Do tuition-free lower secondary education policies matter for antenatal care among women in sub-saharan African countries?

BACKGROUND: Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits. METHODS: To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries. RESULTS: Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics. CONCLUSIONS: The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

The effects of negative economic shocks at birth on adolescents' cognitive outcomes and educational attainment in Malawi.

We provide new evidence of the association between moderate negative economic shocks in utero or shortly after birth and adolescents' cognitive outcomes and educational attainment in Malawi. This is one of the first studies to analyze the effect of not one, but multiple moderate negative economic shocks in a sub-Saharan African (SSA) low-income country (LIC). This focus is important as multiple economic shocks in early life are more representative of the experiences of adolescents in LICs. Combining data on adolescents aged 10-16 from the Adverse Childhood Experiences (ACE) project with the Malawi Longitudinal Study on Families and Health (MLSFH) (N = 1, 559), we use linear and probit regression models to show that girls whose households experienced two or more economic shocks in their year of birth have lower cognitive scores, which are measured using working memory, reading and mathematical tests. Girls also have lower educational attainment, conditional on age. These effects are gendered, as we do not observe similar effects among boys. Overall, our results point to lasting effects of early-life adversity on adolescents, and they highlight that, even in a LIC context where early-life adversity is common, policymakers need to intervene early to alleviate the potential long-term educational impacts of in utero or early life shocks among girls.

Uptake of HIV testing among adolescents and associated adolescent-friendly services.

BACKGROUND: HIV testing remains low among adolescents. Making public health services more adolescent-friendly is one strategy used to encourage testing. However, it remains unclear whether government-led initiatives have a meaningfully impact. METHODS: The current study is observational and utilizes two sources of data (health-facility and adolescent-level) from one round of data collection of an on-going, longitudinal impact evaluation of a pilot cash plus program targeting adolescents. This study linked data from adolescent surveys (n = 2191) to data collected from nearby government-run health facilities (n = 91) in two rural regions of Tanzania. We used log binomial regression models to estimate the association between specific adolescent-friendly health service (AFHS) characteristics and adolescents' uptake of 1) HIV testing and 2) visiting a health care facility in the past year for sexual and reproductive health (SRH) services. RESULTS: Most adolescents (67%) lived in a village with a health facility, and all offered HIV services. We find, however, that AFHS have not been fully implemented. For example, less than 40% of facilities reported that they had guidelines for adolescent care. Only 12% of facilities had a system in place for referral and follow-up with adolescent clients, yet this was an important predictor of both past-year HIV testing (RR = 1.28, p < 0.1) and SRH visits (RR = 1.44, p < 0.05). Less than half (44%) offered services for survivors of gender-based violence (GBV), a significant predictor of past-year HIV testing (RR = 1.20, p < 0.05) and SRH visits (RR = 1.41, p < 0.01) among sexually-active adolescents. CONCLUSIONS: We find that national guidelines on AFHS have not been fully translated into practice at the local level. We highlight particular gaps in adolescent referral systems and GBV services. Scaling up these two essential services could encourage greater HIV testing among a high-risk population, in addition to providing much needed support for survivors of violence.

Emerging partner violence among young adolescents in a low-income country: Perpetration, victimization and adversity.

BACKGROUND: Intimate partner violence (IPV) is prevalent in high- as well as low-income contexts. It results in a substantial public health burden and significant negative socioeconomic and health outcomes throughout the life-course. However, limited knowledge exists about IPV during early adolescence. This period is critical during the transition to adulthood for at least two reasons: it is when the majority of adolescents in low-income countries first encounter dating, sexuality and partnerships, often with older adolescents or adults, and it is also the period when lifelong patterns of violence and norms about acceptable IPV are formed. The current study is one of the first to measure IPV prevalence among young adolescents in a low-income setting, examine the potential etiology, and investigate relationships with gender ideology, poverty, mental health and childhood adversity. METHODS: We surveyed 2,089 adolescents aged 10-16 in Malawi using standardized instruments. We estimated the prevalence of IPV, and use multivariate logistic regression to test potential correlates. RESULTS: More than a quarter (27%) of ever-partnered adolescents in Malawi report being victimized. A substantial proportion of both male and female adolescents (15%) report committing violence against their partner. Girls were more likely than boys to report being a victim of sexual IPV (24% versus 8%), and boys more likely to perpetrate such (9% versus 1%). Almost 10% of the sample had both committed and been a victim of IPV. Cumulative childhood adversity (e.g., physical abuse, witnessing domestic violence) was a consistent and strong correlate of IPV victimization (adjusted odds ratio (aOR) 1.30) and of perpetration (aOR 1.35). Depression and PTSD were likewise associated with IPV victimization in the overall sample. Notably, gender ideology was not predictive of either victimization or perpetration, even among boys. CONCLUSIONS: IPV is common for both male and female young Malawian adolescents, and includes both victimization and perpetration. IPV compounds other adversities experienced by adolescents in this low-income setting, and it is rarely alleviated through help from the health system or other formal support. These findings underscore the need to intervene early when interventions can still break destructive pathways and help foster healthier relationships. This focus on early adolescence is particularly critical in low-income countries given the early onset and rapid pace of the transition to adulthood, with sexual activity, dating and partnership thus being common already in young adolescence. Promising interventions would be those that reduce violence against or around children, as well as those that reduce the impacts of such trauma on mental health during adolescence.

