Gender mainstreaming at 25 years: Toward an inclusive, collaborative, and structured research agenda.

Background: Gender mainstreaming has been central to the development agenda for advancing gender equality globally for nearly three decades. We examined key learning across gender mainstreaming models and experiences and assess key successes and challenges in actualising gender mainstreaming's transformative potential, in order to inform future research agendas. Methods: We reviewed 27 years of peer-reviewed literature on gender mainstreaming (1995-2022) and described scholarly publishing trends on the topic based on a set of 528 articles and bibliographic data retrieved from the Scopus database and supplemental coding. The review provides a thematic synthesis of the extant literature, assessing the evidence base to identify gaps and opportunities for future research and collaboration with practitioners. We also contextualise recent research by tracing common threads of scholarly and practitioner discussions over the last two decades. Results: Publications on gender mainstreaming have increased, primarily from authors with European and USA academic affiliations and funding. Gender mainstreaming in the health and law and policy sectors has been researched most frequently. Trends in co-authorship suggest increasing collaboration among academics, yet limited collaboration among researchers and practitioners. Widespread low citation counts raise concerns about engagement with the literature. Key challenges in gender mainstreaming identified include conceptual clarity, academic-practitioner disjunctures, politics, leadership and organisational culture, men's roles, intersectionality, monitoring and evaluation, and public health sectoral concerns. Conclusions: The gender mainstreaming literature has expanded considerably over the last 25 years, yet there remain critical knowledge gaps, theoretical inconsistencies, weak research methods and evaluation processes, and implementation challenges. Funders, researchers, and practitioners have failed to prioritise bridging north-south and academic-practitioner divides in gender mainstreaming policy, programmes, and research. Integration of intersectionality also remains nascent. A more inclusive, collaborative, and structured research agenda on gender mainstreaming is needed to effect greater change in the face of persistent and new challenges. Engaging and empowering regional women's organisations, collaborative learning and research programmes, and joint research and advocacy groups; implementing gender-attuned editorial policies; and incorporating gender mainstreaming in educational curricula are recommended.

Variation in rates of sexual assault crisis counsellor usage during forensic examination in California: an observational study.

OBJECTIVES: A critical asset to post-assault care of survivors is support from sexual assault crisis counsellors (SACCs). We sought to elucidate variation in implementation between California counties in SACC accompaniment during Sexual Assault Forensic Examination (SAFE). METHODS: SACC attendance data from 2019 was obtained from the California Governor's Office of Emergency Services (CalOES). To assess SACC attendance rates during SAFEs, we requested SAFE quantity data from sheriffs and public health departments, the State Forensic Bureau, and the California Department of Justice (DOJ), but all requests were unanswered or denied. We also sought SAFE data from District Attorneys (DAs) in each county, and received responses from Marin and Contra Costa Counties. To estimate numbers of SAFEs per county, we gathered crime statistics from the Federal Bureau of Investigation's (FBI's) Uniform Crime Reporting Program and OpenJustice, a transparency initiative by the California DOJ. For each data source, we compared SACC attendance to SAFE quantities and incidences of sexual assault statewide. RESULTS: At the state level, data on SACC attendance per CalOES and DOJ archival data on sexual assault were used to approximate relative rates of SACC accompaniment at SAFEs; 83% (30 of 36) of counties had values <50%. The joint sexual assault crisis centre for Contra Costa and Marin Counties reported that 140 SACCs were dispatched in 2019, while DAs in Contra Costa and Marin reported completion of 87 SAFEs in 2019, for a calculated SACC accompaniment rate of 161%. Proxy data sourced from FBI and DOJ crime statistics displayed significant inconsistencies, and DOJ data was internally inconsistent. CONCLUSIONS: SACC accompaniment at SAFEs appears to be low in most California counties, however, limited data accessibility and data discrepancies and inaccuracies (e.g., rates over 100%) prevented reliable determination of SACC accompaniment rates during SAFEs. Substantial improvements in data accuracy and transparency are needed to ensure survivors' adequate access to resources.

