Nadia Diamond-Smith

‘Too many girls, too much dowry’: son preference and daughter aversion in rural Tamil Nadu, India

The southern Indian state of Tamil Nadu has experienced a dramatic decline in fertility, accompanied by a trend of increased son preference. This paper reports on findings from qualitative interviews with women in rural villages about their fertility decision‐making. Specifically addressed are the reasons behind increasing son preference and the consequences of this change. Findings suggest that daughter aversion, fuelled primarily by the perceived economic burden of daughters due to the proliferation of dowry, is playing a larger role in fertility decision‐making than son preference. The desire for a son is often trumped by the worry over having many daughters. Women use various means of controlling the sex of their children, which in this study appear to be primarily female infanticide. It is important to distinguish between son preference and daughter aversion and to examine repercussions of low fertility within this setting.

Misinformation and fear of side-effects of family planning

Fears about the side-effects from family planning are well-documented barriers to use. Many fears are misinformation, while others reflect real experience, and understanding of these is not complete. Using qualitative interviews with women in three countries, this study examines what women feared, how they acquired this knowledge, and how it impacted on decision-making. We aimed to understand whether women would be more likely to use family planning if they were counselled that the side-effects they feared were inaccurate. Across all countries, respondents had a similar host of fears and misinformation about family planning, which were comprised of a mixture of personal experience and rumour. Most fears were method-specific and respondents overwhelmingly stated that they would be more likely to use the family planning method they feared if counselled that there were no side-effects. This suggests programmes should focus on education about family planning methods and method mix.

Estimating the burden of malaria in pregnancy: a case study from rural Madhya Pradesh, India

BackgroundMalaria in pregnancy (MiP) is inadequately researched in India, and the burden is probably much higher than current estimates suggest. This paper models the burden of MiP and associated foetal losses and maternal deaths, in rural Madhya Pradesh, India.MethodsNumber of pregnancies per year was estimated from the number of births and an estimate of pregnancies that end in foetal loss. The prevalence of MiP, risk of foetal loss attributable to MiP and case fatality rate of MiP were obtained from the literature. The estimated total number of pregnancies was multiplied by the appropriate parameter to estimate the number of MiP cases, and foetal loss and maternal deaths attributable to MiP per year. A Monte Carlo simulation sensitivity analysis was done to assess plausibility of various estimates obtained from the literature. The burden of MiP in tribal women was explored by incorporating the variable prevalence of malaria in tribal and non-tribal populations and in forested and non-forested regions within Madhya Pradesh.ResultsEstimates of MiP cases in rural Madhya Pradesh based on the model parameter values found in the literature ranged from 183,000–1.5 million per year, with 73,000–629,000 lost foetuses and 1,500–12,600 maternal deaths attributable to MiP. The Monte Carlo simulation gave a more plausible estimate of 220,000 MiP cases per year (inter-quartile range (IQR): 136,000–305,000), 95,800 lost foetuses (IQR: 56,800–147,600) and 1,000 maternal deaths (IQR: 650–1,600). Tribal women living in forested areas bore 30% of the burden of MiP in Madhya Pradesh, while constituting 18% of the population.ConclusionAlthough the estimates are uncertain, they suggest MiP is a significant public health problem in rural Madhya Pradesh, affecting many thousands of women and that reducing the MiP burden should be a priority.

Barriers to exclusive breastfeeding in the Ayeyarwaddy Region in Myanmar: Qualitative findings from mothers, grandmothers, and husbands

BACKGROUND Myanmar has low rates of exclusive breastfeeding despite many decades of efforts to increase this practice. The purpose of this study is to examine the barriers to exclusive breastfeeding and how different household members participate in decision-making. METHODS We conducted semi-structured interviews with mothers with an infant 6-12 months (24), and a subset of their husbands (10) and their mothers/mothers-in-laws (grandmothers) (10) in rural and urban areas of Laputta, Myanmar. RESULTS Respondents had high levels of knowledge about exclusive breastfeeding, but low adherence. One of the primary barriers to exclusive breastfeeding was that mothers, husbands, and grandmothers believed that exclusive breastfeeding was not sufficient for babies and solid foods and water were necessary. Water and mashed up rice were commonly introduced before 6 months of age. Mothers also faced barriers to exclusive breastfeeding due to the need to return to work outside the home and health related problems. Other family members provide support for mothers in their breastfeeding, however, most respondents stated that decisions about breastfeeding and child feeding were made by the mother herself. CONCLUSIONS Mothers in this part of Myanmar know about exclusive breastfeeding, but need more knowledge about its importance and benefits to encourage them to practice it. More information for other family members could improve adherence to exclusive breastfeeding, as family members often provide food to children and support to breastfeeding mothers. Support for mothers to be able to continue breastfeeding once they return to work and in the face of health problems is also important. Finally, additional information about the types of foods that infants need once they cease breastfeeding could improve infant and child health.