Adverse Childhood Experiences: Prevalence and Association With Adolescent Health in Malawi.

INTRODUCTION: Childhood adversity is robustly associated with poor health across the life course. However, very few studies have examined the prevalence and implications of adverse childhood experiences in low- and middle-income countries. The objective of this study is to measure adverse childhood experiences among adolescents in Malawi and examine the association with mental and physical health outcomes. METHODS: From 2017 to 2018, baseline data were collected among adolescents aged 10-16 years (n=2,089). Respondents were interviewed in their local language at their homes. Respondents completed questions on childhood adversity (Adverse Childhood Experiences-International Questionnaire), self-rated health, mortality expectations, and mental health (Beck Depression Inventory and Post-Traumatic Stress Disorder Scale). Stunting, obesity, and grip strength were measured. Analyses were conducted in 2018. Frequencies described the prevalence of adverse childhood experiences, and adjusted multivariate models examined whether cumulative adversity predicts current health. RESULTS: Adolescents reported a high burden of adversity (i.e., 5 lifetime adverse childhood experiences on average). Adolescents who scored in the top adverse childhood experiences quintile were more likely to report depression (OR=3.11, 95% CI=2.10, 4.60), post-traumatic stress disorder (OR=4.19, 95% CI=2.43, 7.23), worse self-rated health (OR=3.72, 95% CI=2.03, 6.81), and a higher expected likelihood of dying in the next 5 years (RR=5.02, 95% CI=2.15, 7.88) compared with those in the bottom quintile. However, adverse childhood experiences did not demonstrate a graded relationship with obesity, stunting, or grip strength. CONCLUSIONS: These patterns are quite consistent with evidence from high-income countries and suggest that primary prevention of adverse childhood experiences should be a priority to ensure lifelong health in low-resources settings.

Internal migration and child health in Malawi.

A strong and consistent association between migration and health has been found in many settings, but the overwhelming focus of this research has been on adults. In addition, identifying the effect of migration on health largely remains an unresolved challenge, due in part to the inability to distinguish between the effect of migration on health and the selection of children of differing health status into migration streams. In this research we examine the relationship between internal migration and child health in Malawi. We use longitudinal panel data with pre- and post-migration health measures for children and their mothers, which permits us to measure both migration health selection and the effect of migration on health. We also examine if child health changes over time in post-migration destinations. We do not find evidence of migration health selection: children who move have similar pre-migration health status to non-migrant children. We find that the impact of migration on child health is mediated by mothers' characteristics. Before controlling for mothers' health status, we find a strong negative impact of migration on health, particularly for children moving to rural areas or cities, and children moving due to changes in mothers' marital status. After controlling for mothers' health status, however, the negative impact of migration on child health disappears. We also find that child health is worse with longer durations spent in post-migration residence, compared to children who don't move.

Prioritising action to accelerate gender equity and health for women and girls: Microdata analysis of 47 countries.

The Sustainable Development Goals set ambitious targets for health. Meeting such will require drastic improvements in the social conditions for women and girls. Understanding which social conditions have the greatest impact on health can help prioritise action, yet there is little comparative data. We use microdata from 338,580 women in 47 low- and middle-income countries to estimate the relative contributions of improved social determinants in bringing about maternal and child health gains over the past 20 years. Regression analyses examine determinants related to education, work, health services, family, and violence; the potential health benefit that could be derived from improving conditions is calculated. Secondary education and child marriage emerge as the strongest and most consistent predictors of health. The largest impact is seen on adolescent births: we estimate that achieving universal completion of secondary schooling for young women could lower adolescent births by 18 percentage points; eliminating child marriages could lower adolescent births by 11 points. Intervening in these two areas could also bring about substantial reductions in the unmet need for family planning, past-year intimate partner violence, and child mortality. Thus, we suggest prioritising policies targeting secondary education and child marriage in order to accelerate gender equity and health.