Public leadership for gender equality: A framework and capacity development approach for gender transformative policy change.

Public leadership is essential in social change, and pivotal in transforming social and institutional norms related to gender inequality, going well beyond equal representation. It must embrace the potential for all public health leaders, of all genders, to become agents of change who challenge gender injustices and institutionalise gender transformative policies and programmes in public health. To support officials, initially in Ethiopia, and catalyse transformative change, we created a new framework and capacity development approach - Public Leadership for Gender Equality (PL4GE) - which can be customised to respond to each country's context. Drawing from three areas of leadership thought - public, transformative, and feminist leadership - PL4GE takes a public values approach in positioning gender equality as a human right, a common good, and a means to improve health outcomes. PL4GE promotes six key leadership practices - defining purpose and articulating vision, co-creating public value, empowering people, fostering strategic partnerships, navigating power, and embodying personal commitment - and guides public leaders through a capacity development journey of change, facilitating them to identify and activate opportunities for gender transformative change in their work and in turn, more broadly within the public whom they serve. Funding: Bill & Melinda Gates Foundation INV-002664 to Stanford University.

Paediatric use of emergency medical services in India: A retrospective cohort study of one million children.

Background: Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness. Methods: We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory. Results: Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection. Conclusions: EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.

Gender and the impact of COVID-19 on demand for and access to health care: Intersectional analysis of before-and-after data from Kenya, Nigeria, and South Africa.

Background: Global health emergencies can impact men and women differently due to gender norms related to health care and social and economic disruptions. We investigated the intersectionality of gender differences of the impact of COVID-19 on health care access with educational and socio-economic factors in Kenya, Nigeria, and South Africa. Methods: Data were collected by Opinion Research Business International using census data as the sampling frame. We used conditional logistic regression to estimate the change in access to health care after the emergence of the pandemic among men and women, stratified by educational level. We also examined the change in demand for various health care services, stratified by self-reported experiences of financial difficulty due to the pandemic. Results: Among those reporting a need to seek health care in South Africa, there was a statistically significant decline in the ability to see a health care provider during the pandemic among women, but not among men; this gender gap was more evident in those who did not have post-secondary education (odds ratio (OR) = 0.08, P = 0.041 among women; no change among men) than for those with post-secondary education (OR = 0.20, P = 0.142 among women; OR = 0.50, P = 0.571 among men). South African women financially affected by the pandemic had a significant decline in seeking preventive care during the pandemic (OR = 0.23, P = 0.022). No conclusive effects were noted in Nigeria or Kenya. Conclusions: In South Africa, the pandemic and its strict control measures have adversely and disproportionately impacted disadvantaged women, which has implications for the nature of the long-term impact as well as mitigation and preparedness plans.

Gender Norms and Gender Equality in Full-Time Employment and Health: A 97-Country Analysis of the World Values Survey.

