Inequality in iron and folic acid consumption and dietary diversity in pregnant women following exposure to maternal nutrition interventions in three low- and middle-income countries.

OBJECTIVE: Research is available on improved coverage and practices from several large-scale maternal nutrition programmes, but not much is known on change in inequalities. This study analyses wealth and education inequality using Erreygers and Concentration indices for four indicators: adequate iron and folic acid (IFA) consumption, women's dietary diversity, and counselling on IFA and dietary diversity. DESIGN: A pre-test-post-test, control group design. SETTING: Maternal nutrition intervention programmes conducted in Bangladesh, Burkina Faso and Ethiopia during 2015-2022. PARTICIPANTS: Recently delivered women (RDW) and pregnant women (PW). RESULTS: Statistically significant reductions in education inequality were observed for adequate IFA consumption, counselling on IFA and dietary diversity in intervention areas of Bangladesh and for adequate IFA consumption in intervention areas of Burkina Faso.A significant decrease in wealth inequality was observed for adequate IFA consumption in the intervention areas of Bangladesh, whereas a significant increase was observed in the non-intervention areas for counselling on IFA in Ethiopia and for dietary diversity in Burkina Faso. CONCLUSION: The results can be attributed to the extensive delivery system at community level in Bangladesh and being predominantly facility-based in Burkina Faso and Ethiopia. COVID-19 disruptions (in Burkina Faso and Ethiopia) and indicator choice also had a role in the results.The main takeaways for nutrition programmes are as follows: (a) assessing inequality issues through formative studies during designing, (b) monitoring inequality indicators during implementation, (c) diligently addressing inequality through targeted interventions, setting aside resources and motivating frontline workers to reduce disparities and (d) making inequality analysis a routine part of impact evaluations.

Inequalities in large-scale breastfeeding programmes in Bangladesh, Burkina Faso and Vietnam.

Inequalities in breastfeeding programmes and practices have slowed global progress in providing the life-saving protection of breastfeeding for millions of infants despite well-known life-long impacts. As breastfeeding interventions are scaled up, inequalities in coverage and breastfeeding practices should be tracked, particularly in disadvantaged groups, who are likely to suffer the most serious health and developmental impacts of poor childhood nutrition. The literature provides evidence of inequalities in breastfeeding practices, but research is limited on socioeconomic disparities in the coverage of breastfeeding interventions. This paper (1) compares inequalities in breastfeeding practices in intervention and nonintervention areas and (2) documents inequalities in programme coverage by type of intervention. We disaggregated endline evaluation surveys in Bangladesh, Burkina Faso and Vietnam, where rigorous evaluations had documented significant overall improvements, and analysed whether inequalities in breastfeeding practices and programme coverage differed by treatment areas. We used Erreygers index to quantify inequalities and found that breastfeeding practices were largely pro-poor; intervention coverage was not consistently pro-poor. While counselling coverage often favoured women from the poorest quintile, public education/media coverage consistently favoured better-off women. Inequalities favoured more educated mothers in the coverage of combined interventions. None of the programmes had explicit equality objectives. The results indicate the need for introducing specific actions to reduce inequalities in breastfeeding policies and programmes. This is a priority unfinished agenda for nutrition programming.

A decade of conditional cash transfer programs for reproductive health in India: How did equality fare?