Caregiver supportive policies to improve child outcomes in the wake of the HIV/AIDS epidemic: an analysis of the gap between what is needed and what is available in 25 high prevalence countries.

In the wake of the HIV/AIDS epidemic, caregivers are struggling to support HIV-affected children. For reasons of equity and efficiency, their needs can be best met through strong social protections and policies. This paper presents a conceptual framework to help address the needs of HIV-affected caregivers and to prioritize policies. We describe the needs that are common across diverse caregiving populations (e.g., economic security); the needs which are intensified (e.g., leave to care for sick children) or unique to providing care to HIV-affected children (e.g., ARV treatment). The paper then explores the types of social policies that would facilitate families meeting these needs. We outline a basic package of policies that would support HIV-affected families, and would meet goals agreed to by national governments. We examine the availability of these policies in 25 highly affected countries in sub-Saharan Africa. The majority of countries guarantee short-term income protection during illness, free primary school, and educational inclusion of children with special needs. However, there are significant gaps in areas critical to family economic security and healthy child development. Fewer than half of the countries we analyzed guarantee a minimum wage that will enable families to escape poverty; only six have eliminated tuition fees for secondary school; and only three offer paid leave to care for sick children. Filling these policy gaps, as well as making mental health and social services more widely available, is essential to support caregiving by families for HIV-affected children. As part of the HIV agenda, the global community can help national governments advance towards their policy targets. This would provide meaningful protection for families affected by HIV, as well as for millions of other vulnerable families and children across the region.

HIV/AIDS, declining family resources and the community safety net.

Families play central roles in the HIV/AIDS pandemic, caring for both orphaned children and the ill. This extra caregiving depletes two family resources essential for supporting children: time and money. We use recent data from published studies in sub-Saharan Africa to illustrate deficits and document community responses. In Botswana, parents caring for the chronically ill had less time for their preschool children (74 versus 96 hours per month) and were almost twice as likely to leave children home alone (53% versus 27%); these children experienced greater health and academic problems. Caregiving often prevented adults from working full time or earning their previous level of income; 47% of orphan caregivers and 64% of HIV/AIDS caregivers reported financial difficulties due to caregiving. Communities can play an important role in helping families provide adequate childcare and financial support. Unfortunately, while communities commonly offer informal assistance, the value of such support is not adequate to match the magnitude of need: 75% of children's families in Malawi received assistance from their social network, but averaging only US$81 annually. We suggest communities can strengthen the capacity of families by implementing affordable quality childcare for 0-6 year olds, after-school programming for older children and youth, supportive care for ill children and parents, microlending to enhance earnings, training to increase access to quality jobs, decent working conditions, social insurance for the informal sector, and income and food transfers when families are unable to make ends meet.

The extent of community and public support available to families caring for orphans in Malawi.

There are an estimated 15 million AIDS orphans worldwide. Families play an important role in safeguarding orphans, but they may be increasingly compromised by the HIV/AIDS epidemic. The international aid community has recognized the need to help families continue caring for orphaned children by strengthening their safety nets. Before we build new structures, however, we need to know the extent to which community and public safety nets already provide support to families with orphans. To address this gap, we analyzed nationally representative data from 27,495 children in the 2004-2005 Malawi Integrated Household Survey. We found that communities commonly assisted orphan households through private transfers; organized responses to the orphan crisis were far less frequent. Friends and relatives provided assistance to over 75% of orphan households through private gifts, but the value of such support was relatively low. Over 40% of orphans lived in a community with support groups for the chronically ill and approximately a third of these communities provided services specifically for orphans and other vulnerable children. Public programs, which form a final safety net for vulnerable households, were more widespread. Free/subsidized agricultural inputs and food were the most commonly used public safety nets by children's households in the past year (44 and 13%, respectively), and households with orphans were more likely to be beneficiaries. Malawi is poised to drastically expand safety nets to orphans and their families, and these findings provide an important foundation for this process.