Associations between women's empowerment and child development, growth, and nurturing care practices in sub-Saharan Africa: A cross-sectional analysis of demographic and health survey data.

BACKGROUND: Approximately 40% of children 3 to 4 years of age in low- and middle-income countries have suboptimal development and growth. Women's empowerment may help provide inputs of nurturing care for early development and growth by building caregiver capacity and family support. We examined the associations between women's empowerment and child development, growth, early learning, and nutrition in sub-Saharan Africa (SSA). METHODS AND FINDINGS: We pooled data on married women (15 to 49 years) and their children (36 to 59 months) from Demographic and Health Surveys that collected data on child development (2011 to 2018) in 9 SSA countries (N = 21,434): Benin, Burundi, Cameroon, Chad, Congo, Rwanda, Senegal, Togo, and Uganda. We constructed a women's empowerment score using factor analysis and assigned women to country-specific quintile categories. The child outcomes included cognitive, socioemotional, literacy-numeracy, and physical development (Early Childhood Development Index), linear growth (height-for-age Z-score (HAZ) and stunting (HAZ <-2). Early learning outcomes were number of parental stimulation activities (range 0 to 6) and learning resources (range 0 to 4). The nutrition outcome was child dietary diversity score (DDS, range 0 to 7). We assessed the relationship between women's empowerment and child development, growth, early learning, and nutrition using multivariate generalized linear models. On average, households in our sample were large (8.5 ± 5.7 members) and primarily living in rural areas (71%). Women were 31 ± 6.6 years on average, 54% had no education, and 31% had completed primary education. Children were 47 ± 7 months old and 49% were female. About 23% of children had suboptimal cognitive development, 31% had suboptimal socioemotional development, and 90% had suboptimal literacy-numeracy development. Only 9% of children had suboptimal physical development, but 35% were stunted. Approximately 14% of mothers and 3% of fathers provided ≥4 stimulation activities. Relative to the lowest quintile category, children of women in the highest empowerment quintile category were less likely to have suboptimal cognitive development (relative risk (RR) 0.89; 95% confidence interval (CI) 0.80, 0.99), had higher HAZ (mean difference (MD) 0.09; 95% CI 0.02, 0.16), lower risk of stunting (RR 0.93; 95% CI 0.87, 1.00), higher DDS (MD 0.17; 95% CI 0.06, 0.29), had 0.07 (95% CI 0.01, 0.13) additional learning resources, and received 0.16 (95% CI 0.06, 0.25) additional stimulation activities from their mothers and 0.23 (95% CI 0.17 to 0.29) additional activities from their fathers. We found no evidence that women's empowerment was associated with socioemotional, literacy-numeracy, or physical development. Study limitations include the possibility of reverse causality and suboptimal assessments of the outcomes and exposure. CONCLUSIONS: Women's empowerment was positively associated with early child cognitive development, child growth, early learning, and nutrition outcomes in SSA. Efforts to improve child development and growth should consider women's empowerment as a potential strategy.

Maternal Medical Complexity: Impact on Prenatal Health Care Spending among Women at Low Risk for Cesarean Section.

BACKGROUND: Obstetric procedures are among the most expensive health care services, yet relatively little is known about health care spending among pregnant women, particularly the commercially-insured. OBJECTIVE: The objective of this study was to examine the association between maternal medical complexity, as a result of having one or more comorbid conditions, and health care spending during the prenatal period among a national sample of 95,663 commercially-insured women at low risk for cesarean delivery. METHODS: We conducted secondary analyses of 2010-2011 inpatient, outpatient, and professional claims for health care services from the Health Care Cost Institute. Allowed charges were summed for the prenatal and childbirth periods. Ordinary least squares regressions tested associations between maternal health conditions and health care expenditures during pregnancy. RESULTS: Thirty-four percent of pregnant women had one or more comorbidities; 8% had two or more. Pregnant women with one or more comorbidities had significantly higher allowed charges than those without comorbidities (p < .001). Spending during the prenatal period was nearly three times higher for women with preexisting diabetes compared with women with no comorbid conditions. Average levels of prenatal period spending associated with maternal comorbidities were similar for women who had vaginal and cesarean deliveries. Patient characteristics accounted for 30% of the variance in prenatal period expenditures. CONCLUSIONS: The impact of maternal comorbidities, and in particular preexisting diabetes, on prenatal care expenditures should be taken into account as provider payment reforms, such as pay-for performance incentives and bundled payments for episodes of care, extend to maternal and child health-related services.

Intimate Partner Victimization and Health Risk Behaviors Among Pregnant Adolescents.

