Breaking the silence about obstetric violence: Body mapping women's narratives of respect, disrespect and abuse during childbirth in Bihar, India.

BACKGROUND: Evidence on obstetric violence is reported globally. In India, research shows that almost every woman goes through some level of disrespect and abuse during childbirth, more so in states such as Bihar where over 70% of women give birth in hospitals. OBJECTIVE: 1) To understand how women experience and attach meaning to respect, disrespect and abuse during childbirth; and 2) document women's expectations of respectful care. METHODS: 'Body mapping', an arts-based participatory method, was applied. The analysis is based on in-depth interviews with eight women who participated in the body mapping exercise at their homes in urban slums and rural villages. Analysis was guided by feminist relational discourse analysis. FINDINGS: Women reported their experiences of birthing at home, public facilities, and private hospitals in simple terms of what they felt 'good' and 'bad'. Good experiences included being spoken to nicely, respecting privacy, companion of choice, a bed to rest, timely care, lesser interventions, obtaining consent for vaginal examination and cesarean section, and better communication. Bad experiences included unconsented interventions including multiple vaginal examinations by different care providers, unanesthetized episiotomy, repairs and uterine exploration, verbal, physical, sexual abuse, extortion, detention and lack of privacy. DISCUSSION: The body maps capturing birth experiences, created through a participatory method, accurately portray women's respectful and disrespectful births and are useful to understand women's experience of a sensitive issue in a patriarchal culture. An in-depth understanding of women's choices, experiences and expectations can inform changes practices in and policies and help to develop a culture of sharing birth experiences.

Climatic influence on the magnitude of COVID-19 outbreak: a stochastic model-based global analysis.

We investigate the climatic influence on COVID-19 transmission risks in 228 cities globally across three climatic zones. The results, based on the application of a Boosted Regression Tree algorithm method, show that average temperature and average relative humidity explain significant variations in COVID-19 transmission across temperate and subtropical regions, whereas in the tropical region, the average diurnal temperature range and temperature seasonality significantly predict the infection outbreak. The number of positive cases showed a decrease sharply above an average temperature of 10°C in the cities of France, Turkey, the US, the UK, and Germany. Among the tropical countries, COVID-19 in Indian cities is most affected by mean diurnal temperature, and those in Brazil by temperature seasonality. The findings have implications on public health interventions, and contribute to the ongoing scientific and policy discourse on the complex interplay of climatic factors determining the risks of COVID-19 transmission.

Why do some health care providers disrespect and abuse women during childbirth in India?

BACKGROUND: Disrespect and abuse during childbirth can result in fear of childbirth. Consequently, women may be discouraged to seek care, increasing the likelihood for women to choose elective cesarean section in order to avoid humiliation, postnatal depression and even maternal mortality. This study investigates the causes underlying mistreatment of women during childbirth by health care providers in India, where evidence of disrespect and abuse has been reported. METHODS: Qualitative research was undertaken involving 34 in-depth interviews with midwifery and nursing leaders from India who represent administration, advocacy, education, regulation, research and service provision at state and national levels. Data are analysed thematically with NVivo12. The analysis added value by bringing an international perspective from interviews with midwifery leaders from Switzerland and the United Kingdom. FINDINGS: The factors leading to disrespect and abuse of women relate to characteristics of both women and their midwives. Relevant woman-related attributes include her age, gender, physical appearance and education, extending to the social environment including her social status, family support, culture of abuse, myths around childbirth and sex-based discrimination. Midwife-related factors include gender, workload, medical hierarchy, bullying and powerlessness. DISCUSSION: The intersectionality of factors associated with mistreatment during childbirth operate at individual, infrastructural, social and policy levels for both the women and nurse-midwives, and these factors could exacerbate existing gender-based inequalities. Maternal health policies should address the complex interplay of these factors to ensure a positive birthing experience for women in India. CONCLUSION: Maternal health interventions could improve by integrating women-centred protocols and monitoring measures to ensure respectful and dignified care during childbirth.

Forecasting the SARS COVID-19 pandemic and critical care resources threshold in the Gulf Cooperation Council (GCC) countries: population analysis of aggregate data.

