Comparing Cohabiting Unions and Formal Marriages Among Adolescent Girls in Zambia: The Role of Premarital Fertility and Parental Support.

PURPOSE: In developing countries, approximately one in three girls marry before the age of 18; however, early marriage is not a homogenous experience. Cohabitation can be either a precursor or an alternative to marriage, yet studies and programs often conflate marriage types. The purpose of this study is to understand the underlying factors and stability of cohabiting and formal child marriage unions among adolescent girls. METHODS: This mixed-methods study draws on four rounds of quantitative data collected annually between 2013 and 2016 as part of a longitudinal study among girls 10-19 years old in Zambia. In-depth interviews were conducted in 2017 with 32 girls, divided by formal unions and informal unions, randomly selected from the quantitative sample. Multivariate logistic models were estimated to test key associations and Cox regression models used to estimate the hazard of separation/divorce by a certain age. RESULTS: Qualitative findings highlighted that informal unions did not typically have approval of the couples' parents and frequently ended in separation. As compared to formal unions, having both families' approval was associated with 69% lower odds of cohabiting (odds ratio = 0.31, p < .001), while forced entry into union due to pregnancy was associated with 61% greater odds of cohabiting (OR = 1.61, p < .05). Being in a cohabiting union was associated with a 43% greater hazard of union dissolution (hazard ratio = 1.43, p < .05). DISCUSSION: There are key differences between formal marriages and cohabitation among adolescent girls and young women that should be considered when addressing early marriage in research and programs.

Effects of sanitary pad distribution and reproductive health education on upper primary school attendance and reproductive health knowledge and attitudes in Kenya: a cluster randomized controlled trial.

BACKGROUND: Adolescent girls' risk of school dropout and reproductive health (RH) challenges may be exacerbated by girls' attitudes toward their bodies and inability to manage their menstruation. We assessed effects of sanitary pad distribution and RH education on girls in primary grade 7 in Kilifi, Kenya. METHODS: A cluster randomized controlled trial design was used. Eligible clusters were all non-boarding schools in three sub-counties in Kilifi County that had a minimum of 25 girls enrolled in primary grade 7. 140 primary schools, 35 per arm, were randomly assigned to one of four study arms: (1) control; (2) sanitary pad distribution; (3) RH education; or (4) both sanitary pad distribution and RH education. Outcomes were school attendance, school engagement, RH knowledge and attitudes, gender norms, and self-efficacy. For outcomes measured both at baseline and endline, difference-in-differences (DID) models were estimated and for outcomes without baseline data available, analysis of covariance models were used. RESULTS: The study enrolled 3489 randomly selected girls in primary grade 7, with a mean age of 14.4 (SD 1.5). Girls in arms 2 and 4 received on average 17.6 out of 20 packets of sanitary pads and girls in arms 3 and 4 participated on average in 21 out of 25 RH sessions. Ninety-four percent of the baseline sample was interviewed at the end of the intervention with no differential attrition by arm. There was no evidence of an effect on primary school attendance on arm 2 (coefficient [coef] 0.37, 95% CI - 0.73, 1.46), arm 3 (coef 0.14, 95% CI - 0.99, 1.26) or arm 4 (coef 0.58, 95% CI - .37, 1.52). There was increased positive RH attitudes for girls in arm 3 (DID coef. 0.63, 95% CI 0.40-0.86) and arm 4 (DID coef. 0.85, 95% CI 0.64, - 1.07). There was also an increase in RH knowledge, gender norms and self-efficacy in arms 3 and 4. CONCLUSIONS: The findings suggest that neither sanitary pad distribution nor RH education, on their own or together, were sufficient to improve primary school attendance. However, as the RH education intervention improved RH outcomes, the evidence suggests that sanitary pad distribution and RH education can be positioned in broader RH programming for girls. TRIAL REGISTRATION: ISRCTN, ISRCTN10894523. Registered 22 August 2017-Retrospectively registered, http://www.isrctn.com/ISRCTN10894523.

