Climate and Gender: Association Between Droughts and Intimate Partner Violence in India.

Extreme climate events are related to women's exposure to different forms of violence. We examined the relationship between droughts and physical, sexual, and emotional intimate partner violence (IPV) in India by using 2 different definitions of drought: precipitation-based drought and socioeconomic drought. We analyzed data from 2 rounds of a nationally representative survey, the National Family Health Survey, where married women were asked about their experiences of IPV in the previous year (2015-2016 and 2019-2021; n = 122,696). Precipitation-based drought was estimated using remote sensing data and geographic information system (GIS) mapping, while socioeconomic drought status was collected from government records. Logistic regression models showed precipitation-based drought to increase the risk of experiencing physical IPV and emotional IPV. Similar findings were observed for socioeconomic drought; women residing in areas classified as drought-impacted by the government were more likely to report physical IPV, sexual IPV, and emotional IPV. These findings support the growing body of evidence regarding the relationship between climate change and women's vulnerability, and highlight the need for gender responsive strategies for disaster management and preparedness.

Collective efficacy measures for women and girls in low- and middle-income countries: a systematic review.

BACKGROUND: Prior research has shown collective efficacy to be a key determinant of women's well-being. However, much of the work around measuring this construct has been done in high-income geographies, with very little representation from low- and middle-income countries (LMIC). To fill this gap, and guide future research in low resource settings, we aim to summarize best evidence measures of collective efficacy for women and girls from LMICs. METHODS: Following PRISMA guidelines, we systematically searched five databases for English language peer-reviewed literature on measures of collective efficacy, published between 1 January 2009 and 25 August 2020. In addition, we sought expert input for relevant papers in this area. Research staff screened titles, abstracts, and full-text articles in a double-blind review. Inclusion criteria were: (i) original quantitative analysis, and (ii) sample limited to women/girls only (≥ 100), residing in LMICs. RESULTS: We identified 786 unique articles, 14 of which met inclusion criteria. Eligible studies captured a diversity of population groups, including pregnant women, recent mothers, adolescent girls, and female sex workers, from across national settings. Two broad constructs of collective efficacy were captured by the measures: (i) group dynamics, and (ii) collective action. All 14 studies included items on group dynamics in their measures, whereas seven studies included items on collective action. Four studies validated new measures of collective efficacy, and seven provided evidence supporting the relationship between collective efficacy and outcomes related to women's well-being. Overall, measures demonstrated good reliability and validity when tested, and those testing for associations or effects found a positive relationship of collective efficacy with women's health behaviors. CONCLUSION: The past decade has resulted in a number of new collective efficacy measures demonstrating good validity in terms of their associations with key health outcomes among women and girls from across LMIC settings, but there remains no standard measure in the field. Those that exist focus on group dynamics, but less often on collective action. A standard measure of collective efficacy inclusive of group dynamics and collective action can support better understanding of the value of women's collectives across national settings and populations.

Disrupting gender norms in health systems: making the case for change.

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Unintended pregnancy and maternal health complications: cross-sectional analysis of data from rural Uttar Pradesh, India.

BACKGROUND: This study aims to explore the potential association between unintended pregnancy and maternal health complications. Secondarily, we test whether antenatal care (ANC) and community health worker (CHW) visits moderate the observed association between unintended pregnancy and maternal health complications. METHODS: Cross sectional data were collected using a multistage sampling design to identify women who had a live birth in the last 12 months across 25 highest risk districts of Uttar Pradesh (N = 3659). Participants were surveyed on demographics, unintendedness of last pregnancy, receipt of ANC clinical visits and community outreach during pregnancy, and maternal complications. Regression models described the relations between unintended pregnancy and maternal complications. To determine if receipt of ANC and CHW visits in pregnancy moderated associations between unintended pregnancy and maternal complications, we used the Mantel-Haenzel risk estimation test and stratified logistic models testing interactions of unintended pregnancy and receipt of health services to predict maternal complications. RESULTS: Around one-fifth of the women (16.9%) reported that their previous pregnancy was unintended. Logistic regression analyses revealed that unintended pregnancy was significantly associated with maternal complications- pre-eclampsia (AOR:2.06; 95% CI:1.57-2.72), postpartum hemorrhage (AOR:1.46; 95% CI: 1.01-2.13) and postpartum pre-eclampsia (AOR:2.34; 95% CI:1.47-3.72). Results from the Mantel Haenszel test indicated that both ANC and CHW home visit in pregnancy significantly affect the association between unintended pregnancy and postpartum hemorrhage (p < 0.001). CONCLUSION: Unintended pregnancy is associated with increased risk for maternal health complications, but provision of ANC clinical visits and CHW home visits in pregnancy may be able to reduce potential effects of unintended pregnancy on maternal health.