Drivers of facility deliveries in Africa and Asia: regional analyses using the demographic and health surveys.

BackgroundIn the past few decades many countries have worked to increase the number of women delivering in facilities, with the goal of improving maternal and neonatal health outcomes. The purpose of this study is to explore the current situation of facility deliveries in Africa and Asia to understand where and with whom women deliver. Furthermore, we aim to test potential drivers of facility delivery at the individual, household, and community-level.MethodsDemographic and Health Survey data collected since 2003 from 43 countries in Africa and Asia is explored to understand the patterns of where women are delivering. We look at patterns by region and wealth quintile and urban/rural status. We then run a series of multi-level models looking at relationships between individual, household and community-level factors and the odds of a woman delivering in a facility. We explore this for Asia and Africa separately. We also look at correlates of delivery with a trained provider, in a public facility, in a private facility, with a doctor and in a hospital.ResultsThe majority of women deliver in a facility and with a provider; however, about 20% of deliveries are still with no one or a friend/relative or alone. Rates of facility delivery are lower in Asia overall, and a greater proportion of deliveries take place in private facilities in Asia compared to Africa. Most of the individual level factors that have been found in past studies to be associated with delivering in a facility hold true for the multi-country-level analyses, and small differences exist between Asia and Africa. Women who deliver in private facilities differ from women who deliver in public facilities or at home.ConclusionsMost women in Africa and Asia are delivering in a facility, and drivers of facility delivery identified in smaller level or country specific studies hold true in multi-country national level data. More data and research is needed on other drivers, especially at the country-level and relating to the quality of care and maternal health complications.

The relationship between women's experiences of mistreatment at facilities during childbirth, types of support received and person providing the support in Lucknow, India

BACKGROUND a growing body of literature has highlighted the prevalence of mistreatment that women experience around the globe during childbirth, including verbal and physical abuse, neglect, lack of support, and disrespect. Much of this has been qualitative. Research around the world suggests that support during childbirth can improve health outcomes and behaviours, and improve experiences. Support can be instrumental, informational, or emotional, and can be provided by a variety of people including family (husbands, mothers) or health providers of various professional levels. This study explores womens reported experiences of mistreatment during childbirth quantitatively, and how these varied by specific types of support available and provided by specific individuals. METHODS participants were women age 16-30 who had delivered infants in a health facility in the previous five years and were living in slums of Lucknow India. Data were collected on their experiences of mistreatment, the types of support they received, and who provided that support. RESULTS women who reported lack of support were more likely to report mistreatment. Lack of support in regards to discussions with providers and provider information were most strongly associated with a higher mistreatment score. Women who received any type of support from their husband or a health worker were significantly more likely to report lower mistreatment scores. Receiving informational support from a mother/mother-in-law or emotional support from a health worker was also associated with lower mistreatment scores. However, receiving emotional support from a friend/neighbour/other family member was associated with a higher mistreatment score. CONCLUSIONS women rely on different people to provide different types of support during childbirth in this setting. Some of these individuals provide specific types of support that ultimately improve a womans overall experience of her childbirth. Interventions aiming to reduce mistreatment to women during childbirth should consider the important role of increasing support for women, and who might be the most appropriate person to provide the most essential types of support through this process.

Are the population policies of India and China responsible for the fertility decline

In the 1970s, policy‐makers in both India and China, convinced that reducing population growth was critical for ending poverty, instituted coercive population policies. Yet fertility had already been declining in both countries before the population policies were instituted. In China, the total fertility rate (TFR) had already fallen to 2.9 before the institution of the One‐Child Policy. In India, fertility continued to decline at roughly the same rate before, during and after ‘The Emergency’. Regardless of government mandates, couples in both countries before the policies and since have shown a desire to reduce their family size and when given access to family planning, have voluntarily limited the number of children they chose to have.

Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population

BackgroundPerson-centered reproductive health care is recognized as critical to improving reproductive health outcomes. Yet, little research exists on how to operationalize it. We extend the literature in this area by developing and validating a tool to measure person-centered maternity care. We describe the process of developing the tool and present the results of psychometric analyses to assess its validity and reliability in a rural and urban setting in Kenya.MethodsWe followed standard procedures for scale development. First, we reviewed the literature to define our construct and identify domains, and developed items to measure each domain. Next, we conducted expert reviews to assess content validity; and cognitive interviews with potential respondents to assess clarity, appropriateness, and relevance of the questions. The questions were then refined and administered in surveys; and survey results used to assess construct and criterion validity and reliability.ResultsThe exploratory factor analysis yielded one dominant factor in both the rural and urban settings. Three factors with eigenvalues greater than one were identified for the rural sample and four factors identified for the urban sample. Thirty of the 38 items administered in the survey were retained based on the factors loadings and correlation between the items. Twenty-five items load very well onto a single factor in both the rural and urban sample, with five items loading well in either the rural or urban sample, but not in both samples. These 30 items also load on three sub-scales that we created to measure dignified and respectful care, communication and autonomy, and supportive care. The Chronbach alpha for the main scale is greater than 0.8 in both samples, and that for the sub-scales are between 0.6 and 0.8. The main scale and sub-scales are correlated with global measures of satisfaction with maternity services, suggesting criterion validity.ConclusionsWe present a 30-item scale with three sub-scales to measure person-centered maternity care. This scale has high validity and reliability in a rural and urban setting in Kenya. Validation in additional settings is however needed. This scale will facilitate measurement to improve person-centered maternity care, and subsequently improve reproductive outcomes.

Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia

&NA; Growing evidence from a number of countries in Asia and Africa documents a large shift towards facility deliveries in the past decade. These increases have not led to the improvements in health outcomes that were predicted by health policy researchers in the past. In light of this unexpected evidence, we have assessed data from multiple sources, including nationally representative data from 43 countries in Asia and Africa, to understand the size and range of changing delivery location in Asia and Africa. We have reviewed the policies, programs and financing experiences in multiple countries to understand the drivers of changing practices, and the consequences for maternal and neonatal health and the health systems serving women and newborns. And finally, we have considered what implications changes in delivery location will have for maternal and neonatal care strategies as we move forward into the next stage of global action. As a result of our analysis we make four major policy recommendations. (1) An expansion of investment in mid‐level facilities for delivery services and a shift away from low‐volume rural delivery facilities. (2) Assured access for rural women through funding for transport infrastructure, travel vouchers, targeted subsidies for services and residence support before and after delivery. (3) Increased specialization of maternity facilities and dedicated maternity wards within larger institutions. And (4) a renewed focus on quality improvements at all levels of delivery facilities, in both private and public settings.

Advancing a conceptual model to improve maternal health quality: The Person-Centered Care Framework for Reproductive Health Equity

Background: Globally, substantial health inequities exist with regard to maternal, newborn and reproductive health. Lack of access to good quality care—across its many dimensions—is a key factor driving these inequities. Significant global efforts have been made towards improving the quality of care within facilities for maternal and reproductive health. However, one critically overlooked aspect of quality improvement activities is person-centered care. Main body: The objective of this paper is to review existing literature and theories related to person-centered reproductive health care to develop a framework for improving the quality of reproductive health, particularly in low and middle-income countries. This paper proposes the Person-Centered Care Framework for Reproductive Health Equity, which describes three levels of interdependent contexts for women’s reproductive health: societal and community determinants of health equity, women’s health-seeking behaviors, and the quality of care within the walls of the facility. It lays out eight domains of person-centered care for maternal and reproductive health. Conclusions: Person-centered care has been shown to improve outcomes; yet, there is no consensus on definitions and measures in the area of women’s reproductive health care. The proposed Framework reviews essential aspects of person-centered reproductive health care.