Nutritional inequalities among under-five children: a geospatial analysis of hotspots and cold spots in 73 low- and middle-income countries.

BACKGROUND: Child undernutrition is a severe health problem in the developing world, which affects children's development in the long term. This study analyses the extent and patterns of under-five child undernutrition using Demographic and Health Surveys (DHS) for 73 low- and middle-income countries (LMICs). METHODS: First, we mapped the prevalence of undernutrition in the developing world. Second, using the LISA (a local indicator of spatial association) technique, we analyzed the geographical patterns in undernutrition to highlight the localized hotspots (regions with high undernutrition prevalence surrounded by similar other regions), cold spots (regions with low undernutrition prevalence surrounded by similar other regions), and outliers (regions with high undernutrition surrounded by low undernutrition and vice versa). Third, we used Moran's I to find global patterns in child undernutrition. RESULTS: We find that South Asia has the highest under-five child undernutrition rates. The intra-country nutritional inequalities are highest in Burundi (stunting), Kenya (wasting), and Madagascar (underweight). The local indicator of spatial association (LISA) analysis suggests that South Asia, Middle East and North Africa (MENA) region, and Sub-Saharan Africa are undernutrition hotspots and Europe and Central Asia and Latin America, and the Caribbean are undernutrition cold spots (regions with low undernutrition surrounded by similar other regions). Getis Ord-Gi* estimates generally support LISA analysis. Moran's I and Geary's C gave similar results about the global patterns of undernutrition. Geographically weighted regressions suggest that several socioeconomic indicators significantly explain child undernutrition. CONCLUSIONS: We found a significant within and across country variation in stunting, wasting and underweight rates among the under-five children's population. The geospatial analysis also suggested that stunting, wasting, and underweight patterns exhibit clear regional patterns, underscoring the need for coordinated interventions at the regional level.

Association of breast feeding and birth interval with child mortality in Pakistan: a cross-sectional study using nationally representative Demographic and Health Survey data.

OBJECTIVES: This study analysed the association between breast feeding (BF) and birth interval (BI) (both succeeding and preceding) with neonatal mortality (NM), infant mortality (IM) and under-5 mortality (U5M). DESIGN: This cross-sectional study used data from the Pakistan Demographic and Health Survey 2017-2018. SETTINGS: All provinces, Islamabad and Federally Administered Tribal Areas were included in the analysis. PARTICIPANTS: A total of 12 769 children born to ever-married multiparous women aged 30-49 years who gave live birth within 5 years preceding the interview. Multiple births are not included. DATA ANALYSIS: Multivariate logistic regression analysis was used. RESULTS: We found that BF was associated with nearly 98% lower risk of NM (OR 0.015; 95% CI: 0.01 to 0.03; p<0.001), 96% lower risk of IM (OR 0.038; 95% CI: 0.02 to 0.06; p<0.001) and 94% lower risk of U5M (OR 0.050; 95% CI: 0.03 to 0.08; p<0.001). Compared with optimal preceding birth interval (PBI) (36+ months), short PBI (<18 months) was associated with around six times higher risk of NM (OR 5.661; 95% CI: 2.78 to 11.53; p<0.001), over five times risk of IM (OR 4.704; 95% CI: 2.70 to 8.19; p<0.001) and over five times risk of U5M (OR 4.745; 95% CI: 2.79 to 8.07; p<0.001). Disaggregating the data by child's gender, place of residence and mother's occupational status showed that being ever breast fed was associated with a smaller risk of NM, IM and U5M in all three disaggregations. However, the risk of smaller PBI <18 months was generally more pronounced in female children (NM and U5M) or when the children lived in rural areas (NM, IM and U5M). PBI <18 months was associated with greater risk of NM and IM, and smaller risk of U5M when mothers did a paid job. CONCLUSION: This study's significance lies in the fact that it has found BF and BI to be consistent protective factors against NM, IM and U5M. Given Pakistan's economic constraints, optimal BF and BI are the most cost-effective interventions to reduce child mortality.

Impact of high-risk fertility behaviours on underfive mortality in Asia and Africa: evidence from Demographic and Health Surveys.