Family planning counseling and its associations with modern contraceptive use, initiation, and continuation in rural Uttar Pradesh, India.

BACKGROUND: We examine the association between the quality of family planning (FP) counseling received in past 24 months, and current modern contraceptive use, initiation, and continuation, among a sample of women in rural Uttar Pradesh, India. METHODS: This study included data from a longitudinal study with two rounds of representative household survey (2014 and 2016), with currently married women of age 15-49 years; the analysis excluded women who were already using a permanent method of contraceptive during the first round of survey and who reported discontinuation because they wanted to be pregnant (N = 1398). We measured quality of FP counseling using four items on whether women were informed of advantages and disadvantages of different methods, were told of method(s) that are appropriate for them, whether their questions were answered, and whether they perceived the counseling to be helpful. Positive responses to every item was categorized as higher quality counseling, vs lower quality counseling for positive response to less than four items. Outcome variables included modern contraceptive use during the second round of survey, and a variable categorizing women based on their contraceptive use behavior during the two rounds: continued-users, new-users, discontinued-users, and non-users. RESULTS: Around 22% had received any FP counseling; only 4% received higher-quality counseling. Those who received lower-quality FP counseling had 2.42x the odds of reporting current use of any modern contraceptive method (95% CI: 1.56-3.76), and those who received higher quality FP counseling at 4.14x the odds of reporting modern contraceptive use (95% CI: 1.72-9.99), as compared to women reporting no FP counseling. Women receiving higher-quality counseling also had higher likelihood of continued use (ARRR 5.93; 95% CI: 1.97-17.83), as well as new use or initiation (ARRR: 4.2; 95% CI: 1.44-12.35) of modern contraceptives. Receipt of lower-quality counseling also showed statistically significant associations with continued and new use of modern contraceptives, but the effect sizes were smaller than those for higher-quality counseling. CONCLUSIONS: Findings suggest the value of FP counseling. With a patient-centered approach to counseling, continued use of modern contraceptives can be supported among married women of reproductive age. Unfortunately, FP counseling, particularly higher-quality FP counseling remains rare.

Rapid surveys on violence against women in crisis contexts: decision-making guidance based on the UN Women Rapid Gender Assessment surveys on violence against women during COVID-19.

Rapid surveys or assessments offer the possibility to collect data in contexts where classic data collection is not feasible (such as health, humanitarian, or climate crises) and when evidence-based urgent action is needed to mitigate the effects of the crisis. Until the past 5 years, rapid surveys were not widely used by practitioners, researchers, or policy makers to measure the effect of crises on violence against women due to a paucity of empirical evidence on their safety and likely utility in such contexts. In recent years, and particularly during the COVID-19 global pandemic, UN Women led the piloting and implementation of such surveys in various countries. We use our experiences from this work and other studies to offer concrete decision-making guidance-in the form of a checklist-for whether to conduct rapid surveys on violence against women in crisis contexts, with consideration of their value, risks, and the minimum safeguards needed to implement this type of work.

Violence against women on Twitter in India: Testing a taxonomy for online misogyny and measuring its prevalence during COVID-19.

