E. coli contamination of drinking water sources in rural and urban settings: an analysis of 38 nationally representative household surveys (2014-2021).

The world is not on track to achieve universal access to safely managed water by 2030, and access is substantially lower in rural areas. This Sustainable Development Goal target and many other global indicators rely on the classification of improved water sources for monitoring access. We aimed to investigate contamination in drinking water sources, comparing improved and unimproved sources in urban and rural settings. We used data from Multiple Indicator Cluster Surveys, which tested samples from the household water source and a glass of water for Escherichia coli contamination across 38 countries. Contamination was widespread and alarmingly high in almost all countries, settings, and water sources, with substantial inequalities between and within countries. Water contamination was found in 51.7% of households at the source and 70.8% in the glass of water. Some improved sources (e.g., protected wells and rainwater) were as likely to be contaminated as unimproved sources. Some sources, like piped water, were considerably more likely to be contaminated in rural than urban areas, while no difference was observed for others. Monitoring water contamination along with further investigation in water collection, storage, and source classification is essential and must be expanded to achieve universal access to safely managed water.

Maternal adverse childhood experiences (ACEs) and their associations with intimate partner violence and child maltreatment: Results from a Brazilian birth cohort.

Adverse childhood experiences (ACEs) have been found to predict many negative life outcomes. However, very little evidence exists on Intimate Partner Violence (IPV) and Child Maltreatment (CM). We investigated the impact of maternal ACEs on IPV and CM in three different: cumulative risk, individual adversities and particular groupings of ACEs. The 2015 Pelotas Birth Cohort, Southern Brazil, has followed a population-based sample mothers and children repeatedly until children were aged 4 years, when mothers provided data on ACEs, and current IPV and CM. ACEs were examined in three different ways: (i) as a cumulative risk score; (ii) individual adversities; and (iii) patterns of ACEs (Latent Class Analysis: LCA). One quarter (25.4%) of mothers reported having 5+ ACEs in childhood. Compared to mothers with no ACEs, those who reported 5+ ACEs, had 4.9 (95%CI 3.5; 6.7) times the risk of experiencing IPV and 3.8 (95%CI 2.5; 5.6) times the risk of reporting child maltreatment. LCA results also highlighted the major influence of multiple ACEs on later IPV and CM. However, individual ACEs related to violence (exposure to abuse or domestic violence) showed some specificity for both later IPV and CM, over and above the influence of cumulative childhood adversity. This is the first large study to demonstrate a strong link between maternal ACEs and both IPV and CM. Cumulative ACE exposure and some specificity in effects of childhood violence are important for later IPV and CM. Integrated prevention is essential for reducing the intergenerational transmission of adversity and violence.

Sexual violence as a predictor of unintended pregnancy among married women of India: evidence from the fourth round of the National Family Health Survey (2015-16).

BACKGROUND: Sexual Intimate Partner Violence (IPV) is a public health problem globally, with about one in three women experiencing sexual IPV ever in their lifetime. Unintended pregnancy is one of the consequences of sexual IPV and has its repercussions that can span generations. The present study was conducted to estimate the prevalence of sexual intimate partner violence (IPV) and assess the association between sexual IPV and unintended childbirth in India among married women aged 15-49 years. METHODS: The National Family Health Survey-India (NFHS-4) fourth-round dataset was used for the present study. Pregnancies intention was the primary outcome variable, and the main predictor variable was self-reported sexual IPV in the past 12 months. Women's current age, age at marriage, education and occupation, place of residence, wealth quintile, parity, religion, caste, region, mass media exposure, and husband's education were other control variables. Weighted analysis depicted the prevalence of unintended pregnancies and their association with different socio-demographic variables. Binary logistic regression was done in two steps respecting a hierarchical approach for potential confounders. RESULTS: Approximately 6.4% of study participants had ever experienced sexual IPV in India. Prevalence of sexual IPV was significantly higher when the age of marriage was < 19 years, among uneducated, in the lowest wealth index quintile, belonging to scheduled caste, having multiparity, and not having mass media exposure. About 12.1% of pregnancies were considered unintended by the respondents, and 22.9% of women who ever had a history of sexual IPV considered the last pregnancy to be unintentional. Women who experienced sexual IPV were in younger age groups, having parity ≥1, and bigger families had significantly higher odds of having an unintended pregnancy compared to their reference groups. CONCLUSIONS: We observed that sexual IPV has a significant role in unintended pregnancies. Effective counseling means should be rolled out for victims of sexual IPV as it is a taboo subject. The significant factors that can predict unintended pregnancies highlighted in our study should be acknowledged while counseling.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa.

