment, self-identification and distress.

Prior research emphasizes womens distress and responsibility for a couples infertility because of gendered, pronatalist norms. Yet some studies suggest that being personally diagnosed and/or undergoing treatment differentially shapes reactions. We focused on differences in womens experiences with diagnosis and treatment, conceptualized as the medicalized embodiment of infertility. Using regression analysis, we examined two psychosocial outcomes (self-identification as infertile and fertility-specific distress) in a sample of 496 heterosexual, U.S. women from the National Survey of Fertility Barriers. Medicalized embodiment was salient to womens reactions, but had different relationships to self-identification versus distress. Although women experienced distress regardless of type of diagnosis, they were generally less likely to self-identify as infertile unless personally diagnosed. As such, we cannot assume that all women universally experience infertility. Future research should also address self-identification and distress as separate as opposed to simultaneous psychosocial outcomes.

Do Girls Have a Nutritional Disadvantage Compared with Boys? Statistical Models of Breastfeeding and Food Consumption Inequalities among Indian Siblings.

Background India is the only nation where girls have greater risks of under-5 mortality than boys. We test whether female disadvantage in breastfeeding and food allocation accounts for gender disparities in mortality. Methods and Findings Secondary, publicly available anonymized and de-identified data were used; no ethics committee review was required. Multivariate regression and Cox models were performed using Round 3 of India’s National Family and Health Survey (2005–2006; response rate = 93.5%). Models were disaggregated by birth order and sibling gender, and adjusted for maternal age, education, and fixed effects, urban residence, household deprivation, and other sociodemographics. Mothers’ reported practices of WHO/UNICEF recommendations for breastfeeding initiation, exclusivity, and total duration (ages 0–59 months), children’s consumption of 24 food items (6–59 months), and child survival (0–59 months) were examined for first- and secondborns (n = 20,395). Girls were breastfed on average for 0.45 months less than boys (95% CI: = 0.15 months to 0.75 months, p = 0.004). There were no gender differences in breastfeeding initiation (OR = 1.04, 95% CI: 0.97 to 1.12) or exclusivity (OR = 1.06, 95% CI: 0.99 to 1.14). Differences in breastfeeding cessation emerged between 12 and 36 months in secondborn females. Compared with boys, girls had lower consumption of fresh milk by 14% (95% CI: 79% to 94%, p = 0.001) and breast milk by 21% (95% CI: 70% to 90%, p<0.000). Each additional month of breastfeeding was associated with a 24% lower risk of mortality (OR = 0.76, 95% CI: 0.73 to 0.79, p<0.000). Girls’ shorter breastfeeding duration accounted for an 11% increased probability of dying before age 5, accounting for about 50% of their survival disadvantage compared with other low-income countries. Conclusions Indian girls are breastfed for shorter periods than boys and consume less milk. Future research should investigate the role of additional factors driving India’s female survival disadvantage.

Adequately diversified dietary intake and iron and folic acid supplementation during pregnancy is associated with reduced occurrence of symptoms suggestive of pre-eclampsia or eclampsia in Indian women

Background/Objective Pre-eclampsia or Eclampsia (PE or E) accounts for 25% of cases of maternal mortality worldwide. There is some evidence of a link to dietary factors, but few studies have explored this association in developing countries, where the majority of the burden falls. We examined the association between adequately diversified dietary intake, iron and folic acid supplementation during pregnancy and symptoms suggestive of PE or E in Indian women. Methods Cross-sectional data from India’s third National Family Health Survey (NFHS-3, 2005-06) was used for this study. Self-reported symptoms suggestive of PE or E during pregnancy were obtained from 39,657 women aged 15-49 years who had had a live birth in the five years preceding the survey. Multivariable logistic regression analysis was used to estimate the association between adequately diversified dietary intake, iron and folic acid supplementation during pregnancy and symptoms suggestive of PE or E after adjusting for maternal, health and lifestyle factors, and socio-demographic characteristics of the mother. Results In their most recent pregnancy, 1.2% (n=456) of the study sample experienced symptoms suggestive of PE or E. Mothers who consumed an adequately diversified diet were 34% less likely (OR: 0.66; 95% CI: 0.51-0.87) to report PE or E symptoms than mothers with inadequately diversified dietary intake. The likelihood of reporting PE or E symptoms was also 36% lower (OR: 0.64; 95% CI: 0.47-0.88) among those mothers who consumed iron and folic acid supplementation for at least 90 days during their last pregnancy. As a sensitivity analysis, we stratified our models sequentially by education, wealth, antenatal care visits, birth interval, and parity. Our results remained largely unchanged: both adequately diversified dietary intake and iron and folic acid supplementation during pregnancy were associated with a reduced occurrence of PE or E symptoms. Conclusion Having a adequately diversified dietary intake and iron and folic acid supplementation in pregnancy was associated with a reduced occurrence of symptoms suggestive of PE or E in Indian women.

