Neutrophil to lymphocyte ratio in captive olive baboons (Papio anubis): The effects of age, sex, rearing, stress, and pregnancy.

In apes and humans, neutrophil to lymphocyte ratio (NLR) can be used as a predictive indicator of a variety of clinical conditions, longevity, and physiological stress. In chimpanzees specifically, NLR systematically varies with age, rearing, sex, and premature death, indicating that NLR may be a useful diagnostic tool in assessing primate health. To date, just one very recent study has investigated NLR in old world monkeys and found lower NLR in males and nursery-reared individuals, as well as a negative relationship between NLR and disease outcomes. Given that baboons are increasingly used as research models, we aimed to characterize NLR in baboons by providing descriptive data and examinations of baboon NLR heritability, and of the relationships between NLR, age, rearing, and sex in 387 olive baboons (Papio anubis) between 6 months and 19 years of age. We found that (1) mother-reared baboons had higher NLRs than nursery-reared baboons; (2) females had higher NLRs than males; and (3) there was a quadratic relationship between NLR and age, such that middle-aged individuals had the highest NLR values. We also examined NLR as a function of transport to a new facility using a subset of the data. Baboons exhibited significantly higher transport NLRs compared to routine exam NLRs. More specifically, adult baboons had higher transport NLRs than routine NLRs, whereas juveniles showed no such difference, suggesting that younger animals may experience transport stress differently than older animals. We also found that transport NLR was heritable, whereas routine NLR was not, possibly suggesting that stress responses (as indicated in NLR) have a strong genetic component. Consistent with research in humans and chimpanzees, these findings suggest that NLR varies with important biological and life history variables and that NLR may be a useful health biomarker in baboons.

Assessing safe and personalised maternity and neonatal care through a pandemic: a case study of outcomes and experiences in two trusts in England using the ASPIRE COVID-19 framework.

BACKGROUND: The COVID-19 pandemic has resulted in profound and far-reaching impacts on maternal and newborn care and outcomes. As part of the ASPIRE COVID-19 project, we describe processes and outcome measures relating to safe and personalised maternity care in England which we map against a pre-developed ASPIRE framework to establish the potential impact of the COVID-19 pandemic for two UK trusts. METHODS: We undertook a mixed-methods system-wide case study using quantitative routinely collected data and qualitative data from two Trusts and their service users from 2019 to 2021 (start and completion dates varied by available data). We mapped findings to our prior ASPIRE conceptual framework that explains pathways for the impact of COVID-19 on safe and personalised care. RESULTS: The ASPIRE framework enabled us to develop a comprehensive, systems-level understanding of the impact of the pandemic on service delivery, user experience and staff wellbeing, and place it within the context of pre-existing challenges. Maternity services experienced some impacts on core service coverage, though not on Trust level clinical health outcomes (with the possible exception of readmissions in one Trust). Both users and staff found some pandemic-driven changes challenging such as remote or reduced antenatal and community postnatal contacts, and restrictions on companionship. Other key changes included an increased need for mental health support, changes in the availability and uptake of home birth services and changes in induction procedures. Many emergency adaptations persisted at the end of data collection. Differences between the trusts indicate complex change pathways. Staff reported some removal of bureaucracy, which allowed greater flexibility. During the first wave of COVID-19 staffing numbers increased, resolving some pre-pandemic shortages: however, by October 2021 they declined markedly. Trying to maintain the quality and availability of services had marked negative consequences for personnel. Timely routine clinical and staffing data were not always available and personalised care and user and staff experiences were poorly captured. CONCLUSIONS: The COVID-19 crisis magnified pre-pandemic problems and in particular, poor staffing levels. Maintaining services took a significant toll on staff wellbeing. There is some evidence that these pressures are continuing. There was marked variation in Trust responses. Lack of accessible and timely data at Trust and national levels hampered rapid insights. The ASPIRE COVID-19 framework could be useful for modelling the impact of future crises on routine care.