Background: Almost nowhere in the world do women participate as much as men in the labor force. Despite differences in countries' economic, social and cultural contexts, gender norms-unwritten rules of acceptable actions for men and women-have been found to affect women's labor participation across contexts. Gender norms include those regulating who takes care of children, who is expected to earn more, and in which sectors men and women should work. Importantly, norms affect access to labor markets at times of scarcity: when there's only work for one, gender norms can dictate whether a woman or man gets the job. Advocates of equal labor force participation point to evidence that employment can contribute to people's health and well-being; yet the evidence is mixed and contradictory, and mostly comes from high-income countries. In restrictive normative contexts in which women are assigned the role of family caretaker, full time employment (FTE) might be particularly burdensome. At the same time, the literature lacks a cross-country analysis of how gender norms affect women's FTE and their health when employed full time, despite qualitative research providing clear evidence of the influence of gender norms on labor participation. Aims: In this paper we examine: (1) how gender norms affect women's access to FTE across 97 countries; (2) associations between FTE and women's self-reported health self-rated (SRH) across different normative contexts (i.e., countries where it is common vs. uncommon for women to stay home); and (3) how women's FTE and gender norms changed over time in four countries. Data: We used time-series data from the World Values Survey and European Values Survey conducted in over 100 countries between 1981 and 2014. Both surveys attempt to capture norms, beliefs and values in addition to sociodemographic information among a nationally representative adult population in each country. The sample for the cross-sectional analyses (aims 1 and 2) included 97 countries and 131,132 respondents. The sample for aim 3 included data from Argentina, Egypt, Finland and Japan. Variables: Our outcome of interest was pro-equality norms in the context of access to the labor market for women. Respondents were asked "if jobs are scarce, men should have more right to a job than women do?". Response options included no, neither or yes. We created a binary variable to represent pro-equality norms. We included employment status and SRH as exposures of interest. Analysis: We used individual-level data to generate on-average and sex-stratified estimates of the outcome and exposures for each country, at each time point. We estimated the percentage of all respondents, of women, and of men who held pro-equality norms (believe that men should not have more right to a job than women), the percentage who were employed full time, and the average level of SRH. To measure gender inequality in FTE, we also estimated the absolute difference in FTE between women and men for each country at each time point. First, we conducted descriptive, cross-sectional ecological analyses using one survey per country from wave 5 or 6 (whichever was most recent) to examine associations between pro-equality norms and employment status as a proxy for associations between norms and the context of employment in each country. We also examined associations between pro-equality norms and SRH. We then specified adjusted logistic regression models with controls for age, sex and education to examine associations between pro-equality norms and employment status. To examine if the relationship between FTE and SRH varied by normative context, we grouped countries in quartiles of pro-equality norms. Finally, we conducted descriptive ecological analyses of the relationship between pro-equality norms and employment status over time in four countries. Results: Objective 1: Gender norms intersect with socio-cultural contexts in determining women's FTE. While in some countries gender norms aligned positively with women's access to employment (i.e., more equal norms matched more equality in FTE), in Eastern Europe and South America we observed a mismatch. In Eastern Europe we found strong norms against equal access but small sex differences in FTE. In South America, we observed a stark difference in FTE favoring men, despite positive gender norms promoting women's paid employment. Objective 2: We found the association between SRH and FTE to vary across normative contexts. For instance, while in Scandinavian countries it was protective to be a woman in FTE and harmful not to work full-time, we found the opposite effect in Middle Eastern countries. Objective 3: We found a general tendency to move toward greater equality in norms and FTE over time everywhere in the world. However, political and economic events can generate variations over time and setbacks in progress toward equality.We specifically looked at 4 countries: Argentina, Egypt, Finland and Japan and assessed the effects of economic, political and national legislative changes on FTE over time. Implications: This paper contributes to the conversation on tensions between universal justice and contextual factors affecting one's health. To achieve purposeful and global universal health and justice, policy makers and global health practitioners must design effective, context-relevant interventions that are deeply and transparently informed by the values they embody. As we strive to achieve global gender equality, its meanings and purposes will vary across contexts in ways that demand people-led conversations and interventions.

Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh.

BACKGROUND: In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have the potential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment. METHODS: In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48 h of birth and then consecutively for three days. A physician repeated 20% (n = 148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician's danger sign identification and referral decision as the gold standard to validate CHWs' identification of danger signs and referral decisions. RESULTS: The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K = 0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7-100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50-100%) and excellent negative predictive value (NPV) (99-100%). Specificity was high (99-100%) for all ten danger signs. CONCLUSION: CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities. TRIAL REGISTRATION: clinicaltrials.gov NCT03933423 , January 05, 2019.

Innovative methods to analyse the impact of gender norms on adolescent health using global health survey data.