OBJECTIVE: To generate cross-national forecasts of COVID-19 trajectories and quantify the associated impact on essential critical care resources for disease management in Gulf Cooperation Council (GCC) countries. DESIGN: Population-level aggregate analysis. SETTING: Bahrain, Kuwait, Oman, Qatar, United Arab Emirates (UAE) and Saudi Arabia. METHODS: We applied an extended time-dependent SEICRD compartmental model to predict the flow of people between six states, susceptible-exposed-infected-critical-recovery-death, accounting for community mitigation strategies and the latent period between exposure and infected and contagious states. Then, we used the WHO Adaptt Surge Planning Tool to predict intensive care unit (ICU) and human resources capacity based on predicted daily active and cumulative infections from the SEICRD model. MAIN OUTCOME MEASURES: Predicted COVID-19 infections, deaths, and ICU and human resources capacity for disease management. RESULTS: COVID-19 infections vary daily from 498 per million in Bahrain to over 300 per million in UAE and Qatar, to 9 per million in Saudi Arabia. The cumulative number of deaths varies from 302 per million in Oman to 89 in Qatar. UAE attained its first peak as early as 21 April 2020, whereas Oman had its peak on 29 August 2020. In absolute terms, Saudi Arabia is predicted to have the highest COVID-19 mortality burden, followed by UAE and Oman. The predicted maximum number of COVID-19-infected patients in need of oxygen therapy during the peak of emergency admissions varies between 690 in Bahrain, 1440 in Oman and over 10 000 in Saudi Arabia. CONCLUSION: Although most GCC countries have managed to flatten the epidemiological curve by August 2020, trends since November 2020 show potential increase in new infections. The pandemic is predicted to recede by August 2021, provided the existing infection control measures continue effectively and consistently across all countries. Current health infrastructure including the provision of ICUs and nursing staff seem adequate, but health systems should keep ICUs ready to manage critically ill patients.

Challenges and needed reforms in midwifery and nursing regulatory systems in India: Implications for education and practice.

BACKGROUND: In India, nursing regulation is generally weak, midwifery coexists with nursing, and 88% of nursing and midwifery education is provided by the private health sector. The Indian health system faces major challenges for health care provision due to poor quality, indeterminate regulatory functions and lack of reforms. METHODS: We undertook a qualitative investigation to understand midwifery and nursing education, and regulatory systems in India, through a review of the regulatory Acts, and an investigation of the perceptions and experiences of senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision in India with an international perspective. RESULTS: There is a lack of importance accorded to midwifery roles within the nursing system. The councils and Acts do not adequately reflect midwifery practice, and remain a barrier to good quality care provision. The lack of required amendment of Acts, lack of representation of midwives and nurses in key governance positions in councils and committees have restrained and undermined leadership positions, which have also impaired the growth of the professions. A lack of opportunities for professional practice and unfair assessment practices are critical concerns affecting the quality of nursing and midwifery education in private institutions across India. Midwifery and nursing students are generally more vulnerable to discrimination and have less opportunities compared to medical students exacerbated by the gender-based challenges. CONCLUSIONS: India is on the verge of a major regulatory reform with the National Nursing and Midwifery Commission Bill, 2020 being drafted, which makes this study a crucial and timely contribution. Our findings present the challenges that need to be addressed with regulatory reforms to enable opportunities for direct-entry into the midwifery profession, improving nursing education and practice by empowering midwives and nurses with decision-making powers for nursing and midwifery workforce governance.

Disentangling the effects of reproductive behaviours and fertility preferences on child growth in India.

We analysed population data from the 2015-16 National Family Health Survey to disentangle the intricate underlying effects of reproductive behaviours and fertility preferences on child growth. We expected birth interval length to be more strongly associated with stunting than sibsize and these effects to be moderated by whether the child was wanted or unintended (mistimed/unwanted). Regression analyses showed strong and equal effects of short birth interval and sibsize on stunting, when adjusted for potential confounders and unobserved between-mother heterogeneity. There were no statistical associations between stunting and mistiming/unwantedness of index children, suggesting the absence of discrimination against such children. We conclude that while fertility preferences have no effect, reproductive behaviours exert significant influence on child growth. Sibsize has been falling for many years in India but birth interval lengths have remained largely unchanged. The results underscore the need for strengthening uptake of reversible contraceptives to enable longer birth intervals.

Recurrent child mortality risks and parity transition in Nigeria.

BACKGROUND: Fertility rates remain persistently high in Nigeria, with little difference across socioeconomic groups. While the desire for large family size is culturally rooted, there is little understanding of how repeated child mortality experiences influence fertility behaviour and parity transition in Nigeria. METHODS: Using birth history data from the 2013 Nigeria Demographic and Health Survey (NDHS), we applied life table techniques and proportional-hazard regression model to explore the effect of child survival experience on parity transitions. We hypothesize that a woman with one or more child death experience is at elevated risk of progressing towards higher parities. RESULTS: Our findings show that child mortality is concentrated among mothers living in deprived conditions especially in rural areas of the northern part of Nigeria and among those with little or no education and, among those belonging to Hausa/Fulani ethnicity and Islam religion. Mothers with repeated experience of child deaths were significantly at a higher rate of progressing to higher parities than their counterparts (HR: 1.45; 95% CI: 1.31-1.61), when adjusted for relevant biological and socio-demographic characteristics. CONCLUSION: Recurrent experience of child deaths exacerbates the risks to higher parity transition. Interventions aimed at reducing fertility in Nigeria should target promoting child survival and family planning concurrently.

