Validating the implementation of an indicator reporting policies and laws on free public maternal health-related services in the era of universal health coverage: A multi-country cross-sectional study.

BACKGROUND: The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization's Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, "Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?", captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries. METHODS AND FINDINGS: We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15-49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures. CONCLUSIONS: Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.

Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data.

Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility.

Exploring the intersection between country context and priority setting to prevent maternal mortality: A multi-methods study comparing expected vs observed priorities in five countries to validate the obstetric transition model.

Background: The obstetric transition model suggests that, as countries economically develop, the primary causes of maternal mortality change. Countries are assigned to one of five stages based on their maternal mortality ratio to identify priorities for reducing maternal deaths based on predominant determinants of mortality at each stage. We aim to validate the obstetric transition model using data from six diverse low- and middle-income countries representing self-identified priorities for improving maternal health and measurement compiled in a multi-stakeholder process. Methods: We used multiple data sources from Bangladesh, Cote d'Ivoire, India, Mexico, Nigeria, and Pakistan, which included secondary data on country context and primary data derived from two sources: the content of multi-stakeholder meetings, called National Dialogues, which were organised around the 11 key themes identified in the World Health Organization's "Strategies toward ending preventable maternal mortality" (EPMM) and follow-up key informant interviews conducted in five of the seven countries. We conducted the analysis in four phases examining, the country's contextual profile, mapping the key themes and indicators to the model, exploring stakeholder prioritisation, and examining reasons for divergence from the model. Results: Our results suggest that the stages of the obstetric transition generally align with the social, epidemiological, and health systems characteristics that the model predicts to be associated with countries at each stage, with some deviation related to health system deficiencies and barriers to access. Stakeholder priorities in maternal health generally align with those predicted by the model. Equity and women's rights emerged as a priority throughout all stages, not only within countries that are more advanced in the transition, as predicted by the model. Deviations between the model's predictions and country-level prioritisation were often explained by context-specific challenges. Conclusions: This study is one of the first to validate the obstetric transition model using real data. Our findings support the validity of the obstetric transition model as a useful guide to aid decisionmakers in prioritising attention towards addressing maternal mortality. Country context, including equity, remains important to further inform priority-setting.

Improving measures of access to legal abortion: A validation study triangulating multiple data sources to assess a global indicator.

BACKGROUND: Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access. METHODS AND FINDINGS: We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals' responses to the domestic legal frameworks described in the source documents to establish whether professionals consistently applied the law as written. This analysis revealed weaknesses in the criterion validity and construct validity of the "legal status of abortion" indicator. We detected discrepancies between data reported by the global monitoring and accountability mechanisms and the domestic policy reviews, even though all referenced the same source documents. Further, provider surveys unearthed important context-specific barriers to legal abortion not captured by the indicator, including conscientious objection and imposition of restrictions at the provider's discretion. CONCLUSIONS: Taken together, these findings denote weaknesses in the indicator "legal status of abortion" as a proxy for access to safe abortion, as well as inaccuracies in data reported to global monitoring mechanisms. This information provides important groundwork for strengthening indicators for monitoring access to abortion and for renewed advocacy to assure abortion rights worldwide.

Associations of single versus multiple anthropometric failure with mortality in children under 5 years: A prospective cohort study.

BACKGROUND/OBJECTIVES: Stunting, underweight, and wasting are used to monitor nutritional status in children, but they do not identify children with concurrent anthropometric failures (AF). Our study estimates the association between AF and mortality in children with single versus multiple failures, then calculates the percentage of child deaths attributable to AF. SUBJECTS/METHODS: Using data from a prospective, longitudinal study of 3605 children from age 1 to age 5 years in Ethiopia and India, we estimate the association between AF and mortality using conventional definitions (stunting, underweight, and wasting) and the mutually exclusive categories of stunted only underweight only, wasted only, stunted and underweight (SU), underweight and wasted, and stunted, underweight, and wasted (SUW), adjusting for socioeconomic status and other demographic variables. Last, we calculate the population attributable fraction. RESULTS: Children who were SU and SUW had 3.20 (95% CI: 1.69, 6.06; p < 0.001) and 5.52 (95% CI: 2.25, 13.56; p < 0.001) times the odds of death in fully adjusted models by Round 2 compared to children with no failure, while no increased mortality risk was found among children with other categories of failure. We estimate that 42.69% of child deaths can be attributed to children who are SUW (17.02%) or SU (25.67%), accounting for nearly 80% of child deaths from AF. CONCLUSIONS: This study provides new insight to programs and policy to better identify children most at risk of malnutrition-related mortality.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review.