BACKGROUND: Understanding how gender norms affect health is an important entry point into designing programs and policies to change norms and improve gender equality and health. However, it is rare for global health datasets to include questions on gender norms, especially questions that go beyond measuring gender-related attitudes, thus limiting gender analysis. METHODS: We developed five case studies using health survey data from six countries to demonstrate approaches to defining and operationalising proxy measures and analytic approaches to investigating how gender norms can affect health. Key findings, strengths and limitations of our norms proxies and methodological choices are summarised. FINDINGS: Case studies revealed links between gender norms and multiple adolescent health outcomes. Proxys for norms were derived from data on attitudes, beliefs, and behaviours, as well as differences between attitudes and behaviours. Data were cross-sectional, longitudinal, census- and social network-based. Analytic methods were diverse. We found that gender norms affect: 1) Intimate partner violence in Nigeria; 2) Unhealthy weight control behaviours in Brazil and South Africa; 3) HIV status in Zambia; 4) Health and social mobility in the US; and 5) Childbirth in Honduras. INTERPRETATION: Researchers can use existing global health survey data to examine pathways through which gender norms affect health by generating proxies for gender norms. While direct measures of gender norms can greatly improve the understanding of how gender affects health, proxy measures for norms can be designed for the specific health-related outcome and normative context, for instance by either aggregating behaviours or attitudes or quantifying the difference (dissonance) between them. These norm proxies enable evaluations of the influence of gender norms on health and insights into possible reference groups and sanctions for non-compliers, thus informing programmes and policies to shape norms and improve health.

World Health Organization and knowledge translation in maternal, newborn, child and adolescent health and nutrition.

The World Health Organization (WHO) has a mandate to promote maternal and child health and welfare through support to governments in the form of technical assistance, standards, epidemiological and statistical services, promoting teaching and training of healthcare professionals and providing direct aid in emergencies. The Strategic and Technical Advisory Group of Experts (STAGE) for maternal, newborn, child and adolescent health and nutrition (MNCAHN) was established in 2020 to advise the Director-General of WHO on issues relating to MNCAHN. STAGE comprises individuals from multiple low-income and middle-income and high-income countries, has representatives from many professional disciplines and with diverse experience and interests.Progress in MNCAHN requires improvements in quality of services, equity of access and the evolution of services as technical guidance, community needs and epidemiology changes. Knowledge translation of WHO guidance and other guidelines is an important part of this. Countries need effective and responsive structures for adaptation and implementation of evidence-based interventions, strategies to improve guideline uptake, education and training and mechanisms to monitor quality and safety. This paper summarises STAGE's recommendations on how to improve knowledge translation in MNCAHN. They include support for national and regional technical advisory groups and subnational committees that coordinate maternal and child health; support for national plans for MNCAHN and their implementation and monitoring; the production of a small number of consolidated MNCAHN guidelines to promote integrated and holistic care; education and quality improvement strategies to support guidelines uptake; monitoring of gaps in knowledge translation and operational research in MNCAHN.

Real world external validation of metabolic gestational age assessment in Kenya.

Using data from Ontario Canada, we previously developed machine learning-based algorithms incorporating newborn screening metabolites to estimate gestational age (GA). The objective of this study was to evaluate the use of these algorithms in a population of infants born in Siaya county, Kenya. Cord and heel prick samples were collected from newborns in Kenya and metabolic analysis was carried out by Newborn Screening Ontario in Ottawa, Canada. Postnatal GA estimation models were developed with data from Ontario with multivariable linear regression using ELASTIC NET regularization. Model performance was evaluated by applying the models to the data collected from Kenya and comparing model-derived estimates of GA to reference estimates from early pregnancy ultrasound. Heel prick samples were collected from 1,039 newborns from Kenya. Of these, 8.9% were born preterm and 8.5% were small for GA. Cord blood samples were also collected from 1,012 newborns. In data from heel prick samples, our best-performing model estimated GA within 9.5 days overall of reference GA [mean absolute error (MAE) 1.35 (95% CI 1.27, 1.43)]. In preterm infants and those small for GA, MAE was 2.62 (2.28, 2.99) and 1.81 (1.57, 2.07) weeks, respectively. In data from cord blood, model accuracy slightly decreased overall (MAE 1.44 (95% CI 1.36, 1.53)). Accuracy was not impacted by maternal HIV status and improved when the dating ultrasound occurred between 9 and 13 weeks of gestation, in both heel prick and cord blood data (overall MAE 1.04 (95% CI 0.87, 1.22) and 1.08 (95% CI 0.90, 1.27), respectively). The accuracy of metabolic model based GA estimates in the Kenya cohort was lower compared to our previously published validation studies, however inconsistency in the timing of reference dating ultrasounds appears to have been a contributing factor to diminished model performance.