Power relations and negotiations in contraceptive decision-making when husbands oppose family planning: analysis of ethnographic vignette couple data in Southwest Nigeria.

Contraceptive use in Nigeria has remained low at less than 15% for over two decades. Although husbands' opposition is acknowledged as one of the factors impeding women's contraceptive use, little is known about how wives negotiate when their husbands oppose family planning. We addressed this research gap by conducting thematic analyses of qualitative data from 30 interviews of married couples. We employed thematic analysis to identify relevant themes from the transcribed data. The findings clearly demonstrate attitudes highlighting an imbalance in power relations and contraceptive decision-making within marital relationships. By initially complying with the husband's wish as a 'sign of honour', and then making further attempts at convincing him about family planning use, a woman can achieve her contraceptive target, or through the involvement of a third party. Wives are less empowered to overtly use contraceptives when their husbands oppose family planning. However, there are accepted justifications for covert use. The findings underscore the need to strengthen family planning interventions to enable behavioural change among Nigerian men, promote gender and reproductive health rights, and empower women with better negotiation skills.

Socio-economic differentials in minimum dietary diversity among young children in South-East Asia: evidence from Demographic and Health Surveys.

OBJECTIVE: To investigate the socio-economic differentials underlying minimum dietary diversity (MDD) among children aged 6-23 months in three economically diverse South-East Asian countries. DESIGN: The outcome variable MDD was defined as the proportion of children aged 6-23 months who received foods from four of the seven recommended food groups within the 24 h prior to interview. The association between socio-economic factors and MDD, adjusting for relevant characteristics, was examined using logistic regression. SETTING: We used cross-sectional population data from recent Demographic and Health Surveys from Cambodia (2014), Myanmar (2015-16) and Indonesia (2012). SUBJECTS: Total of 8364 children aged 6-23 months. RESULTS: Approximately half of all children met the MDD, varying from 47·7 % in Cambodia (n 1023) to 58·2 % in Indonesia (n 2907) and 24·6 % in Myanmar (n 301). The likelihood (adjusted OR; 95 % CI) of meeting MDD increased for children in the richest households (Cambodia: 2·4; 1·7, 3·4; Myanmar: 1·8; 1·1, 3·0; Indonesia: 2·0; 1·6, 2·5) and those residing in urban areas (Cambodia: 1·4; 1·1, 1·9; Myanmar: 1·7; 1·2, 2·4; Indonesia: 1·7; 1·5, 1·9). MDD deprivation was most severe among children from the poorest households in rural areas. The association between mother's labour force participation and MDD was positive in all three countries but reached significance only in Indonesia (1·3; 1·1, 1·5). CONCLUSIONS: MDD deprivation among young children was significantly high in socio-economically disadvantaged families in all three study settings. MDD requirements are not being met for approximately half of young children in these three South-East Asian countries.

UNPACKING THE DIFFERENTIAL IMPACT OF FAMILY PLANNING POLICIES IN CHINA: ANALYSIS OF PARITY PROGRESSION RATIOS FROM RETROSPECTIVE BIRTH HISTORY DATA, 1971-2005.

Although China's family planning programme is often referred to in the singular, most notably the One-Child policy, in reality there have been a number of different policies in place simultaneously, targeted at different sub-populations characterized by region and socioeconomic conditions. This study attempted to systematically assess the differential impact of China's family planning programmes over the past 40 years. The contribution of Parity Progression Ratios to fertility change among different sub-populations exposed to various family planning policies over time was assessed. Cross-sectional birth history data from six consecutive rounds of nationally representative population and family planning surveys from the early 1970s until the mid-2000s were used, covering all geographical regions of China. Four sub-populations exposed to differential family planning regimes were identified. The analyses provide compelling evidence of the influential role of family planning policies in reducing higher Parity Progression Ratios across different sub-populations, particularly in urban China where fertility dropped to replacement level even before the implementation of the One-Child policy. The prevailing socioeconomic conditions in turn have been instrumental in adapting and accelerating family planning policy responses to reducing fertility levels across China.