Food Price Spikes Are Associated with Increased Malnutrition among Children in Andhra Pradesh, India

Background: Global food prices have risen sharply since 2007. The impact of food price spikes on the risk of malnutrition in children is not well understood. Objective: We investigated the associations between food price spikes and childhood malnutrition in Andhra Pradesh, one of India’s largest states, with >85 million people. Because wasting (thinness) indicates in most cases a recent and severe process of weight loss that is often associated with acute food shortage, we tested the hypothesis that the escalating prices of rice, legumes, eggs, and other staples of Indian diets significantly increased the risk of wasting (weight-for-height z scores) in children. Methods: We studied periods before (2006) and directly after (2009) India’s food price spikes with the use of the Young Lives longitudinal cohort of 1918 children in Andhra Pradesh linked to food price data from the National Sample Survey Office. Two-stage least squares instrumental variable models assessed the relation of food price changes to food consumption and wasting prevalence (weight-for-height z scores). Results: Before the 2007 food price spike, wasting prevalence fell from 19.4% in 2002 to 18.8% in 2006. Coinciding with India’s escalating food prices, wasting increased significantly to 28.0% in 2009. These increases were concentrated among low- (χ2: 21.6, P < 0.001) and middle- (χ2: 25.9, P < 0.001) income groups, but not among high-income groups (χ2: 3.08, P = 0.079). Each 10.0 rupee (

Impaired fertility and perceived difficulties conceiving in Ghana:measurement problems and prospects

0.170) increase in the price of rice/kg was associated with a drop in child-level rice consumption of 73.0 g/d (β: −7.30; 95% CI: −10.5, −3.90). Correspondingly, lower rice consumption was significantly associated with lower weight-for-height z scores (i.e., wasting) by 0.005 (95% CI: 0.001, 0.008), as seen with most other food categories. Conclusion: Rising food prices were associated with an increased risk of malnutrition among children in India. Policies to help ensure the affordability of food in the context of economic growth are likely critical for promoting children’s nutrition.

Quantifying the impact of rising food prices on child mortality in India: a cross-district statistical analysis of the District Level Household Survey

What is the most appropriate measure of impaired fertility for understanding its social consequences in sub-Saharan Africa? The dearth of subjective measures in surveys in the region has prevented comparisons of subjective and objective measures. Perceived difficulties conceiving may have a greater impact than objective measures for social outcomes such as divorce, stigmatization and distress. This study compares 12- (clinical) and 24- (epidemiological) month measures from biomedicine and 5- and 7-year measures from demography with a subjective measure of impaired fertility using correlations, random effects models and test-retest models to assess relationships between measures, their association with sociodemographic characteristics and the stability of measures across time. Secondary panel data (1998-2004) from 1350 Ghanaian women aged 15-49 of all marital statuses are used. Longer waiting times to identification of impaired fertility required by demographic measures result in more stable measures, but perceived difficulties conceiving are most closely aligned with clinical infertility (r=0.61; p<0.05). Epidemiological infertility is also closely aligned with the subjective measure. A large proportion of those identified as having impaired fertility based purely on waiting times are successful contraceptors. Where subjective measures are not available, epidemiological (24-month) measures may be most appropriate for studies of the social consequences of impaired fertility. Accounting for contraceptive use is important in order to avoid false positives. Future research should consider a variety of measures of perceived difficulties conceiving and self-identified infertility to assess which is most valid; in order to accomplish this, it is imperative that subjective measures of infertility be included in social surveys in sub-Saharan Africa.

