Lotus McDougal

Changes in prevalence of girl child marriage in South Asia.

of the medical profession should play a role, but as we stated in our Viewpoint, they are not the only people in society with a stake in the outcome. Dr Johns and colleagues suggest that the market is better suited for determining the distribution of training options than the government. We might argue that in the United States, the market has not done that well. And because the government definitely has skin in the game as the largest payer, it certainly should have the right to influence the manpower and reimbursement issues. We agree that financial considerations are not the only factor in career choices but are pretty sure that if primary care physicians incomes went up by 80% and specialist incomes went down to the same degree, it would change the distribution of services provided to patients. In response to Dr Sheldon, we would simply say that manpower planning in the setting of the market distortions is fraught with difficulties. Perceived shortages can quickly turn into perceived surpluses, and vice versa.

Sexual violence and rape in India

One result to emerge from the National Surveys of Sexual Attitudes and Lifestyles (Natsal) is that the mean lifetime number of opposite-sex sexual partners diff ers signifi cantly between men and women. For instance, for the entire age range (16–74 years) examined by Catherine Mercer and colleagues (Nov 30, p 1781) in the most recent survey, the averages were found to be 14·1 for men and 7·1 for women. However, these averages should always be identical for the general population—given the following reasonable assumptions: fi rstly, that the population consists of equal numbers of men and women; and secondly, that for each member of the population, all of their sexual partners also reside within the population. The discrepancy in the averages has two possible causes: a breakdown of one or both of the assumptions mentioned previously, or an error in the methods of the survey. In the latter, I include the possibility that the information provided by the survey participants is inaccurate. The discrepancy therefore brings into question the extent to which the survey results refl ect the true sexual behaviour of the general population. In view of the importance of this survey with regards to—among other things—shaping health policy in Britain, as well as its presumably substantial effect on public For Natsal see http://www. natsal.ac.uk/ Sexual violence and rape in India

Associations of intimate partner violence with unintended pregnancy and pre-pregnancy contraceptive use in South Asia

OBJECTIVE To assess associations of intimate partner violence (IPV) with pregnancy intendedness and pre-pregnancy contraceptive use among pregnant women in South Asia. STUDY DESIGN Cross-sectional analyses were conducted using the most recent Demographic and Health Surveys from Bangladesh, India and Nepal for married, pregnant women aged 15-49 years who responded to IPV assessments specific to current marriage (N=4738). Adjusted logistic and multinomial regression analyses were conducted with pooled data to assess associations of IPV ever (sexual only, physical only, sexual plus physical or none) with the outcomes of pregnancy intendedness (wanted, mistimed or unwanted) and pre-pregnancy contraceptive use (no, traditional or modern) for the current pregnancy. RESULTS IPV was not associated with a mistimed or unwanted pregnancy. Sexual IPV was associated with pre-pregnancy modern contraceptive use (aOR=2.32, 95% CI=1.24, 4.36); sexual plus physical IPV was associated with pre-pregnancy traditional contraceptive use (aOR=1.85, 95% CI=1.12, 3.07). Post hoc analysis of reasons for pre-pregnancy contraceptive discontinuation revealed that women with a history of IPV, particularly sexual IPV, had higher prevalence of contraceptive failure (sexual only, 37.3%; sexual plus physical, 30.9%; physical only, 22.6%; no IPV, 13.6%). CONCLUSION Pregnant women who experienced sexual IPV from husbands were more likely to use contraceptives pre-pregnancy but had no reduced risk unintended pregnancy, possibly due to higher rates of pre-pregnancy contraceptive failure among those with this history. These findings suggest that victims of sexual IPV are able to acquire and use family planning services but require more support to sustain effective contraceptive use. IMPLICATIONS Family planning services are reaching women affected by sexual IPV, and programs should be sensitive to this concern and the heightened vulnerability to contraceptive failure these women face. Long-acting reversible contraception could be beneficial by allowing women to have greater reproductive control in situations of compromised sexual autonomy.