BACKGROUND: Online misogyny is a violation of women's digital rights. Empirical studies on this topic are however lacking, particularly in low- and middle- income countries. The current study aimed to estimate whether prevalence of online misogyny on Twitter in India changed since the pandemic. METHODS: Based on prior theoretical work, we defined online misogyny as consisting of six overlapping forms: sexist abuses, sexual objectification, threatening to physically or sexually harm women, asserting women's inferiority, justifying violence against women, and dismissing feminist efforts. Qualitative analysis of a small subset of tweets posted from India (40,672 tweets) substantiated this definition and taxonomy for online misogyny. Supervised machine learning models were used to predict the status of misogyny across a corpus of 30 million tweets posted from India between 2018 and 2021. Next, interrupted time series analysis examined changes in online misogyny prevalence, before and during COVID-19. RESULTS: Qualitative assessment showed that online misogyny in India existed most in the form of sexual objectification and sexist abusive content, which demeans women and shames them for their presumed sexual activity. Around 2% of overall tweets posted from India between 2018 and 2021 included some form of misogynistic content. The absolute volume as well as proportion of misogynistic tweets showed significant increasing trends after the onset of COVID-19, relative to trends prior to the pandemic. CONCLUSION: Findings highlight increasing gender inequalities on Twitter since the pandemic. Aggressive and hateful tweets that target women attempt to reinforce traditional gender norms, especially those relating to idealized sexual behavior and framing of women as sexual beings. There is an urgent need for future research and development of interventions to make digital spaces gender equitable and welcoming to women.

Relationship between adolescent friendship networks and contraceptive use and unintended pregnancies in early adulthood in the United States.

OBJECTIVE: To examine the relationship between reproductive attitude of friends during adolescence, and unintended pregnancy outcomes and contraceptive non-use during early adulthood. STUDY DESIGN: We used longitudinal data from the National Longitudinal Study of Adolescent to Adult Health (n = 1866). Adolescent friendship network structures were constructed from the first wave of data to assess reproductive attitudes of friends, measured via 3 subscales: attitude toward contraceptive use, attitude toward sex in adolescence, and attitude toward pregnancy in adolescence. We then used multilevel logistic regression to examine the relationship of friends' reproductive attitudes in adolescence with unintended pregnancy and contraceptive non-use in adulthood. RESULTS: Around one-third of the sample experienced at least one unintended pregnancy, and 12% reported contraceptive non-use. Being friends with individuals who are not accepting of adolescent pregnancy reduced the likelihood of an unintended pregnancy in young adulthood (adjusted odds ratios [aOR]: 0.79; 95% CI: 0.67-0.94); this association varied by sex, being significant only for females (aOR:0.75; 95% CI: 0.58-0.96). Additionally, friends' acceptability of adolescent sex increased the odds of contraceptive use in later life. Individuals with friends who held negative attitude toward contraceptive use during adolescence were more likely to be non-users in later life (aOR:1.37; 95% CI: 1.03-1.81). CONCLUSIONS: Our results suggest a relationship between adolescent social networks and reproductive health outcomes in young adulthood, highlighting the importance of friendship networks for young individuals' reproductive well-being. IMPLICATIONS: Attitudes held by adolescent friends regarding contraceptive use, adolescent sex, and adolescent pregnancy have significant, and distinct associations with an individuals' later-life reproductive health outcomes. Future research should consider evaluation of social network-based sexual and reproductive health interventions aimed at adolescents.

COVID-19 burden, author affiliation and women's well-being: A bibliometric analysis of COVID-19 related publications including focus on low- and middle-income countries.

