Factors associated with female age at first marriage: An analysis using all waves of the Pakistan Demographic and Health Survey.

In conventional Muslim societies, fertility occurs within the marital union. Therefore, fertility outcomes depend on females' age at first marriage (AFM). The present study explores the pattern of AFM in Pakistan, analyses of which are scarce in the literature. We aim to identify the factors associated with the AFM among currently married women in Pakistan. Demographic factors like birth cohort, and socioeconomic and cultural factors such as province and place of residence, education level, whether or not a woman had ever worked before marriage, ethnicity, and husband's education were studied to explore the pattern of female AFM. Data were taken from the Pakistan Demographic and Health Surveys (PDHSs) of 2012-13 and 2017-18, and a comparison was made with the findings from the earlier PDHSs of 1990-91 and 2006-07. The analysis concentrates on women born between 1941 and 1992, aged between 25 and 49 years during the data collection periods. One-way analysis of variance (ANOVA) was used to assess the difference between the mean AFM for different sub-groups of the population. To identify the covariates that are associated with AFM multiple linear regression models were estimated. We observed a gradually increasing trend in female AFM over time among women born after 1950. The ANOVA results revealed that birth cohort, province, and place of residence, female education level, whether or not a woman had ever worked before marriage, ethnicity, and husband's education were significantly associated with AFM (p-values < 0.05). In a multiple regression model, we found that the birth cohort significantly affects the AFM (p-value < 0.05). Having worked before marriage is associated with a statistically significant one-year rise in the AFM. Interestingly, all other ethnic groups have lower AFM compared with women whose mother language was Punjabi. Education has a highly significant effect on the AFM: the regression results revealed that uneducated females have a mean AFM 4 to 5 years lower than highly educated women. The results also revealed that educated men marry older women as compared to uneducated men. We conclude that the education of females and even males in Pakistan could lead to a rise in the female AFM.

The prevalence of hepatitis C virus infection in ß-thalassemia patients in Pakistan: a systematic review and meta-analysis.

BACKGROUND: Hepatitis C virus infection is the most commonly reported bloodborne infection in Pakistan. Frequent blood transfusions in ß-thalassemia patients expose them to a high risk of HCV infection. The purpose of this paper is to summarise the current data on the prevalence of HCV infection in ß-thalassemia patients in Pakistan by using a systematic review and meta-analysis. METHODS: PubMed, EMBASE, Web of Sciences, the Cochrane Library, Directory of Open Access Journal and local databases were systematically searched for studies published between January 1st, 1995 and May 31st, 2019. Meta-analysis was performed using the DerSimonian and Laird random-effects models with inverse variance weighting. The presence of publication bias was tested by Egger test, and the methodological quality of each included article was evaluated by the STROBE. RESULTS: We identified a total of 229 potential studies, of which 27 studies were finally considered in the meta-analysis. The pooled prevalence of HCV in ß-thalassemia patients in Pakistan was 36.21% (95% CI: 28.98-43.75%) based on 5789 ß-thalassemia patients, but there was considerable heterogeneity. Meta-analysis estimated the HCV prevalence among the ß-thalassemia patients at 45.98% (95% CI: 38.15-53.90%) in Punjab, 31.81% (95% CI: 20.27-44.59%) in Sindh, and 28.04% (95% CI: 13.58-45.26%) in Khyber Pakhtunkhwa. Meta-regression analysis showed that geographical location was a key source of heterogeneity. CONCLUSIONS: The pooled prevalence of HCV in ß-thalassemia patients in Pakistan was more than one in three, and higher than in neighbouring countries. It varies regionally within the country. With the use of standard prevention procedures during blood transfusion, the risk of HCV transmission in ß-thalassemia patients could be controlled and the prevalence of HCV in ß-thalassemia patients reduced.

Social inequalities in low birthweight outcomes in Sri Lanka: evidence from the Demographic and Health Survey 2016.