BACKGROUND: Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation. METHODS: Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors. RESULTS: Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area. CONCLUSIONS: Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

Respectful care for mothers and newborns is a right and important part of ensuring that their care is high quality and acceptable to them. Just because there is no mistreatment does not mean that Respectful Maternity Care (RMC) was given. Without a clear framework for provider behaviors that reflect RMC principles, it is hard to ensure every woman and newborn gets respectful care in practice. We compared and combined two frameworks summarizing maternal and newborn rights and came out with seven categories. Then we searched for articles that mentioned provider behaviors reflecting RMC. We found 514 articles and ended up with 54 after careful review, from which we pulled the observable behaviors for providers in each category. Almost all papers mentioned actions to protect women and newborns from harm and mistreatment, to treat them with dignity and respect, and to give information and respect choices. About half of papers mentioned actions to protect privacy and to make sure every mother and newborn gets care when needed. Only 25% of papers mentioned actions to make sure all women and newborns receive equal care, and only 15% included actions to make sure women and newborns are physically free to leave facilities at will, and get care whether or not they can pay. This framework defining RMC behaviors for providers is based on data from many studies and can be useful to look at whether maternal newborn care in facilities meets these standards and to inform training and more research to improve RMC.

How Jordanian and Syrian youth conceptualise their sexual and reproductive health needs: a visual exploration using concept mapping.

Young people in Jordan are caught between the rapid social change that has encompassed the Middle East and the pressure to adhere to the strict norms and values that have defined previous generations, especially with regard to sexual and reproductive health. This study seeks to understand how Jordanian and Syrian adolescents conceptualise their concerns, needs and challenges with respect to their developing sexuality and reproductive health, while offering a comparative perspective by nationality and gender. Study participants were 271 young people aged 15-19. Data were generated using an interactive concept mapping approach. Data collection included brainstorming, pile sorting and rating to create a visual map that was interpreted by the participants. The results of this study show that both Jordanian and Syrian adolescents have a complex understanding of sex, sexuality and reproductive health that they define through broad conceptual spheres which include health, economic and social issues. Differences by gender highlight the conflict between traditional norms and changing social expectations. Both Jordanian and Syrian participants identified the need for diverse informational resources. For Syrians, the results emphasise how the hardship has influenced sexual and reproductive health through a focus on early marriage and need for economic stability.

Landscape analysis of family planning research, programmes and policies targeting young people in Jordan: stakeholder assessment and systematic review.

BACKGROUND: Reaching married and unmarried young people in Jordan with family planning information and services is a priority, especially considering Jordan's large refugee populations. To date, dissemination of family planning research and programmatic experience targeting young people in Jordan has been limited. AIMS: This study aimed to provide in-depth information on family planning intervention programmes, research and policies in Jordan that focus on young people aged 10-24 years. METHODS: Data were gathered through a systematic review of peer-reviewed and grey literature related to reproductive health of young people, and focus groups discussions with stakeholders from 18 relevant governmental and nongovernmental organizations. RESULTS: The literature review included 37 documents produced since 2008, which provide information at the individual, family/community, service delivery and policy levels. Young people in Jordan have limited knowledge of family planning methods and where to obtain family planning services. Little information is available on the availability of family planning services for young people. Several policy documents discuss family planning and reproductive health of young people in Jordan. Focus group discussions identified opportunities to integrate services and strengthen the development of future policies. CONCLUSIONS: The results of this study highlight key lessons learnt, opportunities for interventions and research gaps related to family planning among young people in Jordan. More attention should be paid to understanding and meeting the needs of Jordan's most vulnerable populations of young people, including urban refugees and married adolescents, especially as these populations continue to grow. Future programmes should build from past evidence and explore new areas and interventions.