Background: Published literature documents tremendous gender inequities in the social, economic and health effects of the COVID-19 pandemic, but less evidence has come from low- and middle-income countries (LMICs) and even less from LMIC-based authors. We examine whether a) COVID-19 burden and b) LMIC-based authorship were associated with academic publications related to COVID-19 and women's well-being in LMICs. Methods: We reviewed academic articles on COVID-19 and women's well-being in LMICs published between February 2020 and May 2021 (n=1076 articles), using six electronic databases (PubMed, Web of Science, PsycInfo, EconLit, RePeC, NBER). Multilevel, mixed effects linear regressions assessed the relationships between each of our independent variables - a) COVID-19 burden (cases/100 population, deaths/100 population, deaths/cases) and b) author's country of primary affiliation, with publications related to COVID-19 and women's well-being, both overall and stratified by country income group. Findings: Eight-eight percent of articles had lead and/or senior authors affiliated with in-country institutions. Linear mixed effect models indicate that COVID-19 cases and case fatality ratios in a country were significantly and positively associated with the number of publications related to COVID-19 and women's well-being, though these relationships were significant only in upper-middle income group countries in stratified analyses. LMIC lead and senior authorship were also significantly and positively associated with our outcome, after adjusting for COVID-19 burden. Interpretation: While the majority of COVID-19 research examining women's well-being in LMICs in the first year and a half of the pandemic included country-affiliated author leadership, there were important gaps in representation. Findings highlight the importance of LMIC-based scholars to build local and gendered research in crises. Funding: Bill and Melinda Gates Foundation (INV-018007).

Help seeking behavior by women experiencing intimate partner violence in india: A machine learning approach to identifying risk factors.

BACKGROUND: Despite the low prevalence of help-seeking behavior among victims of intimate partner violence (IPV) in India, quantitative evidence on risk factors, is limited. We use a previously validated exploratory approach, to examine correlates of help-seeking from anyone (e.g. family, friends, police, doctor etc.), as well as help-seeking from any formal sources. METHODS: We used data from a nationally-representative health survey conducted in 2015-16 in India, and included all variables in the dataset (~6000 variables) as independent variables. Two machine learning (ML) models were used- L-1, and L-2 regularized logistic regression models. The results from these models were qualitatively coded by researchers to identify broad themes associated with help-seeking behavior. This process of implementing ML models followed by qualitative coding was repeated until pre-specified criteria were met. RESULTS: Identified themes associated with help-seeking behavior included experience of injury from violence, husband's controlling behavior, husband's consumption of alcohol, and being currently separated from husband. Themes related to women's access to social and economic resources, such as women's employment, and receipt of maternal and reproductive health services were also noted to be related factors. We observed similarity in correlates for seeking help from anyone, vs from formal sources, with a greater focus on women being separated for help-seeking from formal sources. CONCLUSION: Findings highlight the need for community programs to reach out to women trapped in abusive relationships, as well as the importance of women's social and economic connectedness; future work should consider holistic interventions that integrate IPV screening and support services with women's health related services.

Spousal support and work performance during the COVID-19 pandemic among elected women representatives in rural Bihar, India: A cross-sectional, mixed-methods study.

Background: This study examines family support for professional work and domestic labour among Elected Women Representatives' (EWR) in rural Bihar, India, and associations of this support with EWRs' professional performance during the COVID-19 pandemic. Methods: We conducted a cross-sectional, mixed-method study, surveying 1338 EWRs and conducting in-depth interviews with 31 EWRs (Oct 14- Nov 6, 2020). Purposive sampling was used to select the participants. Our team has been working for more than a decade with EWRs across 10 districts in Bihar, providing them with capacity building and community interventions. All EWRs are part of our network, and around 2000 were reached out for the survey. Of these, 1338 consented to participate. Four survey participants from each district were randomly selected and invited for the in-depth interviews. Independent variables for our quantitative analysis included help from husband and other family members on a) EWR work and b) domestic work. Dependent variables, dichotomised as yes/no, assessed EWR workload, COVID-19 work, intervening on violence against women or child marriage, and belief EWRs can have impact. Separate multivariate logistic regression models assessed the hypothesised relationships. All models were adjusted for socio-demographic variables and indicators related to EWR's work experience and community perception or respect. Findings: Most women (76%; n = 1016 EWRs) received help from their husbands with EWR work while 39% reported husband help with domestic labour. Receipt of help from husband with domestic work was associated with increase in official work since the pandemic (aOR: 2.62; 95% CI: 1.84-3.71), arrangement of needed services during COVID-19 (aOR: 2.54; 95% CI:1.65-3.90), and self-belief regarding possibility of EWR impact (aOR: 3.49; 95% CI: 2.25-5.43). Husband's help with EWR work was related to increased odds for intervening to stop violence against women only (aOR: 2.18; 95% CI: 1.32-3.60). In-depth interviews with the selected 31 EWRs underscored an increase in their EWR work under COVID-19. The increase in EWR workload under the pandemic created time constrictions for EWR's domestic labour responsibilities, even as domestic labour responsibilities increased. Interpretation: Our study highlights the importance of husband's help and support in strengthening EWRs outcomes at work in India, with help in domestic work being related to a relatively wider range of outcomes that are indicative of EWR's performance, compared to husband's help with EWR work. These findings emphasize the need for building male responsibility for domestic labour, to improve women's professional performance and outcomes. Our study has few key limitations such as lack of causal interpretations due to reliance on cross-sectional research design, potential for social desirability bias in self-reported data, and absence of information related to changes in patterns of spousal and family support received by the EWRs as a result of the pandemic. Nonetheless, our findings are important, particularly for the context of Bihar, India, where appalling gender gaps still persist in all social and economic aspects of society. Funding: Bill & Melinda Gates Foundation: 2017, OPP1179246 and EMERGE COVID-19 (2019, OPP1163682); David & Lucile Packard Foundation: 2017- 66202.