OBJECTIVE: To investigate social inequalities underlying low birthweight (LBW) outcomes in Sri Lanka. DESIGN: Cross-sectional study. SETTING: This study used the Sri Lanka Demographic and Health Survey 2016, the first such survey to cover the entire country since the Civil War ended in 2001. PARTICIPANTS: Birthweight data extracted from the child health development records available for 7713 babies born between January 2011 and the date of interview in 2016. OUTCOME MEASURES: The main outcome variable was birth weight, classified as LBW (≤2500 g) and normal. METHODS: We applied random intercept three-level logistic regression to examine the association between LBW and maternal, socioeconomic and geographic variables. Concentration indices were estimated for different population subgroups. RESULTS: The population-level prevalence of LBW was 16.9% but was significantly higher in the estate sector (28.4%) compared with rural (16.6%) and urban (13.6%) areas. Negative concentration indices suggest a relatively higher concentration of LBW in poor households in rural areas and the estate sector. Results from fixed effects logistic regression models confirmed our hypothesis of significantly higher risk of LBW outcomes across poorer households and Indian Tamil communities (AOR 1.70, 95% CI 1.02 to 2.83, p<0.05). Results from random intercept models confirmed there was substantial unobserved variation in LBW outcomes at the mother level. The effect of maternal biological variables was larger than that of socioeconomic factors. CONCLUSION: LBW rates are significantly higher among babies born in poorer households and Indian Tamil communities. The findings highlight the need for nutrition interventions targeting pregnant women of Indian Tamil ethnicity and those living in economically deprived households.

Is recent Afghanistan survey data suitable for fertility analysis? A regional investigation based on fertility inhibiting determinants.

Afghanistan has been a country blighted by war over the past five decades and limited research is available on its demography. This study seeks to assess the suitability of recent survey data for Afghanistan (the 2010 Afghanistan Mortality Survey (AMS)and the 2015 Afghanistan Demographic and Health Survey (ADHS)) for estimating levels and trends in fertility. As several fertility measures rely on the quality of age data, we first apply demographic tools for the identification of age misreporting, finding evidence that it is severe. We then explore the consistency of fertility reporting across the two surveys, finding that the 2015 ADHS reports higher fertility among older women than the 2010 AMS although the seasonal pattern of fertility is consistent across the two surveys. We then estimate total fertility rates in 2008-2010 and 2012-2015 and measures of Bongaarts's key proximate determinants of fertility for Afghanistan and its provinces for urban and rural areas separately. The results show that fertility is similar in urban and rural Afghanistan. Although most of the provincial data on the proximate determinants is reasonably consistent with the fertility rates, there are anomalies in some provinces which indicate the possible under-reporting of births. Overall, we conclude that the fertility data in the two surveys can be used with care to give an indication of broad regional fertility patterns and trends in the country.

Effectiveness of the 'Back-to-Sleep' campaigns among healthcare professionals in the past 20†years: a systematic review.

OBJECTIVES: From the late 1980s 'Back-to-Sleep' (BTS) campaigns were run in most developed countries to increase awareness of the supine position's protective effect against sleep-related infant deaths. Once the media awareness-raising action associated with these campaigns ended, healthcare professionals' role became crucial. The goal of this paper is to determine if healthcare professionals' knowledge and parent advice consistent with evidence-based infant sleep recommendations have changed over the past 20 years. SETTING: All studies investigating healthcare professionals' knowledge and/or advice to parents were included in a systematic review. The search was performed in PubMed and in MEDLINE, and 21 studies were identified. RESULTS: The correctness of healthcare professionals' knowledge and parent advice about the supine sleeping position increased over the past 20 years. However, the percentage of those aware that parents should avoid putting their babies to sleep in a prone position is decreasing over time: from about 97% in the 1990s to about 90% at the end of the 2000s. CONCLUSIONS: The effectiveness of the BTS campaigns in publicising the benefits of the supine position is confirmed by this paper. More and more healthcare professionals know that it is the best position to reduce the risk of sleep-related deaths and they recommend it exclusively. However, the decrease in the knowledge about non-prone positions suggests that the campaigns may not have focused enough on the dangers of the prone position.

Childbearing and Economic Work: The Health Balance of Women in Accra, Ghana.