A social-ecological examination into the research, policy and health service delivery environment related to early marriage and sexual and gender-based violence among youth in Jordan.

BACKGROUND: The determinants of sexual- and gender-based violence (SGBV) and early marriage are embedded across different levels of the social ecological system, including at the individual, family, community, and policy levels. In Jordan and the Middle East, SGBV, honor killing, and early marriage are priority public health and human rights issues that often overlap, and affect a significant percentage of youth. Jordan is home to a large number of refugees from across the Middle East, who may be even more vulnerable to these forms of violence than the local youth. The purpose of this analysis is to 1) synthesize the existing literature and 2) present the perspectives of key stakeholders to identify research gaps, programmatic lessons learned, and opportunities for policy change from an ecological perspective at the individual, community, health-system, and policy/legal levels. METHODS: This study includes 1) a systematic literature review of both published and unpublished literature since 2008 and 2) focus group discussions (FGDs) with key stakeholders representing 18 international and local governmental and non-governmental organizations. RESULTS: The literature review included 27 documents. Stakeholder discussions highlighted important research and policy gaps. Prevalence estimates of SGBV, honor killing, and early marriage vary across sources; however, all of them indicate that they remain important issues for youth in Jordan. Several sources indicate that early marriage has been increasing in Jordan since the beginning of the war in Syria, especially among Syrian refugees. Refugee youth are particularly vulnerable to SGBV and early marriage given the worsening economic situation in Jordan. The norms, attitudes, and practices that support SGBV in Jordan appear to be reinforced within families and communities. Despite ongoing programs, SGBV services are limited, especially for youth, and there is little awareness of service availability amongst target populations. Laws and policies continue to offer legal justification for SGBV, honor killing, and early marriage. DISCUSSION: As countries across the Middle East face instability and continue to struggle with the urgent health needs of large refugee and youth populations, this review provides valuable insight relevant to research, programs, and policy in Jordan and across the region.

Contextual Variation in Early Adolescent Childbearing: A Multilevel Study From 33,822 Communities in 44 Low- and Middle-Income Countries.

PURPOSE: Existing literature calls for a deeper examination into how local context influences adolescent sexual and reproductive health outcomes. We seek to describe individual and contextual variation in early adolescent childbearing (younger than 16 years) in 44 low- and middle-income countries by (1) examining the role of individual-level social disadvantage, (2) exploring the ecological influence of context at the country and community level, and (3) assessing whether ecological effects vary according to a woman's wealth. METHODS: We used nationally representative data from 33,822 communities in 44 low- and middle-income countries. We employed multilevel modeling to examine the variation in early adolescent childbearing apportioned to the individual, community, and country levels. RESULTS: Globally, poverty and low educational attainment are associated with early adolescent childbearing. After accounting for individual-level characteristics, significant residual variance remains at both the community and country levels. Routine, individual-level covariates explain 46.4% of the total variance at the community level and 21.3% of the total variance at the country level in relation to the baseline, age-adjusted model. The variance apportioned to the community level is estimated to equal 43.5% (95% confidence interval: .40, .49) of the total variance among the poorest women compared with 32.6% (95% confidence interval: .25, .39) among the richest women. Across countries, we find substantial heterogeneity in the variance observed at the community level. CONCLUSIONS: Our results point to the need for a continued focus on multilevel interventions that include approaches to target both the individual and population levels. More research is needed to identify the mechanisms through which local context influences adolescent sexual and reproductive health outcomes.

Clustered risk: An ecological understanding of sexual activity among adolescent boys and girls in two urban slums in Monrovia, Liberia.