Using machine learning to understand determinants of IUD use in India: Analyses of the National Family Health Surveys (NFHS-4).

Intra-uterine devices (IUDs) are a safe and effective method to delay or space pregnancies and are available for free or at low cost in the Indian public health system; yet, IUD uptake in India remains low. Limited quantitative research using national data has explored factors that may affect IUD use. Machine Learning (ML) techniques allow us to explore determinants of low prevalence behaviors in survey research, such as IUD use. We applied ML to explore the determinants of IUD use in India among married women in the 4th National Family Health Survey (NFHS-4; N = 499,627), which collects data on demographic and health indicators among women of childbearing age. We conducted ML logistic regression (lasso and ridge) and neural network approaches to assess significant determinants and used iterative thematic analysis (ITA) to offer insight into related variable constructs generated from a series of regularized models. We found that couples' shared family planning (FP) goals were the strongest determinants of IUD use, followed by receipt of FP services and desire for no more children, higher wealth and education, and receipt of maternal and child health services. Findings highlight the importance of male engagement and family planning services for IUD uptake and the need for more targeted efforts to support awareness of IUD as an option for spacing, especially for those of lower SES and with lower access to care.

Machine learning analysis of non-marital sexual violence in India.

BACKGROUND: Machine learning techniques can explore low prevalence data to offer insight into identification of factors associated with non-marital sexual violence (NMSV). NMSV in India is a health and human rights concern that disproportionately affects adolescents, is under-reported, and not well understood or addressed in the country. METHODS: We applied machine learning methods to retrospective cross-sectional data from India's nationally-representative National Family Health Survey 4, a demographic and health study conducted in 2015-16, which offers 4000+ variables as potential independent variables. We used Least Absolute Shrinkage and Selection Operator (lasso) or L-1 regularized logistic regression models as well as L-2 regularized logistic regression or ridge models; we conducted an iterative thematic analysis (ITA) of variables generated from a series of regularized models. FINDINGS: Thematic analysis of regularized models highlight that past exposure to violence was most predictive of NMSV, followed by geography, sexual behavior, and poor sexual and reproductive health knowledge. After these, indicators largely related to resources and autonomy (e.g., access to health services, and income generating) were associated with NMSV. Exploratory analysis with the subsample of never married adolescents 15-19 years old, a population with higher representation of recent NMSV, further emphasized the role of wealth and mobility as key correlates of NMSV, along with poor HIV knowledge, tobacco use, higher fertility preferences, and attitudes accepting of marital violence. INTERPRETATION: Findings indicate the validity of machine learning with iterative theme analysis (ITA) to identify factors associated with violence. Findings were consistent with prior work demonstrating associations between NMSV and other violence experiences, but also showed novel correlates such as lower SRH knowledge and service utilization and, for girls, norms and preferences suggesting more restrictive gender norms. Sexual and reproductive health, gender equity and safety focused interventions are important for addressing NMSV in India, particularly for adolescents.