Gender-related data missingness, imbalance and bias in global health surveys.

Global surveys have built-in gender-related biases associated with data missingness across the gender dimensions of people's lives, imbalanced or incomplete representation of population groups, and biased ways in which gender information is elicited and used. While increasing focus is being placed on the integration of sex-disaggregated statistics into national programmes and on understanding effects of gender-based disparities on the health of all people, the data necessary for elucidating underlying causes of gender disparities and designing effective intervention programmes continue to be lacking. Approaches exist, however, that can reasonably address some shortcomings, such as separating questions of gender identification from biological sex. Qualitative research can elucidate ways to rephrase questions and translate gendered terms to avoid perpetuating historical gender biases and prompting biased responses. Non-health disciplines may offer lessons in collecting gender-related data. Ultimately, multidisciplinary global collaborations are needed to advance this evolving field and to set standards for how we measure gender in all its forms.

Effect of sunflower seed oil emollient therapy on newborn infant survival in Uttar Pradesh, India: A community-based, cluster randomized, open-label controlled trial.

BACKGROUND: Hospitalized preterm infants with compromised skin barrier function treated topically with sunflower seed oil (SSO) have shown reductions in sepsis and neonatal mortality rate (NMR). Mustard oil and products commonly used in high-mortality settings may possibly harm skin barrier integrity and enhance risk of infection and mortality in newborn infants. We hypothesized that SSO therapy may reduce NMR in such settings. METHODS AND FINDINGS: This was a population-based, cluster randomized, controlled trial in 276 clusters in rural Uttar Pradesh, India. All newborn infants identified through population-based surveillance in the study clusters within 7 days of delivery were enrolled from November 2014 to October 2016. Exclusive, 3 times daily, gentle applications of 10 ml of SSO to newborn infants by families throughout the neonatal period were recommended in intervention clusters (n = 138 clusters); infants in comparison clusters (n = 138 clusters) received usual care, such as massage practice typically with mustard oil. Primary analysis was by intention-to-treat with NMR and post-24-hour NMR as the primary outcomes. Secondary analysis included per-protocol analysis and subgroup analyses for NMR. Regression analysis was adjusted for caste, first-visit weight, delivery attendant, gravidity, maternal age, maternal education, sex of the infant, and multiple births. We enrolled 13,478 (52.2% male, mean weight: 2,575.0 grams ± standard deviation [SD] 521.0) and 13,109 (52.0% male, mean weight: 2,607.0 grams ± SD 509.0) newborn infants in the intervention and comparison clusters, respectively. We found no overall difference in NMR in the intervention versus the comparison clusters [adjusted odds ratio (aOR) 0.96, 95% confidence interval (CI) 0.84 to 1.11, p = 0.61]. Acceptance of SSO in the intervention arm was high at 89.3%, but adherence to exclusive applications of SSO was 30.4%. Per-protocol analysis showed a significant 58% (95% CI 42% to 69%, p < 0.01) reduction in mortality among infants in the intervention group who were treated exclusively with SSO as intended versus infants in the comparison group who received exclusive applications of mustard oil. A significant 52% (95% CI 12% to 74%, p = 0.02) reduction in NMR was observed in the subgroup of infants weighing ≤1,500 g (n = 589); there were no statistically significant differences in other prespecified subgroup comparisons by low birth weight (LBW), birthplace, and wealth. No severe adverse events (SAEs) were attributable to the intervention. The study was limited by inability to mask allocation to study workers or participants and by measurement of emollient use based on caregiver responses and not actual observation. CONCLUSIONS: In this trial, we observed that promotion of SSO therapy universally for all newborn infants was not effective in reducing NMR. However, this result may not necessarily establish equivalence between SSO and mustard oil massage in light of our secondary findings. Mortality reduction in the subgroup of infants ≤1,500 g was consistent with previous hospital-based efficacy studies, potentially extending the applicability of emollient therapy in very low-birth-weight (VLBW) infants along the facility-community continuum. Further research is recommended to develop and evaluate therapeutic regimens and continuum of care delivery strategies for emollient therapy for newborn infants at highest risk of compromised skin barrier function. TRIAL REGISTRATION: ISRCTN Registry ISRCTN38965585 and Clinical Trials Registry-India (CTRI/2014/12/005282) with WHO UTN # U1111-1158-4665.