Cross-Sectional Time Series Analysis of Associations between Education and Girl Child Marriage in Bangladesh, India, Nepal and Pakistan, 1991-2011

Background Girl education is believed to be the best means of reducing girl child marriage (marriage <18 years) globally. However, in South Asia, where the majority of girl child marriages occur, substantial improvements in girl education have not corresponded to equivalent reductions in child marriage. This study examines the levels of education associated with female age at marriage over the previous 20 years across four South Asian nations with high rates (>20%) of girl child marriage- Bangladesh, India, Nepal and Pakistan. Methods Cross-sectional time series analyses were conducted on Demographic and Health Surveys (DHS) from 1991 to 2011 in the four focal nations. Analyses were restricted to ever-married women aged 20–24 years. Multinomial logistic regression models were used to assess the effect of highest level of education received (none, primary, secondary or higher) on age at marriage (<14, 14–15, 16–17, 18 and older). Results In Bangladesh and Pakistan, primary education was not protective against girl child marriage; in Nepal, it was protective against marriage at <14 years (AOR = 0.42) but not for older adolescents. Secondary education was protective across minor age at marriage categories in Bangladesh (<14 years AOR = 0.10; 14–15 years AOR = .25; 16–17 years AOR = 0.64) and Nepal (<14 years AOR = 0.21; 14–15 years AOR = 0.25; 16–17 years AOR = 0.57), but protective against marriage of only younger adolescents in Pakistan (<14 years AOR = 0.19; 14–15 years AOR = 0.23). In India, primary and secondary education were respectively protective across all age at marriage categories (<14 years AOR = 0.34, AOR = 0.05; 14–15 years AOR = 0.52, AOR = 0.20; 16–17 years AOR = 0.71, AOR = 0.48). Conclusion Primary education is likely insufficient to reduce girl child marriage in South Asia, outside of India. Secondary education may be a better protective strategy against this practice for the region, but may be less effective for prevention of marriage among older relative to younger adolescents.

Effects of young maternal age and short interpregnancy interval on infant mortality in South Asia

One in 14 births to young mothers in Bangladesh, India, Nepal, and Pakistan ends with the death of a child within the first year [1]. Recent analysis of nationally representative data from these nations documents that young maternal age at birth and short interpregnancy interval are significant drivers of infant death among births to young mothers. The aim of the present study was to quantify the proportion of infant deaths attributable to these factors. Using the most recent nationally representative Demographic and Health Survey (DHS) data [2], nation-specific logistic regression analyses were conducted to assess associations of younger maternal age at birth (<18 years vs ≥18 years) and preceding interpregnancy interval (<24 months vs ≥24 months or firstborn) with infant mortality among births to 15-24 year olds. Based on multivariate regression models, the percent of infant deaths attributable to each independent variable of interest was quantified using the population attributable fraction [3]. Population attributable fractions were then applied to 2012 population estimates [4] and age-specific fertility rates [2] to produce an estimate of the number of infant deaths attributable to the factors of interest. Local institutional review board approvals were obtained for DHS data collection, and institutional review board approval was obtained from the University of California, San Diego, USA, for the present analyses. The findings demonstrate that both young maternal age and short interpregnancy interval significantly increase the risk for infant mortality in India and Pakistan, contributing to 23%-26% (>200 000 in 2012) of infant deaths to young mothers in those nations (Table 1). In Bangladesh, only short interpregnancy interval was linked to infant mortality, accounting for 7% of infant deaths to young mothers. In Nepal, young motherhood but not short interpregnancy interval was associated with infant death. Table 1 Associations of young maternal age at birth and short interpregnancy intervals with infant deaths among births to young mothers a The results highlight the importance of delayed marriage and improved contraceptive use among young people as a means of reducing infant mortality rates in South Asia. Although both of the studied factors were not consistently associated with infant deaths across nations, child marriage, young motherhood, and low contraceptive use among adolescent wives are concerns in all of the nations assessed [2]. Nonetheless, India and Pakistan require the greatest focus on these issues. The present findings could, in part, be attributed to the use of older data in India and Pakistan relative to Bangladesh and Nepal; however, India and Pakistan are not on track to achieve Millennium Development Goal 4: the reduction of under-5 mortality by two-thirds between 1990 and 2015. Inadequate progress on contraceptive use and delaying marriage may be impeding this achievement for these nations. Analysis of more recent data, when available, is needed to confirm the study findings.

Associations of marital violence with different forms of contraception: cross-sectional findings from South Asia

To assess associations between marital violence and type of contraception among women in South Asia.