Adolescent girls face a range of challenges that may compromise their chances of completing school or their sexual and reproductive health. These challenges can be even further complicated by girls' feelings of shame about their bodies, in particular about menstruation, or their lack of sanitary products to help them manage menstruation. This study sought out to assess if providing girls in grade 7 in a rural, coastal area of Kenya with sanitary pads and sex education would alleviate some of those challenges. One hundred and forty schools were included in the study and 35 each were randomly assigned to one of the following program packages: (1) standard government provision of pads and health education; (2) regular monthly provision of sanitary pads; (3) sex education; or (4) both regular monthly provision of sanitary pads and sex education. The study found that none of the three program packages had an impact on school attendance, however those that participated in the sex education felt more positively about menstruation, knew more about sexual and reproductive health, had more equitable gender norms and were more self-confident at the end of the program. The study results show that addressing girls' menstrual health challenges are important, but are better positioned as part of comprehensive sexuality education programs addressing stigma and shame associated with menstruation, access to menstrual products, inequitable gender norms and sexual and reproductive health knowledge gaps, as opposed to a girls education intervention.

Intra-grade variability in educational and psychosocial competencies of school going adolescent girls, in the coastal region of Kenya: implications for school based interventions.

BACKGROUND: The onset of puberty and menarche is a potentially vulnerable time for girls. Educational and psychosocial competencies are regarded as essential tools that empower them to successfully navigate the adolescent years. The aim of this study is to evaluate to what extent school going girls are equipped with these key competencies, and how they vary across a given grade cohort. METHODS: Data was collected in Kilifi County, Kenya, from 140 public primary schools from grade 7, across three sub-counties. Bivariate and multivariate analyses were carried out to compare competency outcomes by age groups comprising 10-14 years and 15 year and above. Generalized estimating equations with robust standard errors was used where outcomes were measured as binary outcomes, and linear regression for continuous outcomes. Clustering was factored in at the school level and stratification at the subcounty level. Wilcoxon Rank sum test incorporating clustering effects was used where continuous outcomes were not normally distributed. RESULTS: A total of 3489 adolescent girls were interviewed with a mean age of 14 years (SD:1.5; min:10, max:21). Compared to the lower age group, girls in the higher age group were less likely to have ambitions of furthering their education beyond secondary school (odds ratio (OR):0.63 (95%CI:0.53, 0.74)), more likely to report not feeling confident enough to answer questions in class (OR:1.18 (95%CI:1.02, 1.36) and scored lower on their cognitive, math and literacy tests. They also displayed less positive gender norms (coefficient (coeff):-0.091 (95%CI:-0.16, - 0.022)) and were more likely to agree with intimate-partner violence in marriage (coeff:1.17 (95%CI:1.00, 1.37)). They however scored higher on the decision-making scale (coeff:0.36 (95%CI:0.13, 0.60)) and were more likely to be able to spontaneously name a method of modern contraception (OR:1.56 (95%CI:1.36, 1.80)). CONCLUSION: Large variability in age exits within a grade. Compared to older girls, younger girls were more likely to perform better on their educational and social competencies. In countries with large age ranges per grade, identifying the presence of educational and psychosocial competency variabilities will allow informed decisions to be made on how school-based interventions should be adapted to address the varying needs within a grade. TRIAL REGISTRATION: ISRCTN10894523 , date of registration: 22/08/2017. Retrospectively registered.

Cluster randomized evaluation of the Nia Project: study protocol.