BACKGROUND: The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys. METHODS: We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status. RESULTS: Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = - 1.7%, p < 0.001) and unmarried (AARC = - 4.7%, p < 0.001) AGYW from poorest households in Mozambique. CONCLUSION: Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. RESULTS: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). CONCLUSION: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

Contraception in adolescence: the influence of parity and marital status on contraceptive use in 73 low-and middle-income countries.

BACKGROUND: There is still a large gap in relation to effectively meet the contraceptive needs and family planning goals of adolescents. Our aim was to describe how having a partner and children impact on contraceptive behavior of sexually active female adolescents from low and middle-income countries (LMICs). METHODS: Analyses were based on the most recent Demographic and Health Surveys and Multiple Indicator Surveys carried out since 2005 in 73 LMICs with available data for sexually active women aged 15-19 years. Modern contraceptive prevalence and demand for family planning satisfied with modern methods of contraception (mDFPS) were estimated among three subgroups of adolescents considering their parity and marital status- not married, married without children, and married with children - at national and regional levels. RESULTS: Female adolescents who were married with no children presented the lowest median modern contraceptive prevalence in all world regions, ranging from 2.9% in West & Central Africa to 29.0% in Latin America & Caribbean. Regarding mDFPS, the lowest coverage for married adolescents without children was found in West & Central Africa (12.6%), whereas Latin America & Caribbean presented the highest (50.4%). In East Asia & Pacific, not married adolescents were the group with the lowest mDFPS (17.1%). In 12 countries, mDFPS was below 10% among married adolescents without children: Angola, Chad, Congo, Congo DR, Guinea, Mozambique, Niger, Nigeria, and Senegal in Africa, Philippines and Timor-Leste in Asia and Guyana in Latin America & Caribbean. CONCLUSIONS: In most countries, modern contraceptive prevalence and mDFPS were particularly low among married female adolescents without children, which should be considered a priority group for intervention. The findings suggest that social norms regarding marriage and fertility expectations and other cultural barriers have a role at least as relevant as contraceptive availability. All these aspects need to be considered in the design of family planning strategies to effectively increase modern contraceptive use among adolescents everywhere, particularly in conservative contexts.

Demand for family planning satisfied with modern methods among sexually active women in low- and middle-income countries: who is lagging behind?

BACKGROUND: Family planning is key for reducing unintended pregnancies and their health consequences and is also associated with improvements in economic outcomes. Our objective was to identify groups of sexually active women with extremely low demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries, at national and subnational levels to inform the improvement and expansion of programmatic efforts to narrow the gaps in mDFPS coverage. METHODS: Analyses were based on Demographic and Health Survey and Multiple Indicator Cluster Survey data. The most recent surveys carried out since 2000 in 77 countries were included in the analysis. We estimated mDFPS among women aged 15-49 years. Subgroups with low coverage (mDFPS below 20%) were identified according to marital status, wealth, age, education, literacy, area of residence (urban or rural), geographic region and religion. RESULTS: Overall, only 52.9% of the women with a demand for family planning were using a modern contraceptive method, but coverage varied greatly. West & Central Africa showed the lowest coverage (32.9% mean mDFPS), whereas South Asia and Latin America & the Caribbean had the highest coverage (approximately 70% mean mDFPS). Some countries showed high reliance on traditional contraceptive methods, markedly those from Central and Eastern Europe, and the Commonwealth of Independent States (CEE & CIS). Albania, Azerbaijan, Benin, Chad and Congo Democratic Republic presented low mDFPS coverage (< 20%). The other countries had mDFPS above 20% at country-level, yet in many of these countries mDFPS coverage was low among women in the poorest wealth quintiles, in the youngest age groups, with little education and living in rural areas. Coverage according to marital status varied greatly: in Asia & Pacific and Latin America & the Caribbean mDFPS was higher among married women; the opposite was found in West & Central Africa and CEE & CIS countries. CONCLUSIONS: Almost half of the women in need were not using an effective family planning method. Subgroups requiring special attention include women who are poor, uneducated/illiterate, young, and living in rural areas. Efforts to increase mDFPS must address not only the supply side but also tackle the need to change social norms that might inhibit uptake of contraception.