OBJECTIVES: To provide lifetime estimates of intimate partner victimization among pregnant adolescents and examine associations between victimization and health risk behaviors identified by the Centers for Disease Control and Prevention as leading causes of adolescent morbidity and mortality. METHODS: Participants (n = 1233) were predominantly Latina (58%) and non-Latina Black (34%) pregnant adolescents (aged 14-21 years) enrolled in a randomized controlled trial of group prenatal care in 14 clinical sites in New York City (2008-2012). They completed surveys to assess interpersonal victimization and risk behaviors: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity. RESULTS: Fifty-two percent reported intimate partner victimization, which was associated with nearly all health risk behaviors. CONCLUSIONS: Pregnant adolescents who experienced intimate partner victimization were significantly more likely to engage in health risk behaviors, which can have adverse health consequences. Expanded prevention programs tailored to specific needs of pregnant adolescents are needed. Health care providers and others who work with pregnant adolescents should consistently screen for and intervene in intimate partner victimization.

Maternal Intimate Partner Violence: Relationships with Language and Neurological Development of Infants and Toddlers.

Objectives This longitudinal study examined the influence of Intimate Partner Violence (IPV) experience of pregnant women participating in the Domestic Violence Enhanced Home Visitation Program on the language and neurological development of infants and toddlers. Methods A total of 210 infants and toddlers born to women reporting low, moderate, and high levels of IPV were included in the analysis. Logistic regression analysis was used to determine the bivariate association between maternal IPV and risk of language and neurological delay of infants and toddlers and between covariates and language and neurological delay. Generalized estimating equation models with logit link was used to predict the risk of language and neurological delay of infants and toddlers as a result of maternal IPV. Results Infants and toddlers born to women exposed to moderate levels of IPV had increased odds of language delay compared to infants and toddlers of women who experienced low levels of violence (OR 5.31, 95 % CI 2.94, 9.50, p < 0.001). Infants and toddlers born to women who experienced moderate and high levels of IPV were at higher risk of neurological delay respectively, compared to infants and toddlers of women who experienced low levels of IPV (OR 5.42, 95 % CI 2.99, 9.82, p < 0.001 and OR 2.57, 95 % CI 1.11, 5.61, p = 0.026). Conclusions for Practice Maternal IPV is associated with increased risk of language and neurological delay of infants and toddlers. These findings have implications for health care for women and infants exposed to IPV. Clinicians including pediatricians working with pregnant women should screen for IPV throughout pregnancy to identify women and children at risk. Interventions to reduce maternal IPV and early intervention services for infants and toddlers exposed to IPV are necessary for optimal maternal and child health.

Trends in Health Facility Births in sub-Saharan Africa: An Analysis of Lessons Learned under the Millennium Development Goal Framework.

Sub-Saharan Africa (SSA) has the highest maternal and under-5 mortality rates as well as low facility births, with a high percentage of births occurring in the absence of skilled personnel. We examine trends in health facility births in SSA by geographic areas (urban-rural) and regions; and also the correlation between health facility birth and neonatal mortality rate (NMR). Data come from Demographic and Health Surveys (27 countries), conducted between 1990 and 2014. Median health facility births, urban-rural gaps, and regional variations in health facility births between initial (1990) and latest (2014) surveys were calculated. The median health facility birth increased from 44% at initial survey to 57% at the latest survey. Rural areas had a higher percentage increase in health facility births between initial and latest surveys (16%) than urban areas (6%) with a 2% overall gap reduction between initial and latest surveys. Health facility births were inversely associated with NMR at initial (R2=0.20, p=0.019) and latest (R2=0.26, p=0.007) surveys. To achieve the Sustainable Development Goal target of reducing neonatal mortality, policies should particularly focus on bringing rural areas on par with urban areas.

Engaging and retaining abused women in perinatal home visitation programs.

OBJECTIVES: Intimate partner violence (IPV) during pregnancy affects 0.9% to 17% of women and affects maternal health significantly. The impact of IPV extends to the health of children, including an increased risk of complications during pregnancy and the neonatal period, mental health problems, and cognitive delays. Despite substantial sequelae, there is limited research substantiating best practices for engaging and retaining high-risk families in perinatal home visiting (HV) programs, which have been shown to improve infant development and reduce maltreatment. METHODS: The Domestic Violence Enhanced Home Visitation Program (DOVE) is a multistate longitudinal study testing the effectiveness of a structured IPV intervention integrated into health department perinatal HV programs. The DOVE intervention, based on an empowerment model, combined 2 evidence-based interventions: a 10-minute brochure-based IPV intervention and nurse home visitation. RESULTS: Across all sites, 689 referrals were received from participating health departments. A total of 339 abused pregnant women were eligible for randomization; 42 women refused, and 239 women were randomly assigned (124 DOVE; 115 usual care), resulting in a 71% recruitment rate. Retention rates from baseline included 93% at delivery, 80% at 3 months, 76% at 6 months, and 72% at 12 months. CONCLUSIONS: Challenges for HV programs include identifying and retaining abused pregnant women in their programs. DOVE strategies for engaging and retaining abused pregnant women should be integrated into HV programs' federal government mandates for the appropriate identification and intervention of women and children exposed to IPV.