OBJECTIVES: This study aims to investigate (1) whether the health of working women with young children differs from that of working women without young children, and (2) which social factors mediate the relationship between economic and maternal role performance and health among mothers with young children. METHODS: The analyses uses panel data from 697 women present in both waves of the Women's Health Study for Accra (WHSA-I and WHSA-II); a community based study of women aged 18 years and older in the Accra Metropolitan Area of Ghana conducted in 2003 and 2008-2009. Change in physical and mental health between the survey waves is compared between women with a biological child alive at WHSA-II and born since WHSA-I and women without a living biological child at WHSA-II born in the interval. To account for attrition between the two survey waves selection models were used with unconditional change score models being used as the outcome model. RESULTS: We found in our sample of working women that those who had a child born between WHSA-I and WHSA-II who was still alive at WHSA-II did not experience a change in mental or physical health different from other women. Among working women with young children, educational status, relationship to the household head and household demography were associated with change in mental health at the 5 % level, whilst migration status and household demography was associated with change in physical health scores. CONCLUSION: The results suggest there are no health penalties of combining work and childbearing among women with young children in Accra, Ghana.

Why was Infant Mortality so High in Eastern England in the mid Nineteenth Century?

This paper re-examines the high rates of infant mortality observed in rural areas of eastern England in the early years of civil registration. Infant mortality rates in some rural registration districts in the East Riding of Yorkshire, Cambridgeshire and Norfolk were higher than those in the mill towns of Lancashire. After describing the areas affected, this paper considers three potential explanations: environmental factors, poor-quality child care associated with the employment of women in agriculture, and the possibility that the high rates were the artefactual consequence of migrant women workers bringing their children to these areas. These explanations are then assessed using a range of evidence. In the absence of reliable cause of death data, recourse is had to three alternative approaches. The first involves the use of the exceptionally detailed tabulations of ages at death within the first year of life provided in the Registrar General's Annual Reports for the 1840s to assess whether the 'excess' infant deaths in rural areas of eastern England happened in the immediate post-natal period or later in the first year of life. Second, data on the seasonality of mortality in the 1840s are examined to see whether the zone of 'excess' infant mortality manifested a distinctive seasonal pattern. Finally, a regression approach is employed involving the addition of covariates to regression models. The conclusion is that no single factor was responsible for the 'excess' infant mortality, but a plausible account can be constructed which blends elements of all three of the potential explanations mentioned above with the specific historical context of these areas of eastern England.

Jewish mortality reconsidered.

It is known that mortality of Jews is different from the mortality of the populations that surround them. However, the existence of commonalities in mortality of different Jewish communities across the world has not received scholarly attention. This paper aims to identify common features of the evolution of Jewish mortality among Jews living in Israel and the Diaspora. In the paper the mortality of Jews in Israel is systematically compared with the mortality of the populations of developed countries, and the findings from the earlier studies of mortality of Jews in selected Diaspora communities are re-examined. The outcome is a re-formulation and extension of the notion of the 'Jewish pattern of mortality'. The account of this pattern is based on the consistently low level of behaviourally induced mortality, the migration history of Jewish populations and the enduring influence of early-life conditions on mortality at older ages.

The 'cultural inflation of morbidity' during the English mortality decline: a new look.

This article contributes to the debate about using insurance records to reconstruct historical experiences of sickness during the Western mortality transition. Critics regard these sources as problematic as they measure morbidity indirectly through absences from work; these might be determined not by timeless biological criteria but by more contingent factors, notably shifting norms surrounding the sick role and responses to economic incentives (for which we adopt the generic term 'cultural inflation of morbidity'). We review historical demographers' contributions to this literature and discuss the concepts of moral hazard and the principal/agent problem as developed by health economists. This leads us to frame three empirical tests for 'cultural inflation' which allow us to assess the validity of insurance records for deriving morbidity trends: was there an increasing frequency of claims for complaints of diminishing severity; were unduly prolonged claims noticeable, particularly by older people for whom sickness benefit may have compensated for income insecurity; and did the insurer satisfactorily manage the agency problem to ensure reliable physician gatekeeping? We analyse records of the Hampshire Friendly Society, an exceptionally well-documented fund operational in Southern England, 1825-1989. Findings are based on a dataset of individual sickness histories of a sample of 5552 men and on qualitative documentary analysis of administrative records. On each count our results fail to demonstrate a cultural inflation of morbidity, except perhaps for those aged over 65. However, occasional discussion in the administrative records of economic incentives encouraging unnecessary prolongation of claims means we cannot rule it out entirely.

Estimating fertility rates using the ONS Longitudinal Study--what difference does the inclusion of non-continually resident members make?