BACKGROUND: The onset of puberty and menarche is a specifically vulnerable time for girls, during which they begin to show interest in the opposite sex, while becoming exposed to a myriad of external pressures, including sexual coercion or harassment from boys and men, expectations to marry from their families, and the need to perform well in primary school in order to qualify for secondary school. According to several qualitative studies in Africa, such pressures are exacerbated by girls' lack of knowledge of their bodies, their rights, and the implications of their decisions, and by their inability to manage puberty and adolescence safely and comfortably with appropriate menstrual health and hygiene management (MHM) products. The evaluation of the Nia Project is one of the first to analyze the individual and combined contributions of sanitary pads and provision of comprehensive reproductive health education on girls' education and reproductive health outcomes. METHODS: The design for the evaluation of the Nia Project is a longitudinal, cluster-randomized controlled trial consisting of a baseline survey with a cohort of Class 7 girls, a school quality survey, qualitative data collection, school attendance tracking, and an endline survey at the completion of the 18-month intervention period with the same cohort. The study involves 140 public primary schools in three rural sub-counties (Magarini, Kaloleni and Ganze) of Kilifi County in the Coastal area of Kenya. The research sample includes 3489 girls, with about 25 girls per school on average. Before program implementation, the schools were stratified by sub-county and randomized to one of four study arms (35 schools per arm): 1) control, 2) disposable sanitary pads distribution, 2) reproductive health education, and 4) sanitary pad distribution and reproductive health education. DISCUSSION: The evidence provided will inform program investment and design, and contribute to the literature on the effect of menstrual health-based interventions on girls' agency, safety and life outcomes. TRIAL REGISTRATION: ISRCTN10894523 . Trial Registration Date: August 22, 2017.

Correction: Is Working Risky or Protective for Married Adolescent Girls in Urban Slums in Kenya? Understanding the Association between Working Status, Savings and Intimate-Partner Violence.

[This corrects the article DOI: 10.1371/journal.pone.0155988.].

Is Working Risky or Protective for Married Adolescent Girls in Urban Slums in Kenya? Understanding the Association between Working Status, Savings and Intimate-Partner Violence.

INTRODUCTION: Previous studies have shown that women's empowerment, though beneficial in many aspects, can also increase the risk of intimate-partner violence (IPV). This study seeks to examine the association between work and experience of physical violence among married adolescents, and to understand the impact of access to independent financial resources on this risk. Authors draw on the asset-building framework and the ecological model. METHODS: The data is from a baseline survey of girls aged 15-19 residing in urban slums in four cities and towns in Kenya (Nairobi, Thika, Nakuru and Kisumu). The analytic sample is 452 married girls. Logistic regression is used to examine associations between working status, savings and experience of IPV in the previous six months, controlling for other factors. This is complemented by content analysis of in-depth interviews with 32 adolescent girls and 16 young men. RESULTS: Compared to girls who did not work, working with no regular savings was significantly associated with greater odds (OR = 1.96, p<0.01) of experiencing IPV. There was no difference between girls who did not work and those who worked but had regular savings. Qualitative findings indicate savings decrease girls' dependency on men and allow them to leave abusive partners. DISCUSSION: Findings imply that in these communities with patriarchal gender norms and high levels of poverty, female employment and financial conflicts can be triggers of violence in marriages. On the other hand, girls' management of and access to independent financial resources through savings can potentially help to reduce this risk.

The Adolescent Girls Initiative-Kenya (AGI-K): study protocol.