Sibling support and the educational prospects of young adults in Malawi

Abstract Background: Rates of child malnutrition and mortality in India remain high. We tested the hypothesis that rising food prices are contributing to India’s slow progress in improving childhood survival. Methods : Using rounds 2 and 3 (2002—08) of the Indian District Level Household Survey, we calculated neonatal, infant and under-five mortality rates in 364 districts, and merged these with district-level food price data from the National Sample Survey Office. Multivariate models were estimated, stratified into 27 less deprived states and territories and 8 deprived states (‘Empowered Action Groups’). Results : Between 2002 and 2008, the real price of food in India rose by 11.7%. A 1% increase in total food prices was associated with a 0.49% increase in neonatal (95% confidence interval (CI): 0.13% to 0.85%), but not infant or under-five mortality rates. Disaggregating by type of food and level of deprivation, in the eight deprived states, we found an elevation in neonatal mortality rates of 0.33% for each 1% increase in the price of meat (95% CI: 0.06% to 0.60%) and 0.10% for a 1% increase in dairy (95% CI: 0.01% to 0.20%). We also detected an adverse association of the price of dairy with infant (b = 0.09%; 95% CI: 0.01% to 0.16%) and under-five mortality rates (b = 0.10%; 95% CI: 0.03% to 0.17%). These associations were not detected in less deprived states and territories. Conclusions: Rising food prices, particularly of high-protein meat and dairy products, were associated with worse child mortality outcomes. These adverse associations were concentrated in the most deprived states.

Reimagining infertility: a critical examination of fertility norms, geopolitics and survey bias

BACKGROUND Extended kin networks are an important social and economic resource in Africa. Existing research has focused primarily on intergenerational ties, but much less is known about “lateral” ties, such as those between siblings. In contexts of high adult mortality (i.e., fewer parents and grandparents) sibling interdependencies may assume heightened importance, especially during the transition to adulthood. OBJECTIVE In this paper, we extend the resource dilution perspective that dominates research on sibling relationships in early childhood and propose an alternate framework in which siblings represent a source of economic support that contributes positively to educational outcomes at later stages of the life course. METHODS We draw upon longitudinal data from young adults (age 15–18) in southern Malawi to assess the scope and magnitude of economic transfers among sibship sets. We then explore the relationships between sibship size, net economic transfers between siblings, and four measures of educational progress. RESULTS First, exchanges of economic support between siblings are pervasive in the Malawian context and patterned, especially by birth order. Second, economic support from siblings is positively associated with educational attainment, as well as with the odds of being at grade level in school, both contemporaneously and prospectively. CONCLUSIONS During young-adulthood, economic support from siblings acts as a buffer against the negative association between sibship size and schooling outcomes that has been documented at earlier ages. COMMENTS We question the established notion that siblings unilaterally subtract from resource pools, and argue that sibling support may be consequential for a wide range of demographic outcomes in a variety of cultural contexts. Our findings point to the need for additional research on the importance of lateral kinship ties across cultural settings and throughout the life course.

Barriers and prospects of India’s conditional cash transfer program to promote institutional delivery care: a qualitative analysis of the supply-side perspectives

While it is estimated that 15% of couples worldwide are infertile, this figure hinges critically on the quality, inclusiveness and availability of infertility data sources. Current infertility data and statistics fail to account for the infertility experiences of some social groups. We identify these people as the invisible infertile, and refer to their omission from infertility data and statistics-whether intentional or unintentional-as the process of invisibilization. We identify two processes through which invisibilization in survey data is produced: sampling, with focus on exclusionary definitions of the population at-risk, and survey instrument design, with focus on skip patterns and question wording. Illustrative examples of these processes are drawn from the Integrated Fertility Survey Series and the Demographic and Health Surveys. Empirical research is not designed in an objective vacuum. Rather, survey instruments and sampling techniques are shaped and influenced by the sociocultural norms and geopolitical context of the time and place in which they are created and conducted, reflecting broader social beliefs about family building and reproduction. Furthermore, population policy singularly aimed at curbing overpopulation in high fertility parts of the world limits the type of reproduction data collected, effectively rendering the infertility of some groups epidemiologically unfathomable. In light of these sociocultural and geopolitical forces, many marginalized groups are missing from reproductive health (RH) statistics. The omission of entire groups from the scientific discourse casts doubt on the quality of research questions, validity of the analytic tools, and accuracy of scientific findings. Invisibility may also misguide evidence-based RH and family planning policies and deter equitable access to reproductive healthcare for some social groups, perpetuating social inequalities.