The Effects of Conflict on Fertility: Evidence From the Genocide in Rwanda.

Our study analyzes the fertility effects of the 1994 genocide in Rwanda. We study the effects of violence on both the duration time to the first birth in the early post-genocide period and on the total number of post-genocide births per woman up to 15 years following the conflict. We use individual-level data from Demographic and Health Surveys, estimating survival and count data models. This article contributes to the literature on the demographic effects of violent conflict by testing two channels through which conflict influences fertility: (1) the type of violence exposure as measured by the death of a child or sibling, and (2) the conflict-induced change in local demographic conditions as captured by the change in the district-level sex ratio. Results indicate the genocide had heterogeneous effects on fertility, depending on the type of violence experienced by the woman, her age cohort, parity, and the time horizon (5, 10, and 15 years after the genocide). There is strong evidence of a child replacement effect. Having experienced the death of a child during the genocide increases both the hazard of having a child in the five years following the genocide and the total number of post-genocide births. Experiencing sibling death during the genocide significantly lowers post-genocide fertility in both the short-run and the long-run. Finally, a reduction in the local sex ratio negatively impacts the hazard of having a child in the five years following the genocide, especially for older women.

Four decades following the Khmer rouge: sociodemographic factors impacting depression, anxiety and PTSD in Cambodia.

BACKGROUND: Reliable population-based epidemiological data of Cambodian mental health is lacking. AIMS: This study identifies the prevalence of and factors associated with anxiety, depression and PTSD in Cambodian adults. METHODS: A nationally representative sample of Cambodian adults (N = 2690) was interviewed utilizing the Harvard Trauma Questionnaire (assessment of PTSD symptoms) and the Hopkins Symptom Checklist-25 (assessment of symptoms of anxiety and depression). RESULTS: Respondents expressed high rates of anxiety (27.4%), depression (16.7%) and PTSD (7.6%). Correlations between symptoms and sociodemographic markers varied in significance. Women had significantly higher rates of mental health symptoms than men. Women who were in debt, widowed or divorced and had low levels of education were the most likely to report symptoms. CONCLUSIONS: These findings can inform Cambodian mental health policies and development strategies, especially targeting the most vulnerable groups.

"I Asked Myself If I Would Ever Love My Baby": Mothering Children Born of Genocidal Rape in Rwanda.

The 1994 Rwandan genocide was characterized by brutal acts of widespread sexual violence against women that, for some, led to unwanted pregnancy, childbirth, and motherhood. This study explores the perspectives and experiences of 44 Rwandan women with children born of genocidal rape through in-depth qualitative interviews. Emerging from the data are the themes of identity and belonging, ambivalence, and truth-telling in the mother-child relationship. Findings highlight the lasting and intergenerational legacy of genocidal rape, and practice and policy implications are discussed.

The educational impact of shocks in utero: Evidence from Rwanda.

Research on the impact of violence and conflict on education typically focuses on exposure among a cohort of school-aged children. In line with the fetal origins hypothesis, this paper studies the long-run effect of exposure to adverse maternal health shocks while still in the womb. Exploiting the sudden and discrete nature of the Rwandan genocide and an identification strategy based on temporal and spatial variation, we find that the cohort in utero during the genocide reported on average 0.3 fewer years of schooling in the 2012 Rwanda. Population and Housing Census and was 8% points less likely to finish primary school relative to the cohort in utero just a couple of months later.

Exposure to Genocide as a Risk Factor for Homicide Perpetration in Rwanda: A Population-Based Case-Control Study.

A population-based case-control study was conducted to assess the relationship between genocide exposure and homicide perpetration in Rwanda. A sample of 150 homicide perpetrators who were charged with and confessed to having committed homicide between 1 May 2011 and 31 May 2013 and 450 controls were enrolled. Cases were matched to controls by neighborhood, age and sex. Socio-demographic, background and genocide-related information was collected from study subjects' next of kin. Four characteristics of genocide exposure were: genocide survivor, genocide perpetrator, having lost a first-degree relative to genocide and having a first-degree relative convicted of genocide. We assessed the impact of each genocide-exposure variable using conditional logistic regression. Of the 150 cases, 124 (82.7%) were male and 26 (17.3%) were female. The mean age of the alleged homicide perpetrators was 33 years, with a peak in the age group 20-29 years (39.3%). After adjusting for socio-demographic characteristics and past common criminal records, having a first-degree relative who had been convicted of genocide crimes was a significant predictor for homicide perpetration (odds ratio [OR] = 14.4, 95% confidence interval [CI] = 1.6-129.4). Being a genocide perpetrator, a genocide survivor and having lost a first-degree family member to genocide were not identified as risk factors for homicide perpetration. In Rwanda, young people who experienced early exposure to trauma by witnessing their first-degree relatives' active participation in the genocide, are more likely to commit homicide. Socio-economic and psychotherapeutic programs targeting this population group are needed to rehabilitate these young people for violent behavior change.