Effects of integrated economic and health interventions with women's groups on health-related knowledge, behaviours and outcomes in low-income and middle-income countries: a systematic review protocol.

INTRODUCTION: Economic groups, such as microfinance or self-help groups are widely implemented in low-income and middle-income countries (LMICs). Women's groups are voluntary groups, which aim to improve the well-being of members through activities, such as joint savings, credit, livelihoods development and/or health activities. Health interventions are increasingly added on to existing women's economic groups as a public health intervention for women and their families. Here, we present the protocol for a mixed-methods systematic review we will conduct of the evidence on integrated economic and health interventions on women's groups to assess whether and how they improve health-related knowledge, behaviour and outcomes in LMICs. METHODS AND ANALYSIS: We will search seven electronic databases for published literature, along with manual searches and consultation. The review will include (1) randomised trials and non-randomised quasiexperimental studies of intervention effects of integrated economic and health interventions delivered through women's groups in LMICs, and (2) sibling studies that examine factors related to intervention content, context, implementation processes and costs. We will appraise risk of bias and study quality using standard tools. High and moderate quality studies will be grouped by health domain and synthesised without meta-analysis. Qualitative evidence will be thematically synthesised and integrated into the quantitative synthesis using a matrix approach. ETHICS AND DISSEMINATION: This protocol was reviewed and deemed exempt by the institutional review board at the American Institutes for Research. Findings will be shared through peer-reviewed publication and disseminated with programme implementers and policymakers engaged with women's groups. PROSPERO REGISTRATION NUMBER: CRD42020199998.

Association between maternity waiting home stay and obstetric outcomes in Yetebon, Ethiopia: a mixed-methods observational cohort study.