An analysis of the global diversity of midwifery pre-service education pathways.

BACKGROUND: The development of competent professional midwives is a pre-requisite for improving access to skilled attendance at birth and reducing maternal and neonatal mortality. Despite an understanding of the skills and competencies needed to provide high- quality care to women during pregnancy, birth and the post-natal period, there is a marked lack of conformity and standardisation in the approach between countries to the pre-service education of midwives. This paper describes the diversity of pre-service education pathways, qualifications, duration of education programmes and public and private sector provision globally, both within and between country income groups. METHODS: We present data from 107 countries based on survey responses from an International Confederation of Midwives (ICM) member association survey conducted in 2020, which included questions on direct entry and post-nursing midwifery education programmes. FINDINGS: Our findings confirm that there is complexity in midwifery education in many countries, which is concentrated in low -and middle-income countries (LMICS). On average, LMICs have a greater number of education pathways and shorter duration of education programmes. They are less likely to attain the ICM-recommended minimum duration of 36 months for direct entry. Low- and lower-middle income countries also rely more heavily on the private sector for provision of midwifery education. CONCLUSION: More evidence is needed on the most effective midwifery education programmes in order to enable countries to focus resources where they can be best utilised. A greater understanding is needed of the impact of diversity of education programmes on health systems and the midwifery workforce.

The paradox of choice in the sexual and reproductive health and rights challenges of south-south migrant girls and women in Central America and Mexico: A scoping review of the literature.

The last decade has seen high levels of displacement in Central America and Mexico, with women and girls representing a growing share of this flow. Women and girls face a unique set of sexual and reproductive health risks, both as a direct result of the migration process, and as a consequence of violence, conflict and oppressive gender norms in the region. This scoping review adopts a five-stage process to search for, identify, and review selected literature to answer two questions: (1) what sexual and reproductive health and rights risks, challenges, and needs do women and girls face before and during displacement; and (2) how do issues of sexual and reproductive health and rights influence women and girls' coping mechanisms and decisions in displacement in the region? Extracted data from intersecting literature on migration, gender, and health in the corridors of migration in Central America and Mexico are mapped and analyzed against a framework adapted from the Guttmacher-Lancet Commission on components of sexual and reproductive health and rights. Many Central American and Mexican women and girls flee conditions of gang-related conflict, gender-based violence, poverty, and other situations of extreme disadvantage. Findings from this study demonstrate they face further deprivation and suffering from the denial of health and rights throughout the migratory cycle. This review finds that migrant women and girls encounter considerable barriers to accessing services of sexual and reproductive health, are vulnerable to sexually transmitted infections, and face many violations of sexual and reproductive rights. Young migrants and sex workers, who are often connected with irregular migration in border areas, appear to be particularly vulnerable. Findings also reveal that the literature tends to focus on sexual health and rights, with a relative paucity of evidence on wider reproductive health issues. Of critical importance is how women and girls must constantly balance risk and opportunity in situations of constrained choice, and how their coping strategies and decisions define and influence their migration trajectories and broader wellbeing. This review identifies a gap in the literature around comprehensive studies that define sexual and reproductive health and rights beyond the confines of disease and sexual behavior, as well as a need for greater focus on under-represented migrant groups such as adolescent girls.

Diverse pre-service midwifery education pathways in Cambodia and Malawi: A qualitative study utilising a midwifery education pathway conceptual framework.