Many young people experience sexual debut before they are able to manage risk in order to avoid adverse consequences. Gender norms, social position, and power can undermine an adolescent's ability to exercise agency in their first sexual encounters and negotiate safer sexual behavior. This study examines the intersection of psychosocial and interpersonal factors with the social and physical environment to form an ecological understanding of how the determinants that shape sexual activity differ between boys and girls in two urban slums in Monrovia, Liberia. This study focuses on three different levels: 1) intrapersonal and psychosocial factors, 2) the role of the family and other interpersonal relationships, and 3) the overall community structure. Fifty-three adolescents aged 15-17 years (27 males and 26 females) were recruited to participate in a concept mapping exercise. Concept mapping is a participatory research method that uses both qualitative and quantitative approaches through 1) group discussion, 2) brainstorming, 3) sorting factors into meaningful clusters, and 4) interpretation of the results to create a visual map. Cluster maps include both positive and negative factors that participants believe to influence adolescent sexual activity in their communities, including parental pressure, transactional sex, family status, goals and aspirations, and poverty. The influence of these factors diverged according to participant gender. Participants described how psychosocial, interpersonal, family, and community factors interact with economic and social forces to influence their sexual experience and combine to exacerbate the prevalence of transactional and forced sex. The results highlight the need for multi-level interventions to shape adolescent sexual and reproductive health in positive, rather than harmful, ways.

Socio-economic patterning of food consumption and dietary diversity among Indian children: evidence from NFHS-4.

BACKGROUND/OBJECTIVES: Most interventions to foster child growth and development in India focus on improving food quality and quantity. We aimed to assess the pattern in food consumption and dietary diversity by socioeconomic status (SES) among Indian children. SUBJECTS/METHODS: The most recent nationally representative, cross-sectional data from the National Family Health Survey (NFHS-4, 2015-16) was used for analysis of 73,852-74,038 children aged 6-23 months. Consumption of 21 food items, seven food groups, and adequately diversified dietary intake (ADDI) was collected through mother's 24-h dietary recall. Logistic regression models were conducted to assess the association between household wealth and maternal education with food consumption and ADDI, after controlling for covariates. RESULTS: Overall, the mean dietary diversity score was low (2.26; 95% CI:2.24-2.27) and the prevalence of ADDI was only 23%. Both household wealth and maternal education were significantly associated with ADDI (OR:1.28; 95% CI:1.18-1.38 and OR:1.75; 95% CI:1.63-1.90, respectively), but the SES gradient was not particularly strong. Furthermore, the associations between SES and consumption of individual food items and food groups were not consistent. Maternal education was more strongly associated with consumption of essential food items and all food groups, but household wealth was found to have significant influence on intake of dairy group only. CONCLUSIONS: Interventions designed to improve food consumption and diversified dietary intake among Indian children need to be universal in their targeting given the overall high prevalence of inadequate dietary diversity and the relatively small differentials by SES.

How do Jordanian and Syrian youth living in Jordan envision their sexual and reproductive health needs? A concept mapping study protocol.

INTRODUCTION: Youth in Jordan constitute 20.4% of the population, and many face considerable challenges in addressing their sexual and reproductive health (SRH) needs, such as those related to the prevention of unintended pregnancy and sexually transmitted infections, early marriage and sexual coercion and violence. The findings of previous studies indicate that Jordanian youth require reproductive health-related support, information and services; however, there remains very limited data as to how youth envision their SRH challenges and needs. This protocol outlines the design of a qualitative study using a participatory research methodology called concept mapping. This methodology enables participants to develop a conceptual framework for how they envision their sexual and reproductive health needs. METHODS AND ANALYSIS: This study will use concept mapping, which consists of a structured and iterative participatory research process that engages participants over three data collection sessions in order to generate the information needed to create a visual display of their ideas pertaining their SRH needs, issues and concerns, and how these ideas relate to each other. Each data collection session focuses on a different activity, including brainstorming, pile sorting and interpretation of the results. Data will be analysed using hierarchical cluster analysis and multidimensional scaling. Transcriptions of group discussions will be coded and analysed to add depth to the study results. Two hundred and eighty-eight males and females of Jordanian or Syrian descent living in Jordan will be recruited from four communities across Jordan. ETHICS AND DISSEMINATION: This study meets the requirements of the Declaration of Helsinki and has been approved by the Institutional Review Boards at the Harvard T.H. Chan School of Public Health and the University of Jordan. Study findings will be presented in peer-reviewed, international journals and made available to local programme managers, policy-makers and stakeholders through local dissemination efforts.