Impact of men's perception on family planning demand and uptake in Nigeria.

OBJECTIVE: Evidence from the last three Demographic and Health Surveys (DHS) in Nigeria shows slow progress in family planning (FP) uptake, despite programmatic interventions. While socioeconomic and religious barriers continue to exist, psychosocial factors such as negative contraceptive perceptions by male partners may influence both spousal FP demand and use. Therefore, this research investigates the influence of male partners' contraceptive perceptions on spousal FP demand and use. METHODS: We analysed the couple dataset from the 2013 Nigeria DHS. RESULTS: One in five men held the perception that contraceptive use is women's business whereas two in five men reported that women who use family planning may become promiscuous, especially older men, those with no formal education, Muslims and residents in rural areas and northern region. Results from regression models, controlling for relevant sociodemographic characteristics, show that men's perception that contraception is women's business did not significantly influence FP demand. However, their fear that women who use family planning may become promiscuous was associated with lower odds of FP demand (AOR: 0.86; 95% CI: 0.76-0.97) and increased the odds of traditional methods use (AOR: 1.34; 95% CI: 1.01-1.79). CONCLUSION: The findings direct the need to adopt targeted approach focusing on couples, and reorient policy and program efforts for FP counselling and behavioural changes in men.

Disentangling age-gender interactions associated with risks of fatal and non-fatal road traffic injuries in the Sultanate of Oman.

OBJECTIVE: Road traffic injuries (RTIs) are the leading cause of disability-adjusted life years lost in Oman, Saudi Arabia and United Arab Emirates. Injury prevention strategies often overlook the interaction of individual and behavioural risk factors in assessing the severity of RTI outcomes. We conducted a systematic investigation of the underlying interactive effects of age and gender on the severity of fatal and non-fatal RTI outcomes in the Sultanate of Oman. METHODS: We used the Royal Oman Police national database of road traffic crashes for the period 2010-2014. Our study was based on 35 785 registered incidents: of these, 10.2% fatal injuries, 6.2% serious, 27.3% moderate, 37.3% mild injuries and 19% only vehicle damage but no human injuries. We applied a generalised ordered logit regression to estimate the effect of age and gender on RTI severity, controlling for risk behaviours, personal characteristics, vehicle, road, traffic, environment conditions and geographical location. RESULTS: The most dominant group at risk of all types of RTIs was young male drivers. The probability of severe incapacitating injuries was the highest for drivers aged 25-29 (26.6%) years, whereas the probability of fatal injuries was the highest for those aged 20-24 (26.9%) years. Analysis of three-way interactions of age, gender and causes of crash show that overspeeding was the primary cause of different types of RTIs. In particular, the probability of fatal injuries among male drivers attributed to overspeeding ranged from 3%-6% for those aged 35 years and above to 13.4% and 17.7% for those aged 25-29 years and 20-24 years, respectively. CONCLUSIONS: The high burden of severe and fatal RTIs in Oman was primarily attributed to overspeed driving behaviour of young male drivers in the 20-29 years age range. Our findings highlight the critical need for designing early gender-sensitive road safety interventions targeting young male and female drivers.

Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis.

BACKGROUND: Total domestic and international funding for malaria is inadequate to achieve WHO global targets in burden reduction by 2030. We describe the trends of investments in malaria-related research in sub-Saharan Africa and compare investment with national disease burden to identify areas of funding strength and potentially neglected populations. We also considered funding for malaria control. METHODS: Research funding data related to malaria for 1997-2013 were sourced from existing datasets, from 13 major public and philanthropic global health funders, and from funding databases. Investments (reported in US$) were considered by geographical area and compared with data on parasite prevalence and populations at risk in sub-Saharan Africa. 45 sub-Saharan African countries were ranked by amount of research funding received. FINDINGS: We found 333 research awards totalling US$814·4 million. Public health research covered $308·1 million (37·8%) and clinical trials covered $275·2 million (33·8%). Tanzania ($107·8 million [13·2%]), Uganda ($97·9 million [12·0%]), and Kenya ($92·9 million [11·4%]) received the highest sum of research investment and the most research awards. Malawi, Tanzania, and Uganda remained highly ranked after adjusting for national gross domestic product. Countries with a reasonably high malaria burden that received little research investment or funding for malaria control included Central African Republic (ranked 40th) and Sierra Leone (ranked 35th). Congo (Brazzaville) and Guinea had reasonably high malaria mortality, yet Congo (Brazzaville) ranked 38th and Guinea ranked 25th, thus receiving little investment. INTERPRETATION: Some countries receive reasonably large investments in malaria-related research (Tanzania, Kenya, Uganda), whereas others receive little or no investments (Sierra Leone, Central African Republic). Research investments are typically highest in countries where funding for malaria control is also high. Investment strategies should consider more equitable research and operational investments across countries to include currently neglected and susceptible populations. FUNDING: Royal Society of Tropical Medicine and Hygiene and Bill & Melinda Gates Foundation.