BACKGROUND: Since 2005, India has implemented conditional cash transfer [CCT] programs to promote the uptake of institutional delivery services [ID]. The study aims to assess changes in wealth-based inequality in the use of ID and other maternal health care services during the first decade of Janani Suraksha Yojana and related CCT programs. METHODS: Data from two Demographic and Health Surveys were used to calculate changes in service inequality from 2005 to 2015-16 in the use of three or more antenatal care [ANC] visits, ID, and postnatal care [PNC]. The changes were assessed at the national level, within high and low performing states [HPS and LPS, respectively] and within urban and rural areas of each state category. Erreygers Index [EI] and Wagstaff Index [WI], superior to concentration index, were used to gain different insights into the nature of inequality. EI is an objective measure of inequality irrespective of prevalence while WI is a combined measure of inequality and the average distribution of an indicator that puts more weight on the poor. RESULTS: The results suggest that wealth-based inequalities decreased significantly at the national level. For ID, both indices showed a decline in both HPS and LPS though the change in WI in HPS was insignificant. For ANC, there was a significant decrease in inequality using both indices in HPS but not in LPS. For PNC, there was a significant decrease in inequality using both indices in HPS, and when using WI in LPS, but not when using EI in LPS. CONCLUSION: Overall, the first decade of India's CCT programs saw an impressive reduction in EI for ID but less so for WI suggesting that the benefit of CCTs did not go disproportionately to the poor, which suggests that there is a need to reduce or eliminate the evident leakages. The improvement in uptake and inequality in ANC and PNC was not at par with ID, stressing the need to place greater focus on the continuum of care. The urban rural difference in HPS versus LPS in the changes in inequality reveals that infrastructure is important for CCTs to be more effective.

Risk factors associated with the practice of child marriage among Roma girls in Serbia.

BACKGROUND: Relatively little research on the issue of child marriage has been conducted in European countries where the overall prevalence of child marriage is relatively low, but relatively high among marginalized ethnic sub-groups. The purpose of this study is to assess the risk factors associated with the practice of child marriage among females living in Roma settlements in Serbia and among the general population and to explore the inter-relationship between child marriage and school enrollment decisions. METHODS: The study is based on data from a nationally representative household survey in Serbia conducted in 2010 - and a separate survey of households living in Roma settlements in the same year. For each survey, we estimated a bivariate probit model of risk factors associated with being currently married and currently enrolled in school based on girls 15 to 17 years of age in the nationally representative and Roma settlements samples. RESULTS: The practice of child marriage among the Roma was found to be most common among girls who lived in poorer households, who had less education, and who lived in rural locations. The results of the bivariate probit analysis suggest that, among girls in the general population, decisions about child marriage school attendance are inter-dependent in that common unobserved factors were found to influence both decisions. However, among girls living in Roma settlements, there is only weak evidence of simultaneous decision making. CONCLUSION: The study finds evidence of the interdependence between marriage and school enrollment decisions among the general population and, to a lesser extent, among the Roma. Further research is needed on child marriage among the Roma and other marginalized sub-groups in Europe, and should be based on panel data, combined with qualitative data, to assess the role of community-level factors and the characteristics of households where girls grow up on child marriage and education decisions.

Inequalities in Complementary Feeding Programs in Randomized Intervention and Nonintervention Areas after Program Implementation in Bangladesh, Ethiopia, and Vietnam.

Background: Children in the 6-23-mo age group need to consume adequate energy and nutrients for healthy growth, brain development, cognition, and future productivity. Yet, large deficits remain. Complementary feeding practices can be improved on a large scale, but whether interventions reach and benefit disadvantaged mothers is not known. Objectives: To assess inequalities in complementary feeding practices and coverage following large-scale program implementation in 3 low- and middle-income countries. Methods: We re-analyzed evaluation data from randomized controlled studies conducted in Bangladesh, Ethiopia, and Vietnam and calculated socioeconomic inequality using Erreygers index for intervention and nonintervention areas. Intervention coverage indicators were developed in each country for interpersonal communication, community mobilization, agricultural extension, and media. We compared the direction and magnitude of inequalities in intervention and nonintervention areas. Results: At the endline, coverage, and practices related to complementary feeding were better in intervention areas, but coverage and practices favored the better-off and more educated mothers. In Bangladesh, only 5, and in Vietnam, only 1 out of 16 coverage variables measured favored disadvantaged mothers or were neutral; in Ethiopia, out of 18 coverage variables measured, 11 favored disadvantaged mothers or were neutral, and in all 3 countries, only 5-6 variables out of 16 that were measured favored disadvantaged mothers or were neutral. Conclusions: Inequalities exist both in how children in the 6-23-mo age group are fed and in programs aimed at improving complementary feeding practices. Programs favor the better-off and more educated mothers. We need to better understand context-specific program barriers and tailor targeted interventions to reach disadvantaged mothers.