Exposure to genocide and the risk of schizophrenia: a population-based study.

BACKGROUND: No evidence exists on the association between genocide and the incidence of schizophrenia. This study aims to identify critical periods of exposure to genocide on the risk of schizophrenia. METHOD: This population-based study comprised of all subjects born in European nations where the Holocaust occurred from 1928 to 1945, who immigrated to Israel by 1965 and were indexed in the Population Register (N = 113 932). Subjects were followed for schizophrenia disorder in the National Psychiatric Case Registry from 1950 to 2014. The population was disaggregated to compare groups that immigrated before (indirect exposure: n = 8886, 7.8%) or after (direct exposure: n = 105 046, 92.2%) the Nazi or fascist era of persecutions began. The latter group was further disaggregated to examine likely initial prenatal or postnatal genocide exposures. Cox regression modelling was computed to compare the risk of schizophrenia between the groups, adjusting for confounders. RESULTS: The likely direct group was at a statistically (p < 0.05) greater risk of schizophrenia (hazard ratio = 1.27, 95% confidence interval 1.06-1.51) than the indirect group. Also, the likely combined in utero and postnatal, and late postnatal (over age 2 years) exposure subgroups were statistically at greater risk of schizophrenia than the indirect group (p < 0.05). The likely in utero only and early postnatal (up to age 2 years) exposure subgroups compared with the indirect exposure group did not significantly differ. These results were replicated across three sensitivity analyses. CONCLUSIONS: This study showed that genocide exposure elevated the risk of schizophrenia, and identified in utero and postnatal (combined) and late postnatal (age over 2 years) exposures as critical periods of risk.

Trends and social differentials in child mortality in Rwanda 1990-2010: results from three demographic and health surveys.

BACKGROUND: Rwanda has embarked on ambitious programmes to provide equitable health services and reduce mortality in childhood. Evidence from other countries indicates that advances in child survival often have come at the expense of increasing inequity. Our aims were to analyse trends and social differentials in mortality before the age of 5 years in Rwanda from 1990 to 2010. METHODS: We performed secondary analyses of data from three Demographic and Health Surveys conducted in 2000, 2005 and 2010 in Rwanda. These surveys included 34 790 children born between 1990 and 2010 to women aged 15-49 years. The main outcome measures were neonatal mortality rates (NMR) and under-5 mortality rates (U5MR) over time, and in relation to mother's educational level, urban or rural residence and household wealth. Generalised linear mixed effects models and a mixed effects Cox model (frailty model) were used, with adjustments for confounders and cluster sampling method. RESULTS: Mortality rates in Rwanda peaked in 1994 at the time of the genocide (NMR 60/1000 live births, 95% CI 51 to 65; U5MR 238/1000 live births, 95% CI 226 to 251). The 1990s and the first half of the 2000s were characterised by a marked rural/urban divide and inequity in child survival between maternal groups with different levels of education. Towards the end of the study period (2005-2010) NMR had been reduced to 26/1000 (95% CI 23 to 29) and U5MR to 65/1000 (95% CI 61 to 70), with little or no difference between urban and rural areas, and household wealth groups, while children of women with no education still had significantly higher U5MR. CONCLUSIONS: Recent reductions in child mortality in Rwanda have concurred with improved social equity in child survival. Current challenges include the prevention of newborn deaths.

Long-term mental health outcome in post-conflict settings: Similarities and differences between Kosovo and Rwanda.

BACKGROUND: Few studies investigated the long-term mental health outcome in culturally different post-conflict settings. This study considers two surveys conducted in Kosovo 8 years after the Balkans war and in Rwanda 14 years after the genocide. METHODS: All participants (n = 864 in Kosovo; n = 962 in Rwanda) were interviewed using the posttraumatic stress disorder (PTSD) and major depressive episode (MDE) sections of the Mini International Neuropsychiatric Interview (MINI) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Proportions of participants who met diagnostic criteria for either PTSD or MDE were 33.0% in Kosovo and 31.0% in Rwanda, with co-occurrence of both disorders in 17.8% of the Rwandan sample and 9.5% of the Kosovan sample. Among patients with PTSD, patterns of symptoms significantly differed in the two settings, with avoidance and inability to recall less frequent and sense of a foreshortened future and increased startle response more common in Rwanda. Significant differences were also observed in patients with MDE, with loss of energy and difficulties concentrating less frequent and suicidal ideation more common in Rwanda. Comorbid PTSD and MDE were associated with decreased SF-36 subjective mental and physical health scores in both settings, but significantly larger effects in Kosovo than in Rwanda. CONCLUSION: Culturally different civilian populations exposed to mass trauma may differ with respect to their long-term mental health outcome, including comorbidity, symptom profile and health perception.

Traumatic episodes experienced during the genocide period in Rwanda influence life circumstances in young men and women 17 years later.