BACKGROUND: Maternal age < 18 or > 34 years, short inter-pregnancy birth interval, and higher birth order are considered to be high-risk fertility behaviours (HRFB). Underfive mortality being disproportionately concentrated in Asia and Africa, this study analyses the association between HRFB and underfive mortality in selected Asian and African countries. METHODS: This study used Integrated Public Microdata Series-Demographic and Health Surveys (IPUMS-DHS) data from 32 countries in sub-Saharan Africa, Middle East, North Africa and South Asia from 1986 to 2017 (N = 1,467,728). Previous evidence hints at four markers of HRFB: women's age at birth of index child < 18 or > 34 years, preceding birth interval < 24 months and child's birth order > 3. Using logistic regression, we analysed change in the odds of underfive mortality as a result of i) exposure to HRFB individually, ii) exposure to any single HRFB risk factor, iii) exposure to multiple HRFB risk factors, and iv) exposure to specific combinations of HRFB risk factors. RESULTS: Mother's age at birth of index child < 18 years and preceding birth interval (PBI) < 24 months were significant risk factors of underfive mortality, while a child's birth order > 3 was a protective factor. Presence of any single HRFB was associated with 7% higher risk of underfive mortality (OR 1.07; 95% CI 1.04-1.09). Presence of multiple HRFBs was associated with 39% higher risk of underfive mortality (OR 1.39; 95% CI 1.36-1.43). Some specific combinations of HRFB such as maternal age < 18 years and preceding birth interval < 24 month significantly increased the odds of underfive mortality (OR 2.07; 95% CI 1.88-2.28). CONCLUSION: Maternal age < 18 years and short preceding birth interval significantly increase the risk of underfive mortality. This highlights the need for an effective legislation to curb child marriages and increased public investment in reproductive healthcare with a focus on higher contraceptive use for optimal birth spacing.

Is Attitudinal Acceptance of Violence a Risk Factor? An Analysis of Domestic Violence Against Women in Pakistan.

Violence against women (VAW) is a grave problem in Pakistan, and women from all socioeconomic groups are vulnerable to domestic violence in varying degrees. It is argued that patriarchal definition of gender roles may reinforce the internalized inferiority of women. So, it may not be a mere coincidence that a large number of women in Pakistan justify VAW for various reasons. The objectives of this article are threefold: (a) to identify the drivers of VAW, (b) to see if women's attitudinal acceptance of violence is causally linked with observed violence against women, and (c) to see if attitudinal acceptance of violence mediates between the socioeconomic status of women and observed violence. We used data from the Pakistan Demographic and Health Survey (PDHS) 2012-13. The sample consisted of 3,265 ever married women aged between 15 and 49 years who were interviewed for domestic violence. We used multivariate logit regression analysis to identify the drivers of VAW and used the Karlson-Holm-Breen (KHB) method for mediation analysis. We found that women's attitudinal acceptance of violence, their childhood experience of violence in their parental household, the education of both husband and wife, and some occupation types significantly predicted their experience of spousal violence. In addition, we found that women's attitudinal acceptance of violence mediated the relationships between socioeconomic factors (education and wealth status) and VAW. The significance of the study lies in the fact that it highlights the need to modify the perceptions of violence through change in educational policy. Among multiple other factors, an increase in the economic status of women is an effective hedge against the risk of spousal violence.

Women's choice of delivery site and the surge in private facility-based deliveries in Pakistan: A 28-year trend analysis.

OBJECTIVE: This paper aims at estimating the long-term trends of facility-based and home-based deliveries and identifies the factors associated with the choice of delivery site. STUDY DESIGN: Secondary analysis evaluating the trends in the choice of the delivery site by women of reproductive age using Pakistan Demographic and Health Surveys from 1990-91 to 2017-18. MAIN OUTCOME MEASURES: The main outcome measure of this study is the choice of delivery site. METHOD: This study used data from four waves of Pakistan Demographic and Health Surveys (DHS) corresponding with 1990-91, 2006, 2012-13 and 2017-18. Logistic regression was used for empirical analysis. RESULTS: The odds of home delivery significantly came down in 2017-18 relative to 1990-91 (OR = 0.09; 95% CI:0.08-0.12; P < 0.001), growth in the likelihood of institutional delivery shows wide disparities. While the odds of delivery at the public health facility nearly doubled from 1990 to 91 to 2017-18 (OR = 2.12; 95% CI:1.70-2.65; P < 0.001), the odds of delivery at the private health facilities in the same period increased nearly eight times (OR = 7.78; 95% CI:6.45-9.38; P < 0.001). CONCLUSION: Results suggest an investment gap in public health facilities and an inequitable health care system in Pakistan.

Correlates of home and hospital delivery in Pakistan.

OBJECTIVE: To identify the socio-economic determinants of home-based and institutional delivery in Pakistan. METHODS: This study has used Pakistan Demographic and Health Survey (PDHS) data collected by the National Institute of Population Studies (NIPS), Islamabad, Pakistan, and Macro International Inc. (now ICF International) Calverton, Maryland, United States. It used three episodes of Pakistan Demographic and Health Survey Data from 1990-91, 2006-07 and 2012-13. Data was analysed using descriptive analysis and odds of delivering at hospital were calculated using logistic regression analysis. RESULTS: Home-based delivery was over 4 times higher in 1990-91 compared with institutional delivery 5,465(85.3%) vs. 852(13.3%), and around 2 times higher in 2006-07 5,900(64.7%) vs. 3,128(34.3%). However, in 2012-13, the share of women delivering at home or health facility was roughly the same, i.e. 6,180(51.6%) at home and 5,773(48.2%) at health facility. CONCLUSIONS: There were wide gaps in the rates of institutional delivery among different subgroups, and they were accentuated by the socio-economic and financial disparities, and high illiteracy rates in the lowest wealth quintiles.