A randomized controlled trial of exercise during pregnancy on maternal and neonatal outcomes: results from the PAMELA study.

BACKGROUND: Women are encouraged to be physically active during pregnancy. Despite available evidence supporting antenatal physical activity to bring health benefits for both the mother and child, the most effective way to prevent some maternal and fetal outcomes is still unclear. The purpose of this study was to evaluate the efficacy of an exercise intervention to prevent negative maternal and newborn health outcomes. METHODS: A randomized controlled trial (RCT) nested into the 2015 Pelotas (Brazil) Birth Cohort Study was carried-out with 639 healthy pregnant women, 213 in the intervention group (IG) and 426 in the control (CG) group. An exercise-based intervention was conducted three times/week for 16 weeks from 16-20 to 32-36 weeks' gestation. The main outcomes were preterm birth and pre-eclampsia. Gestational age was calculated based on several parameters, including routine ultrassounds and/or last menstrual period and categorized as < 37 weeks and ≥ 37 weeks for evaluation of preterm birth. Pre-eclampsia was self-reported. Secondary outcomes were gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference. Analyses were performed by intention-to-treat (ITT) and per protocol (70% of the 48 planned exercise sessions). Odds ratio were derived using unconditional logistic regression. RESULTS: The IG and CG did not differ at baseline regarding their mean age (27.2 years ± 5.3 vs. 27.1 years ± 5.7) and mean pre-pregnancy body mass index (25.1 ± 3.9 vs. 25.2 ± 4.1 kg/m2). The mean adherence to the exercise intervention was 27 ± 17.2 sessions (out of a potential 48) with 40.4% attending > = 70% of the recommended exercise sessions. A total of 594 participants (IG:198; CG: 396) were included in the ITT and 479 (IG: 83; CG: 396) were included in the per protocol analyses. There were no significant differences in the incidence of preterm birth and pre-eclampsia between groups in the ITT and per protocol analysis. There were also no differences between the two groups in mean gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference. CONCLUSIONS: While the RCT did not support the benefits of exercise performed during pregnancy on preeclampsia and preterm birth, the exercise program also did not present adverse impacts on newborn health. Our findings may contribute to promote intervention strategies that motivate health providers to encourage pregnant women to be more physically active. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02148965 , registered on 22 May 2014.

Changes in leisure-time physical activity among Brazilian pregnant women: comparison between two birth cohort studies (2004 - 2015).

BACKGROUND: Low levels of leisure-time physical activity (LTPA) during pregnancy have been shown in studies conducted worldwide. Surveillance is extremely important to monitor the progress of physical activity patterns over time and set goals for effective interventions to decrease inactivity among pregnant women. The aim of this study was to evaluate time changes in LTPA among Brazilian pregnant women in an 11-year period (2004-2015) by comparing data from two birth cohort studies. METHODS: Two population-based birth cohort studies were carried out in the city of Pelotas, southern Brazil, in 2004 and 2015. A total of 4244 and 4271 mothers were interviewed after delivery. Weekly frequency and duration of each session of LTPA in a typical week were reported for the pre-pregnancy period and for each trimester of pregnancy. Trends in both recommended LTPA (≥150 min/week) and any LTPA (regardless of weekly amount) were analysed overtime. Changes were also calculated separately for subgroups of maternal age, schooling, family income, parity, pre-pregnancy body mass index and pre-pregnancy LTPA. RESULTS: The proportion of women engaged in recommended levels of LTPA pre-pregnancy increased from 11.2% (95%CI 10.0-12.2) in 2004 to 15.8% (95%CI 14.6-16.9) in 2015. During pregnancy, no changes were observed over the period for the first (10.6 to 10.9%) and second (8.7 to 7.9%) trimesters, whereas there was a decrease from 3.4% (95%CI 2.9-4.0) to 2.4% (95%CI 1.9-2.8) in the last trimester. Major decreases in LTPA in the last trimester were observed among women who were younger, with intermediate to high income, high schooling, primiparous, pre-pregnancy obese and, engaged in LTPA before pregnancy. Changes in any LTPA practice followed the same patterns described for recommended LTPA. CONCLUSIONS: Despite the increase in the proportion of women engaged in LTPA before pregnancy between 2004 and 2005, LTPA levels remained stable during the first and second trimesters of pregnancy and declined during the third gestational trimester over the period. Interventions to encourage the maintenance of LTPA practice throughout pregnancy are urgently needed.