OBJECTIVES: Educated and skilled midwives are required to improve maternal and newborn health and reduce stillbirths. There are three main approaches to the pre-service education of midwives: direct entry, post-nursing and integrated programmes combining nursing and midwifery. Within these, there can be multiple programmes of differing lengths and qualifications, with many countries offering numerous pathways. This study explores the history, rationale, benefits and disadvantages of multiple pre-service midwifery education in Malawi and Cambodia. The objectives are to investigate the differences in education, roles and deployment as well as how key informants perceive that the various pathways influence workforce, health care, and wider health systems outcomes in each country. DESIGN: Qualitative data were collected during semi-structured interviews and analysed using a pre-developed conceptual framework for understanding the development and outcomes of midwifery education programmes. The framework was created before data collection. SETTING: The setting is one Asian and one African country: Cambodia and Malawi. PARTICIPANTS: Twenty-one key informants with knowledge of maternal health care at the national level from different Government and non-governmental backgrounds. RESULTS: Approaches to midwifery education have historical origins. Different pathways have developed iteratively and are influenced by a need to fill vacancies, raise standards and professionalise midwifery. Cambodia has mostly focused on direct-entry midwifery while Malawi has a strong emphasis on dual-qualified nurse-midwives. Informants reported that associate midwifery cadres were often trained in a more limited set of competencies, but in reality were often required to carry out similar roles to professional midwives, often without supervision. While some respondents welcomed the flexibility offered by multiple cadres, a lack of coordination and harmonisation was reported in both countries. KEY CONCLUSIONS: The development of midwifery education in Cambodia and Malawi is complex and somewhat fragmented. While some midwifery cadres have been trained to fulfil a more limited role with fewer competencies, in practice they often have to perform a more comprehensive range of competencies. IMPLICATIONS FOR PRACTICE: Education of midwives in the full range of globally established competencies, and leadership and coordination between Ministries of Health, midwife educators and professional bodies are all needed to ensure midwives can have the greatest impact on maternal and newborn health and wellbeing.

Risks of mining to salmonid-bearing watersheds.

Mining provides resources for people but can pose risks to ecosystems that support cultural keystone species. Our synthesis reviews relevant aspects of mining operations, describes the ecology of salmonid-bearing watersheds in northwestern North America, and compiles the impacts of metal and coal extraction on salmonids and their habitat. We conservatively estimate that this region encompasses nearly 4000 past producing mines, with present-day operations ranging from small placer sites to massive open-pit projects that annually mine more than 118 million metric tons of earth. Despite impact assessments that are intended to evaluate risk and inform mitigation, mines continue to harm salmonid-bearing watersheds via pathways such as toxic contaminants, stream channel burial, and flow regime alteration. To better maintain watershed processes that benefit salmonids, we highlight key windows during the mining governance life cycle for science to guide policy by more accurately accounting for stressor complexity, cumulative effects, and future environmental change.

The Effects of Health Anxiety and Litigation Potential on Symptom Endorsement, Cognitive Performance, and Physiological Functioning in the Context of a Food and Drug Administration Drug Recall Announcement.

Drug recalls and lawsuits against pharmaceutical manufacturers are accompanied by announcements emphasizing harmful drug side-effects. Those with elevated health anxiety may be more reactive to such announcements. We evaluated whether health anxiety and financial incentives affect subjective symptom endorsement, and objective outcomes of cognitive and physiological functioning during a mock drug recall. Hundred and sixty-one participants reported use of over-the-counter pain medications and presented with a fictitious medication recall via a mock Food and Drug Administration (FDA) website. The opportunity to join a class-action lawsuit was manipulated. We assessed health anxiety, recalled drug usage, blood pressure, heart rate, and performance on a computerized Trail Making Test (TMT). Symptom endorsement was strongly predicted by health anxiety. When combined, three health anxiety measures explained 28.5% variance (Cohen's d = 1.26). These effects remain strong after controlling for depression and anxiety. Litigation condition did not predict symptom endorsement. Blood pressure and heart rate were modestly predicted by health anxiety, but not by litigation condition. TMT performance was consistently predicted by health anxiety, with higher scores associated with poorer performance. Although there were no main effects for litigation, interactions consistently emerged for the TMT, with generally poorer performance for those with higher health anxiety in the non-litigation condition; whereas health anxiety was unrelated to performance for the litigation condition. All but one participant joined the litigation when given the opportunity, despite a healthy sample and minimal use of pain medication. Subsequent data from 67 individuals with no mention of the FDA scenario or litigation showed that health anxiety still significantly predicts symptom endorsement (12.6% variance), but the explained variance is less than half that obtained in the FDA scenario. The findings suggest that health anxiety plays a significant role in adverse symptom reporting, beyond anxiety or depression, and this effect is independent of the presence of the FDA recall. The lack of differences for health anxiety and symptom endorsement between litigation and non-litigation conditions rules out malingering. Although it is general practice in drug recalls to list potential adverse side effects caused by medications, this may elicit unintended symptom experiences and health anxious individuals may be more susceptible.

Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators. METHODS: We analyzed national household surveys from 37 countries in SSA, conducted during 1990-2018, to examine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15-24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban-rural residence and educational status (primary or less versus secondary or higher education). RESULTS: In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000-2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10-14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban-rural and wealth-related inequalities remained stagnant or widened during 2000-2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories. CONCLUSION: Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress.

Trends in adolescent first births in sub-Saharan Africa: a tale of increasing inequity?

BACKGROUND: Single aggregate figures for adolescent pregnancy may fail to demonstrate particular population groups where rates are very high, or where progress has been slow. In addition, most indicators fail to separate younger from older adolescents. As there is some evidence that the disadvantages faced by adolescent mothers are greatest for those at the younger end of the spectrum, this is an important omission. This paper provides information on levels and trends of adolescent first births in 22 countries (at national and regional level) disaggregated by age (< 16 years, 16/17 years and 18/19 years), socio-economic status and place of residence. It highlights differences and similarities between countries in the characteristics of women who experience first birth during adolescence, as well as providing information on trends to identify groups where progress in reducing adolescent first births is poor. METHODOLOGY: In this descriptive and trend analysis study we used data from 22 low- and middle-income countries from sub-Saharan Africa that have at least three Demographic and Health Surveys (DHS) since 1990, with the most recent carried out after 2005. Adolescent first births from the most recent survey are analysed by age, wealth, and residence by country and region for women aged 20-24 years at time of survey. We also calculated annual percentage rates of change (using both short- and longer-term data) for adolescent first births disaggregated by age, family wealth and residence and examined changes in concentration indices (CI). FINDINGS: Overall percentages of adolescent first births vary considerably between countries for all disaggregated age groups. The burden of first birth among adolescents is significant, including in the youngest age group: in some countries over 20% of women gave birth before 16 years of age (e.g. Mali and Niger). Adolescent first births are more common among women who are poorer, and live in rural areas; early adolescent first births before 16 years of age are particularly concentrated in these disadvantaged groups. Progress in reducing adolescent first births has also been particularly poor amongst these vulnerable groups, leading to increasing inequity. CONCLUSIONS: Findings from this study show that adolescent births are concentrated among vulnerable groups where progress is often poorest. Strategies and programmes need to be developed to reduce adolescent pregnancies in marginalised young women in low- and middle-income countries.

Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban-rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban-rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

Using geospatial modelling to estimate the prevalence of adolescent first births in Nepal.

INTRODUCTION: Adolescent pregnancy is associated with significant risks and disadvantages for young women and girls and their children. A clear understanding of population subgroups with particularly high prevalence of first births in adolescence is vital if appropriate national responses are to be developed. This paper aims to provide detailed data on socioeconomic and geographic inequities in first births to adolescents in Nepal, including wealth quintile, education, rural/urban residence and geographic region. A key element is the use of geospatial modelling to develop estimates for the prevalence of adolescent births at the district level. METHODS: The study uses data from the 2011 Nepal Demographic and Health Survey. Initial cross-tabulations present disaggregated data by socioeconomic status and basic geographic region. Estimates of prevalence of adolescent first births at the district level are creating by regression modelling using the Integrated Nested Laplace Approximation package in R software. RESULTS: Our findings show that 40% of women had given birth before the age of 20 years, with 5% giving birth before 16 years. First births to adolescents remain common among poorer, less educated and rural women. Geographic disparities are striking, with estimates for the percentage of women giving birth before 20 years ranging from 35% to 53% by region. District level estimates showed even more marked differentials (26%-67% had given birth by 20 years), with marked heterogeneity even within regions. In some districts, estimates for the prevalence of first birth among the youngest age groups (<16 years) are high. CONCLUSION: Important geographic and socioeconomic inequities exist in adolescent first births. In some districts and within some subgroups, there remain high levels of adolescent first births, including births to very young adolescents. The use of Bayesian geospatial modelling techniques can be used by policymakers to target resources.