Planning for work: Exploring the relationship between contraceptive use and women's sector-specific employment in India.

While the health-related benefits of contraceptive use for women are well documented, potential social benefits, including enabling women's employment, have not been well researched. We examine the relationship between contraceptive use and women's employment in India, a country where both factors have remained relatively static over the past ten years. We use data from India's 2015-16 National Family Health Survey to test the association between current contraceptive use (none, sterilization, IUD, condom, pill, rhythm method or withdrawal) and current employment status (none, professional, clerical or sales, agricultural, services or production) with multivariable, multinomial regression; variable selection was guided by a directed acyclic graph. More than three-quarters of women in this sample were currently using contraception; sterilization was most common. Women who were sterilized or chose traditional contraception, relative to those not using contraception, were more likely to be employed in the agricultural and production sectors, versus not being employed (sterilization adjusted relative risk ratio [aRRR] = 1.5, p<0.001 for both agricultural and production sectors; rhythm aRRR = 1.5, p = 0.01 for agriculture; withdrawal aRRR = 1.5, p = 0.02 for production). In contrast, women with IUDs, compared to those who not using contraception, were more likely to be employed in the professional sector versus not being employed (aRRR = 1.9, p = 0.01). The associations between current contraceptive use and employment were heterogeneous across methods and sectors, though in no case was contraceptive use significantly associated with lower relative probabilities of employment. Policies designed to support women's access to contraception should consider the sector-specific employment of the populations they target.

Measuring quality of family planning counselling and its effects on uptake of contraceptives in public health facilities in Uttar Pradesh, India: A cross-sectional analysis.

BACKGROUND: Quality of care in family planning traditionally focuses on promoting awareness of the broad array of contraceptive options rather than on the quality of interpersonal communication offered by family planning (FP) providers. There is a growing emphasis on person-centered contraceptive counselling, care that is respectful and focuses on meeting the reproductive needs of a couple, rather than fertility regulation. Despite the increasing global focus on person-centered care, little is known about the quality of FP care provided in low- and middle- income countries like India. This study involves the development and psychometric testing of a Quality of Family Planning Counselling (QFPC) measure, and assessment of its associations with contraceptives selected by clients subsequently. METHODS: We analyzed cross-sectional survey data from N = 237 women following their FP counselling in 120 public health facilities (District Hospitals and Community Health Centers) sampled across the state of Uttar Pradesh in India. The study captured QFPC, contraceptives selected by clients post-counselling, as well as client and provider characteristics. Based on formative research and using Principal Component Analysis, we developed a 13-item measure of quality of FP counselling. We used adjusted regression models to assess the association between QFPC and contraceptive selected post-counselling. RESULTS: The QFPC measure demonstrated good internal reliability (Cronbach alpha = 0.80) as well as criterion validity, as indicated by client reports of high QFPC being significantly more likely for clients with trained versus untrained counsellors. We found that each point increase in QFPC, including increasing quality of counselling, is associated with higher odds of clients selecting an intrauterine device (IUD) (aRR:1.03; 95% CI:1.01-1.05) and sterilization (aRR:1.06; 95% CI:1.03-1.08), compared to no method selected. CONCLUSIONS: High-quality FP counselling is associated with clients subsequently selecting more effective contraceptives, including IUD and sterilization, in India. High-quality counselling is also more likely among FP-trained providers, highlighting the need for focused training and monitoring of quality care. TRIAL REGISTRATION: CTRI/2015/09/006219. Registered 28 September 2015.

Application of machine learning to understand child marriage in India.