Among datasets available for fertility research in England and Wales, the Office for National Statistics (ONS) Longitudinal Study (LS) is unique in its construction and scale. The large number of individuals who are part of the study means that it is an important dataset for estimating fertility trends in England and Wales by age and parity. This article uses the LS to estimate age-specific fertility rates (ASFRs) for England and Wales between 1991 and 2001. This necessitates great care to ensure that the exposure to risk of birth for female LS members is fully understood. To achieve this, two forms of residential history are defined - consistent cases where the residential information for the LS member is potentially complete for the whole decade and inconsistent cases where there is certainly some form of incompleteness in the residence information. By considering 'all consistent cases', that is both the continuously resident plus those who are not continuously resident but appear to have a complete residential history, we obtain ASFRs which are slightly lower than official statistics figures, but closer to these official figures than ASFRs produced when restricting the sample to LS members who remain continuously resident between 1991 and 2001. The fertility of those consistent cases who are not continuously resident is substantially higher than the rates of continuously resident cases.

Factors associated with contraceptive approval among religious leaders in Pakistan.

Research is needed to understand the role of religion in family planning dynamics, particularly in societies where the views of religious leaders can be an important influence on the reproductive decisions of individuals. This paper attempts to describe the factors associated with approval of contraception among religious leaders in Pakistan. The data are taken from the 1999-2000 Survey of Perception of Religious Leaders about Population Welfare. Regression modelling shows that whether or not religious leaders approve of family planning is associated with their views on the ideal family size, their level of religious education, the specific religious sect to which they belong, their own knowledge and use of family planning, their exposure to television and the region of the country in which they live.

Accessing genitourinary medicine clinics: does it matter where you live?

OBJECTIVES: To determine whether genitourinary medicine (GUM) clinics in England are located conveniently for potential users and to assess whether there are any regional variations in accessibility. METHODS: A surface model was created in ArcGIS to estimate driving times to the nearest GUM clinic and to identify the proportion of the population living more than 30 minutes drive from their nearest clinic. RESULTS: Overall, 3.0% of the population live further than 30 minutes from their nearest clinic. However, this average figure disguises considerable regional variation. While access in London and the South East was excellent, with less than 1% of the population living more than 30 minutes from the nearest clinic, in the South West and the East of England, these percentages rose to 7.7% and 9.2%, respectively. CONCLUSIONS: In some regions of England it is important to consider the physical barriers to clinic access, as inability or unwillingness to undertake a long journey to a GUM clinic may increase the workload in other clinical settings.

Death on a strange isle: the mortality of the stone workers of Purbeck in the nineteenth century.

This paper analyses the mortality of a group of rural workers in an extractive industry, the stone quarriers of the Isle of Purbeck in the southern English county of Dorset. The analysis uses a database created by nominal record linkage of the census enumerators' books and the Church of England baptism and burial registers to estimate age-specific death rates at all ages for males and females, and hence statistics such as the expectation of life at birth. The results are compared with mortality statistics published by the Registrar General of England and Wales (on the basis of the civil registers of deaths) for the registration district of Wareham, in which Purbeck is situated. The stone quarriers had heavier mortality levels than the rest of the population of Purbeck. Closer inspection, however, reveals that their high mortality was confined to males, and was almost entirely due to especially high mortality among boys aged less than five years. In contrast to the experience of coal and metal ore miners, adult male mortality among stone workers was no higher than that among the general population. The final section of the paper considers possible explanations for these results, and suggests that excess mortality among boys in Purbeck from lung diseases might have been responsible.

Identifying individuals engaging in risky sexual behaviour for chlamydia infection in the UK: a latent class approach.

Chlamydia trachomitis is the most common sexually transmitted infection in the UK and the number of cases diagnosed each year continues to rise. Although much is known about the risk factors for chlamydia from previous observational studies, less is known about how individuals put themselves at risk. Do they engage in just one risky type of behaviour or are certain individuals 'risky', engaging in multiple risky behaviours? This paper uses latent class analysis, applied to the National Survey of Sexual Attitudes and Lifestyles II (2000-2001), to determine whether a subgroup of high-risk individuals can be identified and explores which features of their behaviour distinguish them from other groups of lower risk individuals. A 3-class solution was obtained, splitting the sample on the basis of the number of sexual partners in the past year. Those with no sexual partners in the past year (8%) and one sexual partner in the past year (71%) were much less likely to have engaged in any of the other behaviours known to increase chlamydia risk. However, the group who had two or more sexual partners in the past year (21%) were much more likely to have also engaged in other risky behaviours. The number of partners in the past year is therefore a useful marker for identifying those at increased risk of chlamydia infection. Individuals under 25 years old, males and those who were single or previously married were more likely to be allocated to the risky group. However, in spite of observed higher incidence of chlamydia infection, individuals in the black ethnic minority groups did not show an increased prevalence of risky behaviour, after controlling for age, sex and marital status.