Using three indicators to understand the parity-specific contribution of adolescent childbearing to all births.

INTRODUCTION: A strong focus on sexual and reproductive health of female adolescents is a key to achieving sustainable development goals, due to the large size of the current cohort in low-income and middle-income countries (LMICs) and adolescents' biological and social vulnerability. Several indicators of fertility among adolescents are in wide use, but the contribution of adolescent births to all births is poorly understood. We propose and calculate a package of three indicators capturing the contribution of adolescent births to all births, stratified by parity (first and second/higher). METHODS: We used Demographic and Health Survey data for 30 LMICs and vital registration for two high-income countries (to calculate levels and trends across a range of countries) for three time periods: 1990-1999, 2000-2009 and 2010-2015. The three indicators were calculated overall and by age thresholds (<16, <18 and <20 years) and exact ages, for each country and time point. Patterns of changes in indicators for the three cumulative thresholds over time are described. RESULTS: In the 30 LMICs, the percentage of all live births occurring to adolescents varied across countries, with a median of 18% for adolescents <20 years. Three countries (Jordan, Indonesia and Rwanda) had levels below 10%; Bangladesh had the highest at 33%. The contribution of adolescent first-order births to all first-order births was high; a median of 49%. Even among second-order and higher-order births, the contribution of adolescent childbearing was appreciable (median of 6%). Over the period under examination, the proportion of adolescent births among all live births declined in the majority of the LMICs. CONCLUSION: These three indicators add to our understanding of the scale of adolescent childbearing and can be used in conjunction with population estimates to assess the absolute need for age-appropriate and parity-appropriate reproductive, maternal and newborn healthcare and to monitor progress in improving young people's health.

Trends in adolescent first births in five countries in Latin America and the Caribbean: disaggregated data from demographic and health surveys.

BACKGROUND: Adolescents in the Latin American and Caribbean region continue to experience poor reproductive health outcomes, including high rates of first birth before the age of 20 years. Aggregate national level data fails to identify groups where progress is particularly poor. This paper explores how trends in adolescent births have changed over time in five countries (Bolivia, Colombia, Dominican Republic, Haiti, and Peru) using data disaggregated by adolescent age group, wealth and urban / rural residence. METHODS: The study draws on Demographic and Health Survey data from five countries where three surveys are available since 1990, with the most recent after 2006. It examines trends in adolescent births by wealth status and urban/rural residence. RESULTS: There has been little progress in reducing adolescent first births over the last two decades in these countries. Adolescent first births continue to be more common among the poorest and rural residents, and births among the youngest age-group (< 16 years) are particularly concentrated among these populations. CONCLUSION: Adolescent first births continue to be a major issue in these five countries, including amongst the youngest group (< 16 years), although the contexts in which it is occurring are changing over time. Efforts are needed to expand sexual education and services for adolescents and young people, as well as introduce and enforce legislation to provide effective protection from abuse or exploitation. Greater disaggregation of adolescent fertility data is needed if we are to measure progress towards the attainment of the Sustainable Development Goals to "leave no-one behind".

The impact of young maternal age at birth on neonatal mortality: Evidence from 45 low and middle income countries.