Quality and Cost Interventions During the Extended Perinatal Period to Increase Family Planning Use in Kinshasa, DRC: Results From an Initial Study.

BACKGROUND: Most women worldwide do not desire another pregnancy within a year after giving birth, but uptake of modern contraception during this time period is low. We independently tested 2 approaches to increasing contraceptive uptake and the 2 approaches combined using a quasi-experimental study design in Kinshasa, the Democratic Republic of the Congo. METHODS: The primary analytic data came from client exit interviews conducted post-intervention (N=563) from 4 study groups. The first arm (n=150) received free family planning, and the second arm (n=113) a quality inputs intervention involving systematic screening, referral, and immediate provision of long-acting reversible contraceptives (LARCs) after labor and delivery. The third arm (n=150) received a combination of the 2 interventions, and the fourth (n=150) no intervention. Family planning service statistics were also collected throughout the intervention period. RESULTS: Women in the quality arm (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.8 to 10.9) and free/quality arm (OR=6.7; 95% CI, 2.8 to 16.1) were more likely to be properly screened for family planning than women in the control group, but paper referral was seldom implemented in any group. Women in the free arm (OR=3.8; 95% CI, 1.6 to 9.0) and in the free/quality arm (OR=11.0; 95% CI, 4.3 to 27.9) were more likely than the control group to report being properly counseled on family planning. Clients were more likely to be modern contraceptive users (excluding condoms) in the free arm (OR=3.2; 95% CI, 1.4 to 7.2) and in the free/quality arm (OR=8.6; 95% CI, 3.9 to 19.0) than in the control group. Clients in all study arms were more likely to use a LARC compared with the control group (Quality arm: OR=2.9; 95% CI, 1.1 to 7.9. Free arm: OR=5.6; 95% CI, 2.3 to 13.7. Free/quality arm: OR=8.4; 95% CI, 3.4 to 20.6). Service statistics from the combined intervention arm showed that a significantly greater proportion of family planning adoption occurred within the immediate postpartum period (0 to 2 days) in the quality arm (P<.001) and free/quality arm (P<.001) than in the control arm. Quality inputs, free contraceptives, and the combined intervention had positive impacts on aspects of screening and contraceptive uptake. The combined intervention performed best by all measures. CONCLUSION: Providing family planning, including LARCs, in the immediate postpartum period, implementing a systematic screening and referral system, and providing free methods may improve family planning access and uptake in the extended perinatal period in this environment.

Distributional change of women's adult height in low- and middle-income countries over the past half century: An observational study using cross-sectional survey data.

