Comparing barriers and enablers of women's health leadership in India with East Africa and North America.

Background: Women are estimated to hold between 70 and 75% of global health positions worldwide yet persistent inequities in power and leadership remain. There is little information on specific enablers and barriers that women working in public health face in India and how those compare with other regions. Methods: We collected and analyzed information from women working in public health in India and East Africa (Kenya, Rwanda, and Uganda) and in global health (Canada and United States), to understand and document the specific enablers and barriers women face in India, compared with other regions. Findings: Several universal themes emerged around factors enabling (mentors, professional networks, leadership based in empathy and team building) or impeding (obvert bias and family responsibilities) women across all contexts. Within this, there are nuances in how women's leadership growth factors and obstacles play out in India differently than in other contexts. Interpretation: There are important similarities in the enablers and barriers faced by women in India and other geographies and important ways these differs in for women in India. By designing programs and policies at institutional levels to address these factors, we can create a professional ecosystem that works for women in health and beyond. Funding: This research was funded by WomenLift Health, which is funded by the Bill and Melinda Gates Foundation. Representatives from WomenLift Health, listed as authors, participated in the conceptualization of the research to define objectives and core questions, provided commentary and revision to improve the manuscript, and supervised the progress of the research.

Husband's preference for a son and women's nutrition: examining the role of actual and desired family composition on women's anaemia and body mass index in India.

This study examines the relationship between the husband's preference for a son, sex composition of children and risk of anaemia and underweight among married Indian women. Information was collected regarding 29,517 couples having at least one child in the nationally representative 2005-06 National Family Health Survey of India. The exposures were husband's preference for a son and sex composition of children: sons only, daughters only and mixed. Outcome included maternal underweight and moderate/severe anaemia. Husband's preference for a son was not found to be associated with his wife's risk of anaemia or underweight. Sex composition of the children was modestly associated with increased odds of anaemia among women from households with daughters only as compared with those with sons only [AOR: 1.19; 95% CI 1.04, 1.35]. The findings from this population-based study of socio-cultural norms around preference for a son and married Indian women's nutritional status do not support the hypothesis that husband's preference for sons influences the nutritional status of their wives. However, having daughters only is associated with maternal anaemia for reasons that remain to be established.

Son preference and intimate partner violence victimization in India: examining the role of actual and desired family composition.

Son preference has been considered as a determinant of women's risk of intimate partner violence (IPV) experience in India, although quantitative evidence from large nationally representative studies testing this relationship is limited. This study examines the association between husband's son preference, sex composition of children and risk of physical and sexual IPV victimization among wives. Information was collected for 26,284 couples in the nationally representative 2005-2006 National Family Health Survey of India. The exposures were husband's son preference measured as husband's desire for one or more sons greater than the number of daughters and sex composition of the household: only sons, only daughters and mixed. Outcome included past year physical and/or sexual IPV. The results showed that husband's reported son preference (RR: 1.05; 95% CI: 0.98-1.13) and sex composition of children were not associated with risk for IPV victimization in the models adjusted for socio-demographic factors. The findings from this first population-based study of socio-cultural norms around son preference and married Indian women's risk for IPV victimization indicate that cultural preference for sons does not influence women's risk for IPV victimization.

Association between maternal intimate partner violence victimization and childhood immunization in India.

Empirical evidence regarding the relationship between use of child health services and maternal intimate partner violence (IPV) exposure is sparse. The present study examined the relationship between maternal IPV and childhood immunization status in India using the nationally representative NFHS-3 (n = 6947). Exposure was past year IPV and the outcome was full immunization. IPV victimization was associated with decreased likelihood of being fully immunized after controlling for a range of socio-demographic variables. We also found that differences in measurement of the immunization status (self-report vs. health card) had different implications for the observed association; women reporting IPV and not having the vaccination card were most vulnerable to lack of immunization of their children. Findings suggest the need for increased programmatic efforts to prevent both the prevalence of IPV as well as the multiple MCH consequences of such violence.

Violence in contract work among female sex workers in Andhra Pradesh, India.

BACKGROUND: Female sex workers (FSWs) are vulnerable to physical and sexual violence at work. This article examines the prevalence of recent physical and sexual violence victimization and associations of type of sex work among a large sample of young FSWs. METHOD: We used data from a cross-sectional survey on sex trafficking and sex work in southern India that included 1138 FSWs aged 18-25 years residing in 3 districts of Andhra Pradesh state. The independent variable was organization of sex work. FSWs on contract at sex work establishments outside their home district were classified as contract workers, as compared with women who worked autonomously within their home district. Using logistic regression models adjusted for sociodemographic factors, we assessed the relation between contract/ non-contract sex work and various forms of violence experienced by FSWs. RESULTS: Results indicate a high prevalence of work-related physical and sexual violence; 50% FSWs reported physical violence, and 77% reported sexual violence. FSWs performing contract work were at increased risk of physical and sexual violence at work, compared with women engaged in sex work in their home districts. CONCLUSIONS: The findings that contract work outside the home district increases the vulnerabilities faced by FSWs in India suggest that violence and disease prevention services aimed at FSWs would be more effective if organization of sex work--as contract or noncontract--is taken into account.

Abuse from in-laws during pregnancy and post-partum: qualitative and quantitative findings from low-income mothers of infants in Mumbai, India.