Interventions to improve immigrant health. A scoping review.

Background: : Disparities in health between immigrants and their host populations have been described across countries and continents. Hence, interventions for improving health targeting general populations are not necessarily effective for immigrants. To conduct a systematic search of the literature evaluating health interventions for immigrants; to map the characteristics of identified studies including range of interventions, immigrant populations and their host countries, clinical areas targeted and reported evaluations, challenges and limitations of the interventions identified. Following the results, to develop recommendations for research in the field. A scoping review approach was chosen to provide an overview of the type, extent and quantity of research available. Studies were included if they empirically evaluated health interventions targeting immigrants and/or their descendants, included a control group, and were published in English (PubMed and Embase from 1990 to 2015). Most of the 83 studies included were conducted in the USA, encompassed few immigrant groups and used a randomized controlled trial (RCT) or cluster RCT design. Most interventions addressed chronic and non-communicable diseases and attendance at cancer screening services, used individual targeted approaches, targeted adult women and recruited participants from health centres. Outcome measures were often subjective, with the exception of interventions for cardiovascular risk and diabetes. Generally, authors claimed that interventions were beneficial, despite a number of reported limitations. Recommendations for enhancing interventions to improve immigrant health are provided to help researchers, funders and health care commissioners when deciding upon the scope, nature and design of future research in this area.

Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?

OBJECTIVE: To investigate, the impact of maternity-related fee payment policies on the uptake of skilled birth care amongst the poor in Ghana. METHODS: Population data representing 12 288 births between November 1990 and October 2008 from four consecutive rounds of the Ghana demographic and health surveys were used to examine the impact of four major maternity-related payment policies: the full-cost recovery 'cash and carry' scheme; 'antenatal care fee exemption'; 'delivery care fee exemption' and the 'National Health Insurance Scheme (NHIS)'. Concentration curves were used to analyse the rich-poor gap in the use of skilled birth care by the four policy interventions. Multilevel logistic regression was used to examine the effect of the policies on the uptake of skilled birth care, adjusting for relevant predictors and clustering within communities and districts. FINDINGS: The uptake of skilled birth care over the policy periods for the poorest women was trivial when compared with their non-poor counterparts. The rich-poor gap in skilled birth care use was highly pronounced during the 'cash and carry' and 'free antenatal care' policies period. The benefits during the 'free delivery care' and ' NHIS' policy periods accrued more for the rich than the poor. There exist significant differences in skilled birth care use between and within communities and districts, even after adjusting for policy effects and other relevant predictors. CONCLUSIONS: The maternal care fee exemption policies specifically targeted towards the poorest women had limited impact on the uptake of skilled birth care.

A health promotion logic model to review progress in HIV prevention in China.

Using the theory and concepts of health promotion, this paper proposes a logic model for HIV/AIDS prevention and control which provides a structure for describing planned actions and predicted impacts/outcomes from comprehensive HIV prevention interventions. The potential usefulness of the model is examined by reviewing the evolution of HIV prevention and management in China, drawing on evidence from interventions reported from a mixture of study designs and formats. It reports that HIV interventions in China can be considered in two distinctive phases, before and after 2003 when China commenced its 'official' response to the HIV epidemic. The logic model was useful in comparing actions taken over these two periods highlighting the importance of political leadership in distinguishing between the two phases, and the continuing importance of systematic and broadly based public education and communication. We conclude that the logic model can not only be used as a planning model, but can also be applied retrospectively to assess successes and failures in national and local responses to HIV in complex social settings.

How important are community characteristics in influencing children׳s nutritional status? Evidence from Malawi population-based household and community surveys.

Using the 2004 data from the Malawi Integrated Household Survey and the Malawi Community Survey, this study investigates the influence of community characteristics on stunting among children under five years of age in a rural context. Multilevel logistic regression modelling on 4284 children with stunting as the dependent variable shows that availability of daily markets and lineage defined in terms of patrilineal or matrilineal communities were significant community determinants of childhood stunting in Malawi. There were significant differences in socio-economic status between household heads from matrilineal and patrilineal communities. Implementation of strategies that empower communities and households economically such as supporting the establishment of community daily markets and promoting household income generating opportunities can effectively reduce the burden of childhood stunting in Malawi.