Sterilization and union instability in Brazil.

Brazilian women rely on sterilization as the main source of birth control. Sterilization has been one of the causes of the steep decline in fertility in Brazil, at least since the second half of 1970. It is hypothesized that understanding couples' relationships might be key to explaining this high rate of female sterilizations. Possible reasons for the higher level of fertility among women in unstable unions than among women in stable ones could be the less effective use of contraceptive methods, or that women in unstable unions tend to use less effective or reversible contraceptive methods. In this paper discrete time modelling of the timing of sterilization according to union histories is presented. The analysis uses the calendar data of the 1996 Brazilian DHS. It is shown that women in second or higher order unions have a lower risk of sterilization. This result should be taken into account in the analysis of the determinants of female sterilization in Brazil.

Diversity in family planning use among ethnic groups in Guatemala.

This study investigates the ethnic differentials in contraceptive use in the north-eastern Ch'orti area of Guatemala, a region dominated by the Ladino culture. Data come from a household survey and in-depth interviews with service providers carried out in 2001 in the town of Jocotán, and a survey carried out in 1994 in two nearby indigenous villages (aldeas). Descriptive analysis and logistic regression are used to explore the data. Previous DHS surveys have used dress and language to classify ethnic groups. In this paper, an alternative approach based on self-identification is adopted. The results reveal significant differences in contraceptive behaviour among different ethnic groups within the same town and region. The results show that self-identified Ladino women who represented the minority of the population had contraceptive behaviour similar to their counterparts elsewhere in Latin America. The extremely low levels of contraceptive use among indigenous women from the aldeas suggest that the corresponding DHS figures in this region are probably overestimated.

Perception of risk of HIV/AIDS and sexual behaviour in Kenya.

The association between perception of risk of HIV infection and sexual behaviour remains poorly understood, although perception of risk is considered to be the first stage towards behavioural change from risk-taking to safer behaviour. Using data from the 1998 Kenya Demographic and Health Survey, logistic regression models were fitted to examine the direction and the strength of the association between perceived risk of HIV/AIDS and risky sexual behaviour in the last 12 months before the survey. The findings indicate a strong positive association between perceived risk of HIV/AIDS and risky sexual behaviour for both women and men. Controlling for sociodemographic, sexual exposure and knowledge factors such as age, marital status, education, work status, residence, ethnicity, source of AIDS information, specific knowledge of AIDS, and condom use to avoid AIDS did not change the direction of the association, but altered its strength slightly. Young and unmarried women and men were more likely than older and married ones to report risky sexual behaviour. Ethnicity was significantly associated with risky sexual behaviour, suggesting a need to identify the contextual and social factors that influence behaviour among Kenyan people.

Gender, family, and the nutritional status of children in three culturally contrasting states of India.

This paper has three main aims: to measure the clustering of children with low weight for age z-scores within families, to establish whether significant differences exist by gender in weight for age z-scores, and to demonstrate whether the presence of a mother-in-law in the household has any significant impact on the nutritional status of young children. Regression modelling is used to examine the weight for age z-scores of children under the age of four years in Maharashtra, Tamil Nadu and Uttar Pradesh using the 1992-93 Indian National Family Health Survey data. Random effects models measure the clustering of children with low weight for age z-scores in families, controlling for a number of other family factors. Our findings do not reveal significant gender differences in weight for age z-scores. Although little variation was found between family structures in the nutritional status of children, there were significant differences between families after controlling for family type. This suggests that there are differences between families that cannot be explained by a cross-sectional demographic survey. The evidence from this work suggests that nutrition programs need to adopt community nutrition interventions that aim resources at young children from families where children with low weight for age z-scores are found to cluster. However, there is a need for further inter-disciplinary research to collect data from families on behavioural factors and resource allocation in order that we might better understand why some families are more prone to having children with low weight for age z-scores. The diversity in the significant covariates between the three states in the models has shown the need for Indian nutrition programs to adopt state-specific approaches to tackling malnutrition.