OBJECTIVES: This study explores the impact of early motherhood on neonatal mortality, and how this differs between countries and regions. It assesses whether the risk of neonatal mortality is greater for younger adolescent mothers compared with mothers in later adolescence, and explores if differences reflect confounding socio-economic and health care utilisation factors. It also examines how the risks differ for first or subsequent pregnancies. METHODS: The analysis uses 64 Demographic and Health Surveys collected between 2005 and 2015 from 45 countries to explore the relationship between adolescent motherhood (disaggregated as <16 years, 16/17 years and 18/19 years) and neonatal mortality. Both unadjusted bivariate association and logistic regression are used. Regional level multivariate models that adjust for a range of socio-economic, demographic and health service utilisation variables are estimated. Further stratified models are created to examine the excess risk for first and subsequent births separately. FINDINGS: The risk of neonatal mortality in all regions was markedly greater for infants with mothers under 16 years old, although there was marked heterogeneity in patterns between regions. Adjusting for socio-economic, demographic and health service utilisation variables did not markedly change the odds ratios associated with age. The increased risks associated with adolescent motherhood are lowest for first births. CONCLUSION: Our findings particularly highlight the importance of reducing adolescent births among the youngest age group as a strategy for addressing the problem of neonatal mortality, as well ensuring pregnant adolescents have access to quality maternal health services to protect the health of both themselves and their infants. The regional differences in increased risk are a novel finding which requires more exploration.

Living in the city: school friendships, diversity and the middle classes.

Much of the literature on the urban middle classes describes processes of both affiliation (often to the localities) and disaffiliation (often from some of the non-middle-class residents). In this paper, we consider this situation from a different position, drawing on research exploring whether and how children and adults living in diverse localities develop friendships with those different to themselves in terms of social class and ethnicity. This paper focuses on the interviews with the ethnically diverse, but predominantly white British, middle-class parent participants, considering their attitudes towards social and cultural difference. We emphasize the importance of highlighting inequalities that arise from social class and its intersection with ethnicity in analyses of complex urban populations. The paper's contribution is, first, to examine processes of clustering amongst the white British middle-class parents, particularly in relation to social class. Second, we contrast this process, and its moments of reflection and unease, with the more deliberate and purposeful efforts of one middle-class, Bangladeshi-origin mother who engages in active labour to facilitate relationships across social and ethnic difference.

Understanding processes of risk and protection that shape the sexual and reproductive health of young women affected by conflict: the price of protection.

BACKGROUND: It is assumed that knowing what puts young women at risk of poor sexual health outcomes and, in turn, what protects them against these outcomes, will enable greater targeted protection as well as help in designing more effective programmes. Accordingly, efforts have been directed towards mapping risk and protective factors onto general ecological frameworks, but these currently do not take into account the context of modern armed conflict. A literature overview approach was used to identify SRH related risk and protective factors specifically for young women affected by modern armed conflict. PROCESSES OF RISK AND PROTECTION: A range of keywords were used to identify academic articles which explored the sexual and reproductive health needs of young women affected by modern armed conflict. Selected articles were read to identify risk and protective factors in relation to sexual and reproductive health. While no articles explicitly identified 'risk' or 'protective' factors, we were able to extrapolate these through a thorough engagement with the text. However, we found that it was difficult to identify factors as either 'risky' or 'protective', with many having the capacity to be both risky and protective (i.e. refugee camps or family). Therefore, using an ecological model, six environments that impact upon young women's lives in contexts of modern armed conflict are used to illustrate the dynamic and complex operation of risk and protection - highlighting processes of protection and the 'trade-offs' between risks. CONCLUSION: We conclude that there are no simple formulaic risk/protection patterns to be applied in every conflict and post-conflict context. Instead, there needs to be greater recognition of the 'processes' of protection, including the role of 'trade-offs' (what we term as 'protection at a price'), in order to further effective policy and practical responses to improve sexual and reproductive health outcomes during or following armed conflict. Focus on specific 'factors' (such as 'female headed household') takes attention away from the processes through which factors manifest themselves and which often determine whether the factor will later be considered 'risk inducing' or protective.