BACKGROUND: Many adolescent girls in Kenya and elsewhere face considerable risks and vulnerabilities that affect their well-being and hinder a safe, healthy, and productive transition into early adulthood. Early adolescence provides a critical window of opportunity to intervene at a time when girls are experiencing many challenges, but before those challenges have resulted in deleterious outcomes that may be irreversible. The Adolescent Girls Initiative-Kenya (AGI-K) is built on these insights and designed to address these risks for young adolescent girls. The long-term goal of AGI-K is to delay childbearing for adolescent girls by improving their well-being. INTERVENTION: AGI-K comprises nested combinations of different single-sector interventions (violence prevention, education, health, and wealth creation). It will deliver interventions to over 6000 girls between the ages of 11 and 14 years in two marginalized areas of Kenya: 1) Kibera in Nairobi and 2) Wajir County in Northeastern Kenya. The program will use a combination of girl-, household- and community-level interventions. The violence prevention intervention will use community conversations and planning focused on enhancing the value of girls in the community. The educational intervention includes a cash transfer to the household conditioned on school enrollment and attendance. The health intervention is culturally relevant, age-appropriate sexual and reproductive health education delivered in a group setting once a week over the course of 2 years. Lastly, the wealth creation intervention provides savings and financial education, as well as start-up savings. METHODS/DESIGN: A randomized trial will be used to compare the impact of four different packages of interventions, in order to assess if and how intervening in early adolescence improves girls' lives after four years. The project will be evaluated using data from behavioural surveys conducted before the start of the program (baseline in 2015), at the end of the 2-year intervention (endline in 2017), and 2 years post-intervention (follow-up in 2019). Monitoring data will also be collected to track program attendance and participation. Primary analyses will be on an intent-to-treat basis. Qualitative research including semi-structured interviews of beneficiaries and key adult stakeholders in 2016 and 2018 will supplement and complement the quantitative survey results. In addition, the cost-effectiveness of the interventions will be assessed. DISCUSSION: AGI-K will provide critical evidence for policy-makers, donors and other stakeholders on the most effective ways to combine interventions for marginalized adolescent girls across sectors, and which packages of interventions are most cost-effective. TRIAL REGISTRATION: ISRCTN77455458 , December 24, 2015.

Evaluation of Berhane Hewan: a program to delay child marriage in rural Ethiopia.

CONTEXT: Early marriage limits girls' opportunities and compromises their health, yet in Sub-Saharan Africa many girls are married before the age of 18, and few programs have sought to increase the age at marriage on the continent. METHODS: Berhane Hewan was a two-year pilot project conducted in 2004-2006 that aimed to reduce the prevalence of child marriage in rural Ethiopia, through a combination of group formation, support for girls to remain in school and community awareness. A quasi-experimental research design with baseline and endline surveys was used to measure changes in social and educational participation, marriage age, reproductive health knowledge and contraceptive use. Chi-square tests, proportional hazards models and logistic regressions were conducted to assess changes associated with the project. RESULTS: The intervention was associated with considerable improvements in girls' school enrollment, age at marriage, reproductive health knowledge and contraceptive use. Particularly among girls aged 10-14, those exposed to the program were more likely than those in the control area to be in school at the endline survey (odds ratio, 3.0) and were less likely to have ever been married (0.1). However, among girls aged 15-19, those in the intervention area had an elevated likelihood of having gotten married by the endline (2.4). Sexually experienced girls exposed to the intervention had elevated odds at endline of having ever used contraceptives (2.9). CONCLUSIONS: The success of the Berhane Hewan program, one of the first rigorously evaluated interventions to delay marriage in Sub-Saharan Africa, suggests that well-designed and effectively implemented programs can delay the earliest marriages until later adolescence.

Prolonged second stage of labor and postpartum hemorrhage.

OBJECTIVE: To examine the relationship between prolonged second stage and postpartum hemorrhage (PPH). METHODS: We conducted a retrospective case-control study of all cases of PPH which occurred at four Southern California hospitals in 2003. Cases were identified by ICD-9 codes and confirmed by chart reviews, and non-cases were randomly selected as controls. The relationship between PPH and prolonged second-stage was examined using bivariate and multivariate analyses. RESULTS: The sample consisted of 91 cases and 323 controls. Cases were significantly more likely than controls to have had a prolonged second stage of labor, over a range of definitions for PPH and prolonged second stage. In multivariable analyses, prolonged second stage was associated with greater than three-fold (OR = 3.35; 95% CI 1.22-9.19) increased risk for PPH. CONCLUSION: Prolonged second stage is an important risk factor for PPH. Close supervision is warranted for women with a prolonged second stage.