BACKGROUND: During Rwanda's genocide period in 1994, about 800,000 people were killed. People were murdered, raped and seriously injured. This retrospective study investigated prevalence and frequency of traumatic episodes and associated psychosocial effects in young adults in Rwanda over the lifetime, during the genocide period and in the past three years. METHODS: This is a cross-sectional population-based study conducted among men and women, aged 20 to 35 years, residing in the Southern province of Rwanda. The study population, randomly selected in a multi stage procedure, included 477 females and 440 males. Data collection was performed through individual interviewing with a structured questionnaire during the period December 2011- January 2012. The Harvard Trauma Questionnaire was used to assess traumatic episodes. All data was sex-disaggregated. Differences between groups were measured by chi square and Fischer's exact test. Associations with socio-demographic and psychosocial factors were estimated by use of odds ratios with 95% confidence intervals in bi- and multivariate analyses. RESULTS: The participants in this study were 3 to 18 years of age in 1994, the year of the genocide. Our sample size was 917 participants, 440 men and 477 women. Women were to a higher extent exposed to traumatic episodes than men during their lifetime, 83.6% (n = 399) and 73.4% (n = 323), respectively. During the genocide period, 37.5% of the men/boys and 35.4% of the women/girls reported such episodes while in the past three years (2009-2011) 25.0% of the men and 23.1% of the women did. Women were more exposed to episodes related to physical and sexual violence, while men were exposed to imprisonment, kidnapping and mass killings. Victims of such violence during the genocide period were 17 years later less educated although married (men OR 1.47; 0.98-2.19; women OR 1.54; 1.03-2.30), without children (men OR 1.59; 1.08-2.36; women OR 1.86; 1.11-3.08) and living under extremely poor circumstances. CONCLUSION: The participants in this population-based study witnessed or experienced serious traumatic episodes during the genocide, which influenced their life circumstances 17 years later. Such traumatic episodes are however still taking place. The reasons for this need further investigation.

'I think my future will be better than my past': examining support group influence on the mental health of HIV-infected Rwandan women.

Urgent need exists for improved psychological services among HIV-infected women in post-genocide Rwanda. Psychological problems associated with trauma and sexual violence (i.e., depression, posttraumatic stress disorder [PTSD]) place women at increased risk for sexual risk behaviour, low health-seeking behaviour, delay of antiretroviral therapy (ART) and reduced ART adherence. We explored experiences of HIV-infected Rwandan women attending psychosocial support groups and their narratives about how participation affected their mental health and HIV treatment. Focus group discussions examined participants' reasons for support group attendance, perceived psychological benefit of support groups, influence on ART adherence, and other influences on health behaviors and attitudes. Rwandan women (aged 18-65) were randomly selected from 10 health clinic-facilitated support groups for HIV-infected trauma survivors in Kigali. Results identified positive psychological and physical changes as well as behaviour changes in relationships with men, which participants attributed to support group attendance. Data showed significant improvement in mental health, ART adherence and HIV serostatus disclosure resulting from group attendance. Participants acknowledged limitations of support groups with respect to addressing poverty and hunger. Implementing psychosocial support groups may leverage clinical outcomes and rejuvenate the well-being of HIV-infected women with interpersonal trauma and/or PTSD and depressive symptoms, particularly those from post-conflict countries.

Mental and physical health in Rwanda 14 years after the genocide.

PURPOSE: To examine the socio-demographic determinants of post-traumatic stress disorder (PTSD) and its association with major depressive episode and self-perceived physical and mental health in a large random sample of the Rwandan population 14 years after the 1994 genocide. METHODS: Using the Mini International Neuropsychiatric Interview and Medical Outcomes Study 36-Item Short-Form (SF-36) translated in Kinyarwanda, we interviewed 1,000 adult residents from the five provinces of Rwanda. Socio-demographic data and specific somatic symptoms were also recorded. Data analysis included 962 questionnaires. RESULTS: Participants were predominantly female (58.9%), aged between 16 and 34 years (53.2%), with a low level of education (79.7% below secondary school). Prevalence of PTSD was estimated to be 26.1%. In multivariable analysis, factors associated with PTSD were being aged between 25 and 34 years, living in extreme poverty, having endured the murder of a close relative in 1994, being widowed or remarried, having lost both parents and living in the South Province. Participants who fulfilled diagnostic criteria for PTSD were significantly more often affected with major depression (68.4 vs. 6.6%, P < 0.001) and substance dependence (7.6 vs. 3.5%, P = 0.013) than respondents without PTSD. They scored significantly lower on all SF-36 subscales. Somatic symptoms such as hiccups, fainting and loss of speech or hearing delineated a specific pattern of post-traumatic stress syndrome. CONCLUSIONS: PTSD remains a significant public health problem in Rwanda 14 years after the genocide. Facilitating access to appropriate care for all those who need it should be a national priority.