BACKGROUND: Prior research documents that India has the greatest number of girls married as minors of any nation in the world, increasing social and health risks for both these young wives and their children. While the prevalence of child marriage has declined in the nation, more work is needed to accelerate this decline and the negative consequences of the practice. Expanded targets for intervention require greater identification of these targets. Machine learning can offer insight into identification of novel factors associated with child marriage that can serve as targets for intervention. METHODS: We applied machine learning methods to retrospective cross-sectional survey data from India on demographics and health, the nationally-representative National Family Health Survey, conducted in 2015-16. We analyzed data using a traditional regression model, with child marriage as the dependent variable, and 4000+ variables from the survey as the independent variables. We also used three commonly used machine learning algorithms- Least Absolute Shrinkage and Selection Operator (lasso) or L-1 regularized logistic regression models; L2 regularized logistic regression or ridge models; and neural network models. Finally, we developed and applied a novel and rigorous approach involving expert qualitative review and coding of variables generated from an iterative series of regularized models to assess thematically key variable groupings associated with child marriage. FINDINGS: Analyses revealed that regularized logistic and neural network applications demonstrated better accuracy and lower error rates than traditional logistic regression, with a greater number of features and variables generated. Regularized models highlight higher fertility and contraception, longer duration of marriage, geographic, and socioeconomic vulnerabilities as key correlates; findings shown in prior research. However, our novel method involving expert qualitative coding of variables generated from iterative regularized models and resultant thematic generation offered clarity on variables not focused upon in prior research, specifically non-utilization of health system benefits related to nutrition for mothers and infants. INTERPRETATION: Machine learning appears to be a valid means of identifying key correlates of child marriage in India and, via our innovative iterative thematic approach, can be useful to identify novel variables associated with this outcome. Findings related to low nutritional service uptake also demonstrate the need for more focus on public health outreach for nutritional programs tailored to this population.

Associations of intimate partner violence and reproductive coercion with contraceptive use in Uttar Pradesh, India: How associations differ across contraceptive methods.

Intimate partner violence (IPV) and reproductive coercion (RC)-largely in the form of pressuring pregnancy-appear to contribute to low use of contraceptives in India; however, little is known about the extent to which these experiences differentially affect use of specific contraceptive methods. The current study assessed the association of IPV and RC with specific contraceptive methods (Intrauterine Devices [IUDs], pills, condoms) among a large population-based sample of currently married women (15-49 years, n = 1424) living in Uttar Pradesh. Outcomes variables included past year modern contraceptive use and type of contraceptive used. Primary independent variables included lifetime experience of RC by current husband or in-laws, and lifetime experiences of physical IPV and sexual IPV by current husband. Multivariate logistic regression models were developed to determine the effect of each form of abuse on women's contraceptive use. Approximately 1 in 7 women (15.1%) reported experiencing RC from their current husband or in-laws ever in their lifetime, 37.4% reported experience of physical IPV and 8.3% reported experience of sexual IPV by their current husband ever in their lifetime. Women experiencing RC were less likely to use any modern contraceptive (AOR: 0.18; 95% CI: 0.9-0.36). Such women also less likely to report pill and condom use but were more likely to report IUD use. Neither form of IPV were associated with either overall or method specific contraceptive use. Study findings highlight that RC may influence contraceptive use differently based on type of contraceptive, with less detectable, female-controlled contraceptives such as IUD preferred in the context of women facing RC. Unfortunately, IUD uptake remains low in India. Increased access and support for use, particularly for women contending with RC, may be important for improving women's control over contraceptive use and reducing unintended pregnancy.

Mapping the patchwork: Exploring the subnational heterogeneity of child marriage in India.