Unique and shared risk factors for early childhood victimisation and polyvictimisation in a Brazilian population-based birth cohort.

Background: Identifying modifiable risk factors for child victimisation and polyvictimisation (exposure to multiple types of victimisation) is critical for informing prevention efforts, yet little evidence is available in low- and middle-income countries. The authors aimed to estimate the prevalence of child victimisation and polyvictimisation, and examine unique and shared risk factors in a population-based cohort in Southern Brazil. Methods: Lifetime child victimisation was based on maternal report when children were aged 4 years old (N∼3900) and included five types of victimisation (conventional crime, child maltreatment, peer/sibling victimisation, sexual victimisation, and witnessing/indirect victimisation) and polyvictimisation. Based on a socioecological model, possible risk factors were examined in four levels: community, maternal and family, parent, and child. Findings: Conventional crime and peer/sibling victimisation were the most common types of victimisation (46.0 and 46.5%, respectively), followed by witnessing/indirect victimisation (27.0%), and child maltreatment (11.3%). Sexual victimisation had the lowest prevalence (1.4%). One in 10 (10.1%) children experienced polyvictimisation. In general, boys had higher victimisation rates than girls. There were few risk factors related only to specific types of victimisation (e.g., child disability was uniquely associated with child maltreatment and peer/sibling victimisation). Instead, most risk factors were shared across nearly all victimisation types and also associated with polyvictimisation. These shared risk factors were: violent neighbourhood and low social cohesion, maternal adverse childhood experiences, younger maternal age, parental antisocial behaviour, intimate partner violence against mothers, and maternal depression. Interpretation: These findings reveal a general pattern of accumulative risk effects for different types of victimisation and polyvictimisation, rather than unique risk profiles in children aged four year Prevention efforts should target risk factors at multiple levels (e.g.,: community, maternal and family and parent) during early childhood. Funding: Wellcome Trust grant 10735_Z_18_Z.

Intimate partner violence during pregnancy and quality of life in Southern Brazil: a cross-sectional study, 2022.

OBJECTIVE: To analyze the association between intimate partner violence during pregnancy (IPVP) and quality of life (QOL). METHODS: A cross-sectional study was conducted with pregnant women receiving care in Primary Health Care in the municipality of Criciúma, Santa Catarina state, Brazil, in 2022; QOL was assessed in the physical, psychological, social relationship and environmental domains using WHOQOL-Bref instrument; IPVP was evaluated by means of the World Health Organization Violence Against Women; Crude and adjusted linear regression analyses were performed. RESULTS: A total of 389 pregnant women were evaluated; IPVP was observed in 13.6% of cases; in the adjusted analysis, IPVP remained associated with physical, psychological and social relationship domains; pregnant women who experienced IPVP had a reduction in their QOL score by 9.77, 11.07 and 8.95 points, respectively, when compared to those who did not experience IPVP. CONCLUSION: IPVP was associated with poorer QOL in the physical, psychological and social relationships domains. Health services equipped to address and prevent violence against pregnant women are essential. MAIN RESULTS: Intimate partner violence (IPV) was observed in 13.6% of pregnant women and was associated with poorer quality of life in the physical, psychological and social relationship domains. IMPLICATIONS FOR SERVICES: The results emphasize the need for an intersectoral approach in addressing the issue, with specialized healthcare centers for situations of violence integrated with social assistance and public security. PERSPECTIVES: Development of intersectoral policies and actions that strengthen existing ones and ensure social and healthcare assistance to pregnant women victims of violence and their children, given the negative impact of IPVP on quality of life.

Why are pregnant women physically inactive? A qualitative study on the beliefs and perceptions about physical activity during pregnancy.

