Descriptive study of the role of household type and household composition on women's reproductive health outcomes in urban Uttar Pradesh, India.

BACKGROUND: More needs to be known about the role intra-familial power dynamics play in women's reproductive health outcomes, particularly in societies like Northern India characterized by patriarchy and extended families. The key research question we explore is: how important are living arrangements (e.g., presence of the mother-in-law, presence of an elder sister-in-law, and living in the husband's natal home) on contraceptive use behaviors and decision to deliver at an institution? METHODS: Representative data collected in 2010 from six cities in Uttar Pradesh are used to examine the above research question. This study uses multivariable logistic regression methods to examine the association between women's household type (husband's natal home vs. not husband's natal home) and household composition (lives with mother-in-law; and lives with elder sister-in-law) and modern family planning use and institutional delivery. RESULTS: More than sixty percent of women in the sample live in their husband's natal home, one-third live with their mother-in-law, and only three percent live with an elder sister-in-law. Findings demonstrate that women who live either with the mother-in-law or in the husband's natal home are more likely to use modern family planning than those women living neither with the mother-in-law nor in the husband's natal home. In addition, living with an elder sister-in-law is associated with less family planning use. For institutional delivery, women who live with the mother-in-law have higher institutional delivery than those not living with the mother-in-law. Multivariable analyses demonstrate that, controlling for other factors associated with modern family planning use, women living with neither the mother-in-law nor in the husband's natal home are the least likely to use modern family planning. Similar findings are found for institutional delivery such that those women living with neither the mother-in-law nor in the husband's natal home are the least likely to have an institutional delivery, controlling for demographic factors associated with institutional delivery. CONCLUSIONS: Where women live and who they live with matters. Future reproductive health programs for urban India should consider these context specific factors in programs seeking to improve women's reproductive health outcomes.

Limiting adverse birth outcomes in resource-limited settings (LABOR): protocol of a prospective intrapartum cohort study.

Background: Each year, nearly 300,000 women and 5 million fetuses or neonates die during childbirth or shortly thereafter, a burden concentrated disproportionately in low- and middle-income countries. Identifying women and their fetuses at risk for intrapartum-related morbidity and death could facilitate early intervention. Methods: The Limiting Adverse Birth Outcomes in Resource-Limited Settings (LABOR) Study is a multi-country, prospective, observational cohort designed to exhaustively document the course and outcomes of labor, delivery, and the immediate postpartum period in settings where adverse outcomes are frequent. The study is conducted at four hospitals across three countries in Ghana, India, and Zambia. We will enroll approximately 12,000 women at presentation to the hospital for delivery and follow them and their fetuses/newborns throughout their labor and delivery course, postpartum hospitalization, and up to 42 days thereafter. The co-primary outcomes are composites of maternal (death, hemorrhage, hypertensive disorders, infection) and fetal/neonatal adverse events (death, encephalopathy, sepsis) that may be attributed to the intrapartum period. The study collects extensive physiologic data through the use of physiologic sensors and employs medical scribes to document examination findings, diagnoses, medications, and other interventions in real time. Discussion: The goal of this research is to produce a large, sharable dataset that can be used to build statistical algorithms to prospectively stratify parturients according to their risk of adverse outcomes. We anticipate this research will inform the development of new tools to reduce peripartum morbidity and mortality in low-resource settings.

The Senegal urban reproductive health initiative: a longitudinal program impact evaluation.

OBJECTIVES: This paper presents the impact of key components of the Senegal Urban Reproductive Health Initiative, including radio, television, community-based activities, Muslim religious-leader engagement and service quality improvement on modern contraceptive use by all women and the sub-sample of poor women. STUDY DESIGN: This study uses baseline (2011) and endline (2015) longitudinal data from a representative sample of urban women first surveyed in 2011 to examine the impact of the Initiative's demand- and supply-side activities on modern contraceptive use. RESULTS: By endline, there was increased exposure to radio and television programming, religious leaders speaking favorably about contraception, and community-based initiatives. In the same period, modern contraceptive use increased from 16.9% to 22.1% with a slightly larger increase among the poor (16.6% to 24.1%). Multivariate analyses demonstrate that women exposed to community-based activities were more likely to use modern contraception by endline (marginal effect (ME): 5.12; 95% confidence interval (CI): 2.50-7.74) than those not exposed. Further, women living within 1 km of a facility with family planning guidelines were more likely to use (ME: 3.54; 95% CI: 1.88-5.20) than women without a nearby facility with guidelines. Among poor women, community-based activities, radio exposure (ME: 4.21; 95% CI: 0.49-7.93), and living close to program facilities (ME: 4.32; 95% CI: 0.04-8.59) impacted use. CONCLUSIONS: Community-based activities are important for reaching urban women, including poor women, to achieve increased contraceptive use. Radio programming is also an important tool for increasing demand, particularly among poor women. Impacts of other program activities on contraceptive use were modest. IMPLICATIONS: This study demonstrates that community-based activities led to increased modern contraceptive use among all women and poor women in urban Senegal. These findings can inform future programs in urban Senegal and elsewhere in francophone Africa.

Longitudinal Evaluation of the Tupange Urban Family Planning Program in Kenya.