Despite dramatic reductions in child marriage over the past decade, more than one in four girls in India still marry before reaching age 18. This practice is driven by a complex interplay of social and normative beliefs and values that are inadequately represented in national- or even state-level analyses of the drivers of child marriage. A geographic lens was employed to assess variations in child marriage prevalence across Indian districts, identify hot and cold spots, and quantify spatial dependence and heterogeneity in factors associated with district levels of child marriage. Data were derived from the 2015-16 National Family Health Survey and the 2011 India Census, and represent 636 districts in total. Analyses included global Moran's I, LISAs, spatial Durbin regression and geographically weighted regression. This study finds wide inter- and intra-state heterogeneity in levels of child marriage across India. District levels of child marriage were strongly influenced by geographic characteristics, and even more so by the geographic characteristics of neighboring districts. Districts with higher levels of female mobile phone access and newspaper use had lower levels of child marriage. These relationships, however, were all subject to substantial local spatial heterogeneity. The results indicate that characteristics of neighboring districts, as well as characteristics of a district itself, are important in explaining levels of child marriage, and that those relationships are not constant across India. Child marriage reduction programs that are targeted within specific administrative boundaries may thus be undermined by geographic delineations that do not necessarily reflect the independent and interdependent characteristics of the communities who live therein. The geographic, social and normative characteristics of local communities are key considerations in future child marriage programs and policies.

Associations between recent intimate partner violence and receipt and quality of perinatal health services in Uttar Pradesh.

BACKGROUND: India suffers some of the highest maternal and neonatal mortality rates in the world. Intimate partner violence (IPV) can be a barrier to utilization of perinatal care, and has been associated with poor maternal and neonatal health outcomes. However, studies that assess the relationship between IPV and perinatal health care often focus solely on receipt of services, and not the quality of the services received. METHODS AND FINDINGS: Data were collected in 2016-2017 from a representative sample of women (15-49yrs) in Uttar Pradesh, India who had given birth within the previous 12 months (N = 5020), including use of perinatal health services and past 12 months experiences of physical and sexual IPV. Multivariate logistic regression models assessed whether physical or sexual IPV were associated with perinatal health service utilization and quality. Reports of IPV were not associated with odds of receiving antenatal care or a health worker home visit during the third trimester, but physical IPV was associated with fewer diagnostic tests during antenatal visits (beta = -0.30), and fewer health topics covered during home visits (beta = -0.44). Recent physical and recent sexual IPV were both associated with decreased odds of institutional delivery (physical IPV AOR 0.65; sexual IPV AOR 0.61), and recent sexual IPV was associated with leaving a delivery facility earlier than recommended (AOR = 1.87). Neither form of IPV was associated with receipt of a postnatal home visit, but recent physical IPV was associated with fewer health topics discussed during such visits (beta = -0.26). CONCLUSIONS: In this study, reduced quantity and quality of perinatal health care were associated with recent IPV experiences. In cases where IPV was not related to care receipt, IPV remained associated with diminished care quality. Additional study to understand the mechanisms underlying associations between IPV and care qualities is required to inform health services.

More than credit: Exploring associations between microcredit programs and maternal and reproductive health service utilization in India.

Microcredit programs are increasingly popular interventions aimed at enabling women's economic empowerment in low- and middle-income countries. Resultant improved income, and social support from co-members of microcredit programs, may lead to increased utilization of health services. But existing research is inconclusive. This study investigates the association of microcredit program awareness and participation, with maternal and postpartum reproductive health service utilization in India. We use data from a nationally representative survey, the National Family Health Survey (2015-16), and assess three indicators of maternal health service utilization: receipt of four or more antenatal check-ups, institutional delivery, and postnatal check-up among women who had a child less than 5 years of age (N = 32,880). Reproductive health service utilization is assessed via postpartum contraceptive use within 12 months of childbirth, among women who had a live birth in the 12-59 months preceding the survey (N = 24,258). We use binomial and multinomial logistic regression models to examine associations. Additionally, we use propensity score matching to account for self-selection bias. One-third of women are aware of microcredit programs in their community/village, but only 6% have ever taken a loan from these programs. Both microcredit program awareness and participation are associated with higher odds of antenatal care, postnatal check-ups, as well as use of a modern method of contraceptive within 12 months of childbirth, even after accounting for self-selection bias. Stratified analysis by household wealth show that significant associations seen in our primary analyses are significant only for the poorest women. Findings highlight the potential value of microcredit programs in improving health service utilization during and after pregnancy, particularly among poor women. Microcredit program benefits extend beyond their participants. Non-participants living close to the programs also have greater odds of maternal and reproductive health service utilization, suggesting a spillover effect of these programs at the community level.