BACKGROUND: Adult height reflects childhood circumstances and is associated with health, longevity, and maternal-fetal outcomes. Mean height is an important population metric, and declines in height have occurred in several low- and middle-income countries, especially in Africa, over the last several decades. This study examines changes at the population level in the distribution of height over time across a broad range of low- and middle-income countries during the past half century. METHODS AND FINDINGS: The study population comprised 1,122,845 women aged 25-49 years from 59 countries with women's height measures available from four 10-year birth cohorts from 1950 to 1989 using data from the Demographic and Health Surveys (DHS) collected between 1993 and 2013. Multilevel regression models were used to examine the association between (1) mean height and standard deviation (SD) of height (a population-level measure of inequality) and (2) median height and the 5th and 95th percentiles of height. Mean-difference plots were used to conduct a graphical analysis of shifts in the distribution within countries over time. Overall, 26 countries experienced a significant increase, 26 experienced no significant change, and 7 experienced a significant decline in mean height between the first and last birth cohorts. Rwanda experienced the greatest loss in height (-1.4 cm, 95% CI: -1.84 cm, -0.96 cm) while Colombia experienced the greatest gain in height (2.6 cm, 95% CI: 2.36 cm, 2.84 cm). Between 1950 and 1989, 24 out of 59 countries experienced a significant change in the SD of women's height, with increased SD in 7 countries-all of which are located in sub-Saharan Africa. The distribution of women's height has not stayed constant across successive birth cohorts, and regression models suggest there is no evidence of a significant relationship between mean height and the SD of height (ß = 0.015 cm, 95% CI: -0.032 cm, 0.061 cm), while there is evidence for a positive association between median height and the 5th percentile (ß = 0.915 cm, 95% CI: 0.820 cm, 1.002 cm) and 95th percentile (ß = 0.995 cm, 95% CI: 0.925 cm, 1.066 cm) of height. Benin experienced the largest relative expansion in the distribution of height. In Benin, the ratio of variance between the latest and earliest cohort is estimated as 1.5 (95% CI: 1.4, 1.6), while Lesotho and Uganda experienced the greatest relative contraction of the distribution, with the ratio of variance between the latest and earliest cohort estimated as 0.8 (95% CI: 0.7, 0.9) in both countries. Limitations of the study include the representativeness of DHS surveys over time, age-related height loss, and consistency in the measurement of height between surveys. CONCLUSIONS: The findings of this study indicate that the population-level distribution of women's height does not stay constant in relation to mean changes. Because using mean height as a summary population measure does not capture broader distributional changes, overreliance on the mean may lead investigators to underestimate disparities in the distribution of environmental and nutritional determinants of health.

Ecological and social patterns of child dietary diversity in India: a population-based study.

OBJECTIVE: Dietary diversity (DD) measures dietary variation in children. Factors at the child, community, and state levels may be associated with poor child nutritional outcomes. However, few studies have examined the role of macro-level factors on child DD. This study seeks to 1) describe the distribution of child DD in India, 2) examine the variation in DD attributable to the child, community and state levels, and 3) explore the relationship between community socioeconomic context and child DD. RESEARCH METHODS AND PROCEDURES: Using nationally representative data from children aged 6-23 months in India, multilevel models were used to determine the associations between child DD and individual- and community-level factors. RESULTS: There was substantial variation in child DD score across demographic and socioeconomic characteristics. In an age and sex-only adjusted regression model, the largest portion of variation in child DD was attributable to the child level (75%) while the portions of variance attributable to the community-level and state level were similar to each other (15% and 11%). Including individual-level socioeconomic factors explained 35.6 percent of the total variation attributed to child DD at the community level and 24.8 percent of the total variation attributed to child DD at the state level. Finally, measures of community disadvantage were associated with child DD in when added to the fully adjusted model. CONCLUSIONS: This study suggests that both individual and contextual factors are associated with child DD. These results suggest that a population-based approach combined with a targeted intervention for at-risk children may be needed to improve child DD in India.

Improved maternal health since the ICPD: 20 years of progress.

BACKGROUND: The 1994 Conference on Population and Development (ICPD) was a turning point in the field of sexual and reproductive health--repositioning population and development programs globally in the context of reproductive rights, gender equity, and women's empowerment. PROGRESS SINCE ICPD: ICPD solidified the importance of women's health and safe motherhood alongside other health and development priorities while laying the groundwork for the Millennium Development Goals. CHALLENGES: Some goals envisioned by ICPD have been met. Others still need to be addressed. Global declines in maternal mortality are indicative of success, although improving measurement, quality of care and access to services, while addressing the social determinants that influence maternal health remain priorities. RECOMMENDATIONS: Renewed political will to address the remaining challenges is necessary for the post-2015 development agenda so that women's health throughout the world continues to be supported with ambitious, yet feasible goals that take into account the world's evolving development priorities.