This study aimed to describe the beliefs and perceptions of pregnant women and healthcare providers about physical activity during pregnancy. Using a qualitative approach, 30 pregnant women and the 14 healthcare providers caring for them were interviewed in the second trimester of pregnancy. We included women who maintained, decreased, or stopped physical activity since becoming pregnant. They were divided into low (≤ 8 years) and high schooling (> 8 years). Semi-structured, in-depth interviews were conducted and guided by three key questions: (1) When does physical activity during pregnancy start to be considered a wrong behavior?; (2) What are the main barriers (biological or others) to physical activity?; and (3) Do the actions of healthcare providers and people close to pregnant women reinforce barriers? Interviews were audio recorded, transcribed, and analyzed based on recurring themes. All women changed their physical activity behavior (decreased or stopped) when they discovered their pregnancy. Fear of miscarriage, contractions, bleeding, and of causing malformations in the baby were the most reported reasons for decreasing or stopping physical activity. Participants also lacked access to consistent information and healthcare providers' support on the benefits of physical activity. Despite the current international recommendations to regular physical activity during pregnancy, uncertainty regarding its benefits remains. Interventions to promote physical activity during this period should include the training of healthcare providers so they can advise and discard ideas contrary to mother-child health benefits.

Gender Division of Housework and Intimate Partner Violence Among Mothers of Toddlers During the COVID-19 Pandemic: Findings from the 2019 Rio Grande (Brazil) Birth Cohort.

During the COVID-19 pandemic, we evaluated the association between gender division of housework and intimate partner violence (IPV) victimization in a population-based cohort of mothers. We collected data on psychological, physical, and sexual IPV using an adapted version of the World Health Organization Violence Against Women instrument and division of housework using a validated questionnaire. We used logistic regression to calculate adjusted odds ratios. We found that in mothers who reported an unequal gender division of housework (higher load), the odds of suffering psychological, physical, or sexual IPV were higher during the first and second years of the pandemic.

Cross-National Associations between Age at Marriage and Intimate Partner Violence among Young Women: An Analysis of Demographic and Health Surveys from 48 Countries.

We estimated the associations between age at first marriage and recent intimate partner violence (IPV) among women young women aged 20-24 years using data from demographic and health surveys (DHS) conducted at 48 low- and middle-income countries (LMICs). We fitted a multilevel logistic regression model controlling for sociodemographic covariates. Our pooled analyses revealed that age at marriage is strongly associated with past year IPV in a non-linear way, with steep reductions in violence when young women marry after age 15 and a continued decline in IPV for every year marriage is delayed up to age 24. The risk of physical IPV was 3.3 times higher among women married at age 15 (24.4%, 95% CI 19.7; 29.2%) compared to young women married at age 24 (7.5%, 95% CI 5.8; 9.2%). For sexual IPV, girls married at 15 had 2.2 times higher risk compared to those married at 24 (7.5%, 95% CI 5.6; 9.5% vs. 3.4%, 95% CI 2.7; 4.2%, respectively). For psychological IPV, the relative risk was 3.4 for the same comparison (married at 15: 20.1%, 95% CI 14.6; married at 24: 25.5% vs. 6.0%, 95% CI 3.4; 8.6%). Country specific analyses showed that, age at marriage was negatively associated with physical and psychological IPV in nearly half of the countries (n/48) and with sexual IPV in ten countries. Our findings underscore the importance of integrating violence prevention and response interventions into efforts to prevent child marriage, as well as the health, educations and social services young women access.

The Leading Causes of Death in Children and Adolescents in Brazil, 2000-2020.

INTRODUCTION: Despite promising reductions in mortality from infectious diseases, premature death is a still major public health problem in Brazil. However, little is known about which diseases and injury mechanisms are the main causes of premature death. This paper aimed to detail the trends in leading causes of death among children and adolescents in Brazil. METHODS: Data were extracted from medical death certificates from the Brazilian Mortality Information System for children and adolescents aged 1-19 years for 2000-2020. The 10 leading causes of death for children and adolescents were defined using primary cause of death codes, grouped by death for diseases and mechanism for injury, according to the ICD-10. All analyses were completed in 2022. RESULTS: From 2000 through 2020, there was a total of 772,729 child and adolescent deaths in Brazil. Despite an overall 34% reduction in child and adolescent mortality from 2000 to 2020, improvements were less pronounced for injury-related deaths than for communicable diseases. Therefore, by 2020, over half of deaths were from injury-related causes. Firearm-related injury was by far the leading cause, accounting for 21% of all deaths. There was a 38% reduction in firearm deaths in the last 4 years against a previously increasing trend, and homicide accounted for over 90% of all firearm deaths because suicide by firearm was rare. CONCLUSIONS: Injury-related deaths among children and adolescents are a growing concern in Brazil, and firearms are the current leading cause of child and adolescent death.