CONTEXT: Levels of fertility and contraceptive use have long fluctuated in Kenya. The multicomponent Tupange program, part of the Urban Reproductive Health Initiative, was initiated in 2011 to increase use of modern family planning methods. METHODS: Women aged 15-49 in the five Kenyan cities where Tupange was implemented were interviewed in 2010 and reinterviewed in 2014 to obtain information on their contraceptive use and exposure to components of the Tupange program. Fixed-effects models were estimated to identify associations between program exposure and use of modern family planning methods. Analyses were performed to determine the relative cost-effectiveness of program components. RESULTS: During the four-year follow-up period, the proportion of women using modern contraceptives increased from 45% to 52%, and the proportion of users who were using long-acting or permanent methods rose from 6% to 19%. The fixed-effects model indicated that modern method use was associated with having heard Tupange-related local radio programming and marginally associated with having discussed family planning with a community health worker (CHW); among women who were unmarried or did not give birth during the study period, modern method use was associated with living near program facilities. Local radio programming was the most cost-effective program component, followed by proximity to Tupange facilities and discussions with CHWs. CONCLUSIONS: Urban reproductive health programs seeking to increase use of modern family planning methods in Kenya and other Sub-Saharan African settings should consider multicomponent approaches that include CHW activities, local radio programming and improvements to the supply environment.

Impact evaluation of the Urban Health Initiative in urban Uttar Pradesh, India.

OBJECTIVES: The Urban Health Initiative (UHI) was initiated in 2009 with the goal of increasing family planning (FP) use among the poor in urban areas of Uttar Pradesh, India. The Measurement, Learning & Evaluation project (MLE) was tasked with rigorous impact evaluation of the UHI. This paper presents the impact evaluation findings of the UHI program. STUDY DESIGN: The MLE design includes a longitudinal sample of women and health facilities with baseline (2010) and endline (2014) data collection in six cities in Uttar Pradesh, India. At baseline, samples representative of women in each city were selected with oversampling of the poor. Eighty-four percent of women interviewed at baseline were reinterviewed 4 years later at endline. The longitudinal data support a within/fixed-effects approach to identification of program impact on changes in modern FP use. RESULTS: Impact evaluation results show significant effects of exposure to both demand and supply side program activities. In particular, women exposed to brochures (marginal effect: 6.96, p<.001), billboards/posters/wall hangings (marginal effect: 2.09, p<.05), and FP on the television (marginal effect: 2.46, p<.001) were significantly more likely to be using a modern method at endline. In addition, we found borderline significance for being exposed to a community health worker (marginal effect: 1.66, p<.10) and living close to an improved public and private supply environment where UHI undertook activities (marginal effects and p values: 2.48, p<.05 and 1.56, p<.10, respectively). CONCLUSIONS: UHI program activities were designed to complement the Government of India's strategies aimed at ensuring access to and provision of FP to urban poor populations. The effective demand- and supply-side strategies of the UHI program are therefore likely to be sustainable and scalable to other urban areas in India. IMPLICATIONS STATEMENT: Findings from this study are important for designing sustainable and scalable FP strategies for urban India where increases in FP use will be relevant for meeting international FP targets.

Physical activity patterns during pregnancy.

PURPOSE: The aim of the study was to describe the mode, frequency, duration, and intensity of physical activity among pregnant women, to explore whether these women reached the recommended levels of activity, and to explore how these patterns changed during pregnancy. METHODS: This study, as part of the third phase of the Pregnancy, Infection, and Nutrition Study, investigated physical activity among 1482 pregnant women. A recall of the different modes, frequency, duration, and intensity of physical activity during the past week was assessed in two telephone interviews at 17-22 and 27-30 wk of gestation. RESULTS: Most women reported some type of physical activity during both periods. Child and adult care giving, indoor household, and recreational activities constituted the largest proportion of total reported activity. The overall physical activity level decreased during pregnancy, particularly in care giving, outdoor household, and recreational activity. Women who were active during the second and the third trimesters reported higher levels of activity in all modes of activity than those who became active or inactive during pregnancy. The majority did not reach the recommended level of physical activity. CONCLUSION: These data suggest that self-reported physical activity decreased from the second to the third trimesters, and only a small proportion reached the recommended level of activity during pregnancy. Further research is needed to explore if physical activity rebounds during the postpartum period.

Dissecting the brain's internal clock: how frontal-striatal circuitry keeps time and shifts attention.

The ability of organisms to time and coordinate temporal sequences of events and to select particular aspects of their internal and external environments to which they will attend is vital to the organism's ability to adapt to the world around them. Numerous psychological theories have been proposed that describe how organisms might accomplish such stimulus selection and represent discrete temporal events as well as rhythm production. In addition, a large number of studies have demonstrated that damage to the frontostriatal circuitry appears to compromise the ability of organisms to successfully shift attention and behavior to adapt to changing temporal contexts. This suggests that frontostriatal circuitry is involved in the ability to make such shifts and to process temporal intervals. A selective review is accomplished in this article which focuses upon the specific neural mechanisms that may be involved in interval timing and set shifting. It is concluded that prefrontal cortex, substantia nigra pars compacta, pedunculopontine nucleus, and the direct and indirect pathways from the caudate to the thalamus may provide the neuroanatomical and neurophysiological substrates that underlie the organism's ability to shift its attention from one temporal context to another.

Factors associated with HIV/AIDS knowledge and risk perception in rural Malawi.

Measures of HIV/AIDS knowledge and risk perception are important because they are often linked to behavioral change both in theory and in practice. This study examines knowledge and risk perception by assessing their relationship with demographic characteristics, first source of HIV/AIDS information, and behavioral and cognitive risk exposures among men and women in a rural district of Malawi. The data come from a panel study of 940 women aged 15-34 years and 661 men aged 20-44 years. Descriptive statistics and multivariate regression models are used for the analysis. The results indicate that knowledge of HIV/AIDS does not necessarily translate into perceived risk. In addition, there appears to be a gender difference in the influence of cognitive and behavioral factors on perceived risk.