Adverse pregnancy outcomes and sexual violence among female sex workers who inject drugs on the United States-Mexico border

This study examines the prevalence of miscarriage/stillbirth among female sex workers who inject drugs (FSW-IDUs) and measures its associations with physical and sexual violence. Baseline data from 582 FSW-IDUs enrolled in an HIV intervention study in Tijuana and Ciudad Juárez, Mexico were used for current analyses. 30% of participants had experienced at least one miscarriage/stillbirth, 51% had experienced sexual violence, and 49% had experienced physical violence. History of miscarriage/stillbirth was associated with sexual violence (adjusted odds ratio [aOR] = 1.7, p = .02) but not physical violence. Additional reproductive risks associated with miscarriage/stillbirth included high numbers of male clients in the previous month (aOR = 1.1 per 30 clients, p = 0.04), history of abortion (aOR = 3.7, p < .001), and higher number of pregnancies (aOR = 1.4 per additional pregnancy, p < .001). Programs and research with this population should integrate reproductive health and consider gender-based violence.

Lesotho’s Minimum PMTCT Package: lessons learned for combating vertical HIV transmission using co-packaged medicines

Mother‐to‐child transmission of HIV can be reduced to<5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility‐based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant.

A decade of investments in monitoring the HIV epidemic: how far have we come? A descriptive analysis

BackgroundThe 2001 Declaration of Commitment (DoC) adopted by the General Assembly Special Session on HIV/AIDS (UNGASS) included a call to monitor national responses to the HIV epidemic. Since the DoC, efforts and investments have been made globally to strengthen countries’ HIV monitoring and evaluation (M&E) capacity. This analysis aims to quantify HIV M&E investments, commitments, capacity, and performance during the last decade in order to assess the success and challenges of national and global HIV M&E systems.MethodsM&E spending and performance was assessed using data from UNGASS country progress reports. The National Composite Policy Index (NCPI) was used to measure government commitment, government engagement, partner/civil society engagement, and data generation, as well as to generate a composite HIV M&E System Capacity Index (MESCI) score. Analyses were restricted to low and middle income countries (LMICs) who submitted NCPI reports in 2006, 2008, and 2010 (n =78).ResultsGovernment commitment to HIV M&E increased considerably between 2006 and 2008 but decreased between 2008 and 2010. The percentage of total AIDS spending allocated to HIV M&E increased from 1.1% to 1.4%, between 2007 and 2010, in high-burden LMICs. Partner/civil society engagement and data generation capacity improved between 2006 and 2010 in the high-burden countries. The HIV MESCI increased from 2006 to 2008 in high-burden countries (78% to 94%), as well as in other LMICs (70% to 77%), and remained relatively stable in 2010 (91% in high-burden countries, 79% in other LMICs). Among high-burden countries, M&E system performance increased from 52% in 2006 to 89% in 2010.ConclusionsThe last decade has seen increased commitments and spending on HIV M&E, as well as improved M&E capacity and more available data on the HIV epidemic in both high-burden and other LMICs. However, challenges remain in the global M&E of the AIDS epidemic as we approach the 2015 Millennium Development Goal targets.

Intersections of girl child marriage and family planning beliefs and use: qualitative findings from Ethiopia and India

Abstract Child marriage and subsequent early first birth is a considerable social, economic and health concern, and a pervasive practice in sub-Saharan Africa and South Asia. This study explores barriers and facilitators to family planning among women and girls, and their marital decision-makers subsequent to receipt of child marriage prevention programmes in Ethiopia and India. In-depth interviews with 128 women and girls who were married as minors or who cancelled or postponed marriage as minors and their marital decision-makers were analysed using content analysis. Respondents identified social norms, including child marriage and pressure to have children, and lack of information as barriers to family planning. Benefits included delayed first birth and increased birth spacing, improved maternal and child health and girls’ educational attainment. Respondents associated family planning use with delayed pregnancy and increased educational attainment, particularly in Ethiopia. Child marriage prevention programmes were identified as important sources of family planning information. Ethiopia’s school-based programme strengthened access to health workers and contraception more so than India’s community-based programme. Findings highlight young wives’ vulnerability with regard to reproductive control, and support the need for multi-sector approaches across communities, schools and community health workers to improve family planning among young wives.This brief documents CARE’s Tipping Point project and how it encouraged men and boys to take up tasks that are not typical for their gender. It offers tips on how to replicate this approach in your own work. In rural communities in Bangladesh’s Sunamgank district household chores take up much of women and girls’ days. This limits their time for themselves their friends and community engagement. The campaign called Amra-o-Korchi (“We are also doing” in Bangla) supported men and boys to take up tasks that are not typical for their gender. Men and boys took part in public competitions around cooking stitching and laundry. These small competitions culminated in a large public event –which saw men and boys go head to head to test their cooking skills.