Effects of the Pelotas (Brazil) Peace Pact on violence and crime: a synthetic control analysis.

Background: City-led interventions are increasingly advocated to achieve the UN's Sustainable Development Goal to reduce violence for all. We used a new quantitative evaluation method to examine whether a flagship programme, called the "Pelotas Pact for Peace" (the Pacto), has been effective in reducing violence and crime in the city of Pelotas, Brazil. Methods: We used synthetic control methodology to assess the effects of the Pacto from August 2017 to December 2021, and separately before and during the COVID-19 pandemic. Outcomes included monthly rates of homicide and property crime, and yearly rates of assault against women and school drop-out. We constructed synthetic controls (counterfactuals) based on weighted averages from a donor pool of municipalities in Rio Grande do Sul. Weights were identified using pre-intervention outcome trends and confounders (sociodemographics, economics, education, health and development, and drug trafficking). Findings: The Pacto led to an overall 9% reduction in homicide and 7% reduction in robbery in Pelotas. These effects were not uniform across the full post-intervention period as clear effects were only seen during the pandemic period. A 38% reduction in homicide was also specifically associated with the criminal justice strategy of Focussed Deterrence. No significant effects were found for non-violent property crimes, violence against women, and school dropout, irrespective of the post-intervention period. Interpretation: City-level interventions that combine public health and criminal justice approaches could be effective in tackling violence in Brazil. Continued monitoring and evaluation efforts are increasingly needed as cities are proposed as key opportunities for reducing violence for all. Funding: This research was funded by the Wellcome Trust [grant number: 210735_Z_18_Z].

Intimate partner violence victimisation and its association with maternal parenting (the 2015 Pelotas [Brazil] Birth Cohort): a prospective cohort study.

BACKGROUND: Intimate partner violence (IPV) is highly prevalent in low-income and middle-income countries and has been a major obstacle towards reaching global health targets for women and children. We aimed to investigate cross-sectional and longitudinal associations between IPV victimisation and maternal parenting practices of young children in a population-based birth cohort study in Brazil. METHODS: The 2015 Pelotas Birth Cohort is an ongoing, prospective cohort, including all hospital births occurring between Jan 1 and Dec 31, 2015, in the city of Pelotas, Brazil. When children were aged 4 years, mothers reported on emotional, physical, and sexual IPV victimisation in the past 12 months. Parenting outcomes were assessed through filming the mother and child in interactive tasks at age 4 years and maternal interviews at ages 4 years and 6-7 years. Interactive tasks were filmed at the Centre for Epidemiological Research facilities. Directly observed outcomes included negative (eg, coercive) and positive (eg, sensitivity and reciprocity) parenting interactions independently coded by a team of psychologists. Self-reported parenting was measured using the subscales on quality of parent-child relationship, positive encouragement, parental consistency, and coercive behaviour of the Parenting and Family Adjustment Scales questionnaire. Unadjusted and adjusted linear regression analyses were performed to assess the associations. FINDINGS: Of the 4275 livebirths enrolled in the cohort, 3730 mother-child dyads were included in our analytical sample at age 4 years and 3292 at age 6-7 years. After adjusting for all potential confounders, emotional IPV and physical or sexual IPV were associated with the following self-reported parenting outcomes: poor parent-child relationship quality (emotional IPV: p=0·011), lower parental consistency (emotional IPV: p<0·001, physical or sexual IPV: p=0·0053), and more coercive behaviour (emotional IPV: p<0·001, physical or sexual IPV: p=0·0071) at age 4 years. Associations were not observed for self-reported positive encouragement and filmed parenting outcomes in fully adjusted models. Longitudinally, IPV at age 4 years predicted similar outcomes when children were aged 6-7 years. INTERPRETATION: In this large cohort study, maternal IPV victimisation was consistently associated with poorer parent-child relationship, decreased parental consistency, and increased harsh parenting reported by mothers of young children. As well as initiatives to prevent IPV, parenting interventions focused on supporting the capacity of caregivers to provide nurturing care delivered at key stages early in the life course are crucial. FUNDING: Wellcome Trust. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Climate change is a threat multiplier for violence against children.