To examine experiences of perinatal (in pregnancy or post-partum) abuse from in-laws and to assess associations between such experiences and perinatal intimate partner violence (IPV) from husbands, as reported by Indian women residing in low-income communities in Mumbai. The present study includes both qualitative and quantitative research conducted across two phases of study. The qualitative phase involved face-to-face, semi-structured in-depth interviews (n = 32) with women seeking health care for their infants (6 months or younger) and self-reporting emotional or physical abuse from their husband. The quantitative arm involved survey data collection (n = 1,038) from mothers seeking immunization for their infants 6 months or younger at three large Urban Health Centers in Mumbai. Results of the qualitative study documented the occurrence of both non-physical and physical abuse from in-laws during pregnancy and post-partum. Non-physical forms of abuse included forced heavy domestic labor, food denial and efforts toward prevention of medical care acquisition. Quantitative results demonstrated that 26.3% of the sample reported perinatal abuse (non-physical and physical) from in-laws and that women experiencing perinatal sexual or physical IPV from husbands were significantly more likely to report perinatal abuse from in-laws (AOR = 5.33, 95% CI = 3.93-7.23). Perinatal abuse from in-laws is not uncommon among women in India and may be compromising maternal and child health in this context; such abuse is also linked to perinatal violence from husbands. Programs and interventions that screen and address IPV in pregnant and post-partum populations in India should be developed to include consideration of in-laws.

Women's autonomy and experience of physical violence within marriage in rural India: evidence from a prospective study.

Evidence regarding the relationship between married women's autonomy and risk of marital violence remains mixed. Moreover, studies examining the contribution of specific aspects of women's autonomy in influencing the risk of marital violence using measures of autonomy that incorporate its dynamic nature are rare. We investigated the relationship between women's autonomy and their experience of marital violence in rural India using prospective data. We used data on 4,904 rural women drawn from two linked studies: the NFHS-2, conducted during 1998-1999 and a follow-up study for a subgroup of women carried out during 2002-2003. Three dimensions of autonomy were used: financial autonomy, freedom of movement, and household decision-making. Marital violence was measured as experience of physical violence in the year prior to the follow-up survey. Findings indicate the protective effects of financial autonomy and freedom of movement in reducing the risk of marital violence in the overall model. Furthermore, region-wise analysis revealed that in the more gender equitable settings of south India, financial autonomy exerted a protective influence on risk of marital violence. However, in the more gender-stratified settings of north India, none of the dimensions of autonomy were found to have any protective effect on women's risk of marital violence. Results argue for an increased focus on strategies aimed at improving women's financial status through livelihood skill-building opportunities, development of a strong savings orientation, and asset-building options.

Sex trafficking, physical and sexual violence, and HIV risk among young female sex workers in Andhra Pradesh, India.

OBJECTIVE: To estimate the prevalence of sex trafficking as a mode of entry into sex work and to examine associations between sex trafficking and HIV vulnerability, recent violence experience, and symptoms of sexual ill health among young female sex workers (FSWs). METHODS: A cross-sectional survey of 1137 FSWS aged 18-25 years residing in Andhra Pradesh, India, was conducted. RESULTS: In total, 574 (50.5%) FSWs entered sex work via trafficking. Trafficked FSWs had an increased risk of experiencing sexual violence (adjusted odds ratio [AOR] 2.09; 95% confidence interval [CI], 1.42-3.06) and physical/sexual violence (AOR 1.93; 95% CI, 1.24-3.01), and reporting more clients (AOR 2.25; 95% CI, 1.56-3.22) and more work days per week (AOR 1.48; 95% CI, 1.09-2.02). Symptoms of sexual ill health were not associated with mode of entry into sex work. CONCLUSION: There is a high prevalence of entry into sex work via trafficking among young FSWs. A history of sex trafficking is associated with greater risk of recent physical and sexual violence and of HIV. Public health interventions must focus attention on young FSWs.

Treatment-seeking for symptoms of reproductive tract infections among young women in India.

CONTEXT: Small proportions of Indian women report seeking treatment for symptoms suggestive of reproductive tract infections (RTIs). Most studies on treatment-seeking have focused broadly on women of reproductive age, and little is known about the experiences of adolescent girls and young women, particularly the unmarried. METHODS: Data from 2,742 married and 2,108 unmarried women aged 15-24 who reported at least one symptom of an RTI in the past three months were drawn from a subnationally representative survey of youth in India in 2006-2008. Multivariate logistic regression analysis was conducted to identify associations between respondents' characteristics and treatment-seeking from a formal medical provider. In addition, among those who had used such providers, associations between characteristics and use of private rather than public providers were identified. RESULTS: About two-fifths of married and one-third of unmarried women had sought treatment from formal medical providers for their RTI symptoms. While married women's experience of intimate partner violence was negatively associated with seeking treatment from a formal provider (odds ratio, 0.8), their perceived access to sexual and reproductive health services and their awareness of STI symptoms were positively associated with such treatment (1.3-1.4). Both married and unmarried women were more likely to seek treatment from private than from public providers, and two indicators of women's autonomy were positively correlated with using private providers (1.6-2.8). CONCLUSIONS: Limited treatment-seeking for RTI symptoms by young women underscores the need to address power imbalances within marriage and to encourage health care providers to develop appropriate strategies to reach younger, as well as unmarried, women.