The Association between Iron and Folic Acid Supplementation and Malaria Prophylaxis and Linear Growth among Children and Neonatal Mortality in Sub-Saharan Africa-A Pooled Analysis.

The majority of research on linear growth among children is confined to South Asia and focuses on iron and folic acid (IFA) supplementation during pregnancy, without considering malaria prophylaxis. Similarly, there is limited evidence on the association of antenatal IFA supplementation and malaria prophylaxis with neonatal mortality in sub-Saharan Africa (SSA). This study aims to address these gaps. A pooled analysis of demographic and health survey (DHS) data from 19 countries in SSA was conducted to study the association between IFA supplementation and malaria prophylaxis and linear growth and neonatal mortality. Multivariate logistic and linear regression models were used. Malaria prophylaxis was significantly associated with stunting, height-for-age Z scores (HAZ scores), and neonatal mortality, but IFA supplementation was not associated with these outcomes. When women's height and body mass index (BMI) were introduced in the model, a significant association between combined malaria prophylaxis and IFA supplementation was found with HAZ scores only. For severe stunting, no significant association was found with either in the two models. In conclusion, this study underscores the importance of antenatal malaria prophylaxis as a potential intervention for nutrition outcomes (linear growth) and neonatal mortality, as well as the importance of coordinating efforts between malaria and the health and nutrition sectors to improve these outcomes in the countries of SSA.

Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia.

BACKGROUND: One strategic approach available to policy makers to improve the availability of reproductive and child health care supplies and services as well as the sustainability of programs is to expand the role of the private sector in providing these services. However, critics of this approach argue that increased reliance on the private sector will not serve the needs of the poor, and could lead to increases in socio-economic disparities in the use of health care services. The purpose of this study is to investigate whether the expansion of the role of private providers in the provision of modern contraceptive supplies is associated with increased horizontal inequity in modern contraceptive use. METHODS: The study is based on multiple rounds of Demographic and Health Survey data from four selected countries (Nigeria, Uganda, Bangladesh, and Indonesia) in which there was an increase in the private sector supply of contraceptives. The methodology involves estimating concentration indices to assess the degree of inequality and inequity in contraceptive use by wealth groups across time. In order to measure inequity in the use of modern contraceptives, the study uses multivariate methods to control for differences in the need for family planning services in relation to household wealth. RESULTS: The results suggest that the expansion of the private commercial sector supply of contraceptives in the four study countries did not lead to increased inequity in the use of modern contraceptives. In Nigeria and Uganda, inequity actually decreased over time; while in Bangladesh and Indonesia, inequity fluctuated. CONCLUSIONS: The study results do not offer support to the hypothesis that the increased role of the private commercial sector in the supply of contraceptive supplies led to increased inequity in modern contraceptive use.

Predicting Maternal Health Care Use by Age at Marriage in Multiple Countries.

PURPOSE: In light of the global pervasiveness of child marriage and given that improving maternal health care use is an effective strategy in reducing maternal and child morbidity and mortality, the available empirical evidence on the association of child marriage with maternal health care utilization seems woefully inadequate. Furthermore, existing studies have not considered the interaction of type of place of residence and parity with child marriage, which can give added insight to program managers. METHODS: Demographic Health Survey data for seven countries are used to estimate logistic regression models including interactions of age at marriage with area of residence and birth order. Adjusted predicted probabilities at representative values and marginal effects are computed for each outcome. RESULTS: The results show a negative association between child marriage and maternal health care use in most study countries, and this association is more negative in rural areas and with higher orders of parity. However, the association between age at marriage and maternal health care use is not straightforward but depends on parity and area of residence and varies across countries. The marginal effects in use of delivery care services between women married at age 14 years or younger and those married at age 18 years or older are more than 10% and highly significant in Bangladesh, Burkina Faso, and Nepal. CONCLUSIONS: The study's findings call for the formulation of country-and age at marriage-specific recommendations to improve maternal and child health outcomes.

Expansion in the private sector provision of institutional delivery services and horizontal equity: evidence from Nepal and Bangladesh.