BACKGROUND: The climate crisis is the biggest threat to the health, development, and wellbeing of the current and future generations. While there is extensive evidence on the direct impacts of climate change on human livelihood, there is little evidence on how children and young people are affected, and even less discussion and evidence on how the climate crisis could affect violence against children. PARTICIPANTS AND SETTING: In this commentary, we review selected research to assess the links between the climate crisis and violence against children. METHODS: We employ a social-ecological perspective as an overarching framework to organize findings from the literature and call attention to increased violence against children as a specific, yet under-examined, direct and indirect consequence of the climate crisis. RESULTS: Using such a perspective, we examine how the climate crisis exacerbates the risk of violence against children at the continually intersecting and interacting levels of society, community, family, and the individual levels. We propose increased risk of armed conflict, forced displacement, poverty, income inequality, disruptions in critical health and social services, and mental health problems as key mechanisms linking the climate crisis and heightened risk of violence against children. Furthermore, we posit that the climate crisis serves as a threat multiplier, compounding existing vulnerabilities and inequities within populations and having harsher consequences in settings, communities, households, and for children already experiencing adversities. CONCLUSIONS: We conclude with a call for urgent efforts from researchers, practitioners, and policymakers to further investigate the specific empirical links between the climate crisis and violence against children and to design, test, implement, fund, and scale evidence-based, rights-based, and child friendly prevention, support, and response strategies to address violence against children.

Health effects associated with exposure to intimate partner violence against women and childhood sexual abuse: a burden of proof study.

The health impacts of intimate partner violence against women and childhood sexual abuse are not fully understood. Here we conducted a systematic review by comprehensively searching seven electronic databases for literature on intimate partner violence-associated and childhood sexual abuse-associated health effects. Following the burden of proof methodology, we evaluated the evidence strength linking intimate partner violence and/or childhood sexual abuse to health outcomes supported by at least three studies. Results indicated a moderate association of intimate partner violence with major depressive disorder and with maternal abortion and miscarriage (63% and 35% increased risk, respectively). HIV/AIDS, anxiety disorders and self-harm exhibited weak associations with intimate partner violence. Fifteen outcomes were evaluated for their relationship to childhood sexual abuse, which was shown to be moderately associated with alcohol use disorders and with self-harm (45% and 35% increased risk, respectively). Associations between childhood sexual abuse and 11 additional health outcomes, such as asthma and type 2 diabetes mellitus, were found to be weak. Although our understanding remains limited by data scarcity, these health impacts are larger in magnitude and more extensive than previously reported. Renewed efforts on violence prevention and evidence-based approaches that promote healing and ensure access to care are necessary.

The role of female permanent contraception in meeting the demand for family planning in low- and middle-income countries.

OBJECTIVE: Our aim was to describe the reliance on female permanent contraception among women with demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries (LMICs) and to describe socio-economic and demographic patterns of permanent contraception in countries with high use. STUDY DESIGN: Using data from the latest national health survey carried out in LMICs, we estimated mDFPS and the share of each contraceptive method used. Countries with a share of more than 25% of female permanent contraception were further explored for differences by wealth, number of living children, woman's age, and by the intersection of woman's age and number of living children. RESULTS: In the 20 countries studied, between 6% and 94% of the contracepting population used modern methods. Female permanent contraception accounted for more than half of women using modern contraceptives in India, Dominican Republic, El Salvador, Mexico, and Colombia. In India and Tonga, more than 20% of women using contraceptives with fewer than 2 living children were using female permanent contraception. Among women with 2 living children, countries with the highest reliance on permanent contraception were India (79%), El Salvador (61%), Cuba (55%), Colombia (52%), and Thailand (51%). Dominican Republic, El Salvador, India, and Mexico presented high levels of permanent contraception among younger women, with reliance higher than 30% among women aged 25 to 29 and 50% or more among women aged 30 to 34. CONCLUSIONS: Reliance on permanent contraception was high in several countries and among women aged less than 35 years. IMPLICATIONS: Our results may help policymakers and health managers improve family planning services in low- and middle-income settings. We identified high use of female permanent contraception among modern contraceptive users in several countries, even among young women with fewer children.