BACKGROUND: A strategy for reducing adverse pregnancy outcomes is the expanded implementation of maternity waiting homes (MWHs). We assessed factors influencing MWH use, as well as the association between MWH stay and obstetric outcomes in a hospital in rural Ethiopia. METHODS: Data from medical records of the Glenn C. Olson Memorial Primary Hospital obstetric ward were cross matched with records from the affiliated MWH between 1 and 2011 to 31 March 2014. Poisson regression with robust variance was conducted to estimate the relative risk (RR) of childbirth complications associated with MWH use vs. non-use. Five key informant interviews of a convenience sample of three MWH staff and two users were conducted and a thematic analysis performed of social, cultural, and economic factors underlying MWH use. RESULTS: During the study period, 489 women gave birth at the hospital, 93 of whom were MWH users. Common reasons for using the MWH were post-term status, previous caesarean section/myomectomy, malposition/malpresentation, and low-lying placenta, placenta previa, or antepartum hemorrhage, and hypertension or preeclampsia. MWH users were more likely than non-users to have had a previous caesarean Sec. (15.1 % vs. 5.3 %, p < 0.001) and to be post-term (21.5 % vs. 3.8 %, p < 0.001). MWH users were also more likely to undergo a caesarean Sec. (51.0 % vs. 35.4 %, p < 0.05) and less likely (p < 0.05) to have a spontaneous vaginal delivery (49.0 % vs. 63.6 %), obstructed labor (6.5 % vs. 14.4 %) or stillbirth (1.1 % vs. 8.6 %). MWH use (N = 93) was associated with a 77 % (adjusted RR = 0.23, 95 % Confidence Interval (CI) 0.12-0.46, p < 0.001) lower risk of childbirth complications, a 94 % (adjusted RR = 0.06, 95 % CI 0.01-0.43, p = 0.005) lower risk of fetal and newborn complications, and a 73 % (adjusted RR = 0.27, 95 % CI 0.13-0.56, p < 0.001) lower risk of maternal complications compared to MWH non-users (N = 396). Birth weight [median 3.5 kg (interquartile range 3.0-3.8) vs. 3.2 kg (2.8-3.5), p < 0.001] and 5-min Apgar scores (adjusted difference = 0.25, 95 % CI 0.06-0.44, p < 0.001) were also higher in offspring of MWH users. Opportunity costs due to missed work and need to arrange for care of children at home, long travel times, and lack of entertainment were suggested as key barriers to MWH utilization. CONCLUSIONS: This observational, non-randomized study suggests that MWH usage was associated with significantly improved childbirth outcomes. Increasing facility quality, expanding services, and providing educational opportunities should be considered to increase MWH use.

Levels and potential drivers of under-five mortality sex ratios in low- and middle-income countries.

BACKGROUND: Non-biological childhood mortality sex ratios may reflect community sex preferences and gender discrimination in health care. OBJECTIVE: We assessed the association between contextual factors and gender bias in under-five mortality rates (U5MR) in low- and middle-income countries. METHODS: Full birth histories available from Demographic and Health Surveys and Multiple Indicator Cluster Surveys (2010-2018) in 80 countries were used to estimate U5MR male-to-female sex ratios. Expected sex ratios and their residuals (difference of observed and expected) were derived from a linear regression model, adjusted for overall mortality. Negative residuals indicate more likelihood of discrimination against girls, and we refer to this as a measure of potential gender bias. Associations between residuals and national development and gender inequality indices and with survey-derived child health care indicators were tested using Spearman's correlation. RESULTS: Mortality residuals for under-five mortality were not associated with national development, education, religion, or gender inequality indices. Negative residuals were more common in countries where boys were more likely to be taken to health services than girls (rho -0.24, 95% confidence interval -0.45, -0.01). CONCLUSIONS: Countries where girls were more likely to die than boys, accounting for overall mortality levels, were also countries where boys were more likely to receive health care than girls. Further research is needed to understand which national characteristics explain the presence of gender bias, given that the analyses of development levels and gender equality did not discriminate between countries with or without excess mortality of girls. Reporting on child mortality separately by sex is required to enable such advances.

The role of piped water supplies in advancing health, economic development, and gender equality in rural communities.

In rural areas of sub-Saharan Africa, one in eight households obtain drinking water from a piped system; the rest fetch water from improved and unimproved sources located at some distance from their homes. This task falls primarily to women and girls, creating time poverty and risks to safety and health. In this paper, we present a conceptual model that elaborates the mechanisms linking access to piped water with food security and long-term economic impacts. These hypotheses were tested in a quasi-experimental study of four villages in rural Zambia using a combination of household surveys, Global Positioning System transponders, and water meters to measure time spent fetching water, water consumption, and how water was being utilized for domestic and productive activities. Households receiving the piped water intervention spent a median of 3.8 h per week less fetching water, savings that accrued primarily to women and girls. Household water consumption increased 32%, which was used for both domestic and productive uses. Increases in the frequency of gardening and the size of garden plots in treatment households were observed. Households receiving piped water reported being happier, healthier, and having more time to participate in work inside or outside the home. We find that piped water supplies can promote the economic development and well-being of rural households, with particular benefits to women and girls, conditional upon pricing and management models that ensure sustainable service.