Wealth-related inequity in the use of maternal healthcare services continues to be a substantial problem in most low- and middle-income countries. One strategic approach to increase the use of appropriate maternal healthcare services is to encourage the expansion of the role of the private sector. However, critics of such an approach argue that increasing the role of the private sector will lead to increased inequity in the use of maternal healthcare services. This article explores this issue in two South Asian countries that have traditionally had high rates of maternal mortality-Nepal and Bangladesh. The study is based on multiple rounds of nationally representative household survey data collected in Nepal and Bangladesh from 1996 to 2011. The methodology involves estimating a concentration index for each survey to assess changes in wealth-related inequity in the use of institutional delivery assistance over time. The results of the study suggest that the expansion of private sector supply of institutional-based delivery services in Nepal and Bangladesh has not led to increased horizontal inequity. In fact, in both countries, inequity was shown to have decreased over the study period. The study findings also suggest that the provision of government delivery services to the poor protects against increased wealth-related inequity in service use.

Association between child marriage and reproductive health outcomes and service utilization: a multi-country study from South Asia.

PURPOSE: Despite the pervasiveness of child marriage and its potentially adverse consequences on reproductive health outcomes, there is relatively little empirical evidence available on this issue, which has hindered efforts to improve the targeting of adolescent health programs. The purpose of this study was to assess the association of child marriage with fertility, fertility control, and maternal health care use outcomes in four South Asian countries: India, Bangladesh, Nepal, and Pakistan. METHODS: Data for the study come from the most recent Demographic and Health Surveys conducted in the study countries; we used a subsample of women aged 20-24 years. Child marriage, defined as first marriage before 18 years of age, is categorized into two groups: first married at ages 15-17 years and first married at age ≤14 years. We used multivariate logistic regression models. RESULTS: The results of the study suggest that child marriage is significantly associated with a history of rapid repeat childbirth, current modern contraceptive use, female sterilization, not using contraception before first childbirth, pregnancy termination, unintended pregnancy, and inadequate use of maternal health services, although the associations are not always consistent across countries. Furthermore, women who married in early adolescence or childhood show a higher propensity toward most of the negative outcomes, compared with women who married in middle adolescence. CONCLUSIONS: Child marriage adds a layer of vulnerability to women that leads to poor fertility control and fertility-related outcomes, and low maternal health care use.

Association between tendency towards depression and severity of rheumatoid arthritis from a national representative sample: the Medical Expenditure Panel Survey.

OBJECTIVES: The association between RA and depression has been well documented but so far there is not much research at a national level and none using a quick classification system of RA. The purpose of this study is to further determine if this association varies by differing severity in functional status of RA patients. METHODS: This study involved a retrospective pooled cross-sectional analysis of the Household Component of Medical Expenditure Panel Survey (MEPS) for the years 2004-2006. Each year's medical conditions file was merged with the person-level consolidated file. A total of 289 individuals comprised the final adult sample of RA and related diseases. RA cases were classified into four classes of functional status according to the ACR classification criteria. Tendency towards depression was ascertained by Patient Health Questionnaire (PHQ-2) scores with scores greater than or equal to three classified as high tendency towards depression. Multivariate logistic regression with survey weights was done using SAS 9.1. RESULTS: After controlling for other relevant factors, patients belonging to Class III RA were 5.92 times more likely and those belonging to Class II RA were 3.78 times more likely to have high tendency towards depression as compared to Class I RA patients. Older age groups (>or=68 years) and physical activity were other significant predictors but in a negative direction, whereas a co-morbidity index of two showed a significant positive association. CONCLUSION: The study provides important evidence that in a nationally representative sample of US non-institutionalized civilians, there is a strong association of depression to RA and related diseases by functional severity. However, the findings should be interpreted with caution because the data does not offer any information on duration in relation to PHQ-2 scores, thus making it hard to deduce if tendency towards depression was present before the diagnosis of RA. Furthermore, disease-specific and data-specific validation of the Charlson comorbidity index has not been done which leaves the possibility of residual confounding.