Women's fertility and allostatic load in the post-reproductive years: An analysis of the Indonesian Family Life Survey.

We know little about the effects of the reproductive health burden in contexts where unsafe abortions, miscarriages, stillbirths, and low-quality maternal care are common. The aim of this study is to investigate the use of allostatic load to understand the impact of reproductive histories on later-life health. We applied path models to the Indonesian Family Life Survey with a sample of 2,001 women aged 40+. Although number of children was not associated with allostatic load, pregnancies not ending in live birth and parenthood before age 18 were both negatively associated with health. We also identified clear cohort and educational effects and a possible rural advantage. Our contribution is twofold: we highlight the importance of reproductive histories beyond live births on women's later-life health in a context of increasing population ageing, and we demonstrate the applicability of using allostatic load to measure health outside the Global North.

Secular trends in premature and early menopause in low-income and middle-income countries.

BACKGROUND: While secular trends in high-income countries show an increase in the mean age at menopause, it is unclear if there is a similar pattern in low-income and middle-income countries (LMICs), where women's exposure to biological, environmental and lifestyle determinants of menopause may differ. Premature (before age 40 years) and early (ages 40-44 years) menopause could have negative repercussions on later life health outcomes which in ageing societies could mean further stress on low-resource health systems. An evaluation of such trends in LMICs has been hampered by the suitability, quality and comparability of data from these countries. METHODS: Using 302 standardised household surveys from 1986 to 2019, we estimate trends and CIs using bootstrapping in the prevalence of premature and early menopause in 76 LMICs. We also developed a summary measure of age at menopause for women who experience menopause before the age of 50 years based on demographic estimation methods that can be used to measure menopausal status in surveys with truncated data. RESULTS: Trends indicate an increasing prevalence of early and premature menopause in LMICs, in particular in sub-Saharan Africa and South/Southeast Asia. These regions also see a suggested decline of the mean age at menopause with greater variation across continents. CONCLUSIONS: This study enables the analysis of menopause timing by exploiting data generally used for the study of fertility by methodologically allowing the use of truncated data. Findings show a clear increase in prevalence of premature and early menopause in the regions with the highest fertility with possible consequences for later life health. They also show a different trend compared with high-income regions, confirming a lack of generalisability and the importance of accounting for nutritional and health transitions at the local level. This study calls for further data and research on menopause on a global scale.

Forecasting of cohort fertility by educational level in countries with limited data availability: The case of Brazil.

The Brazilian period total fertility rate (PTFR) dropped to 1.8 in 2010 (1.5 among those with high education). Due to shifts in fertility timing, the PTFR may provide a misleading picture of fertility levels. The consequences of these changes for the cohort total fertility rate (CTFR)-a measure free from tempo distortions-and for educational differences in completed fertility remain unknown. Due to data limitations, CTFR forecasts in low- and middle-income countries are rare. We use Brazilian censuses to reconstruct fertility rates indirectly and forecast the CTFR for all women and by educational level. Four forecasting methods indicate that the CTFR is unlikely to fall to the level of the PTFR. Educational differences in the CTFR are likely to be stark, at 0.7-0.9, larger than in many high-income countries with comparable CTFRs. We show how the CTFR can be forecasted in settings with limited data and call for more research on educational differences in completed fertility in low- and middle-income countries.

Pathways to food insecurity in the context of conflict: the case of the occupied Palestinian territory.

BACKGROUND: Conflict reduces availability of production input and income, increases the number of days households had to rely on less preferred foods, and limits the variety of foods eaten and the portion size of meals consumed. While existing studies examine the impact of conflict on different food security measures (e.g., Food Consumption Score, Food Insecurity Experience Scale), the relationship between these measures as well as their relationship with political, economic, and agricultural factors remain under explored. Food insecurity may not only be an externality of conflict but also food deprivation may be utilized as a weapon to discourage residency in contested territories or to incentivize rebellions. METHODOLOGY: This paper examines the association between political factors (e.g., violence, policies that require permit for passage in one's own hometown), economic factors (e.g., loss of assets, unemployment), agricultural factors (e.g., shortage of water, poor weather conditions), and food insecurity experience and dietary diversity in a conflict setting-that of the occupied Palestinian territory (oPt). The study employs generalized structural equation models to analyze the 'Survey on socio-economic conditions for Palestinian households 2014' dataset compiled by the Palestinian Central Bureau of Statistics-which contains a representative sample of the population in the oPt at governorate and locality levels. RESULTS: We find that in the West Bank, residence in Area C-administered by Israel in both civil and security issues and contains illegal Israeli settlements and outposts-is associated with a higher level of agricultural hardship (p < 0.01) but lower economic hardship (p < 0.01) and a higher dietary diversity (p < 0.001), as compared to those living outside of Area C. In the Gaza Strip, living within one kilometer to a buffer zone is associated with lower dietary diversity (p < 0.01), higher level of political hardship (p < 0.01), and higher level food insecurity experience (p < 0.01) compared to not living in close proximity to a buffer zone. Concomitantly, in the Gaza Strip, food insecurity experience is associated with approximately a one-point reduction in dietary diversity as measured by the food consumption score (p < 0.01). CONCLUSIONS: The results suggest that broader socio-political conditions in the oPt impact different aspects of food security through augmenting the economic and agricultural hardships that are experienced by the residents. As such, it is important to address these broader political and economic structures in order to have more sustainable interventions in reducing food insecurity.

The mental health impact of multiple deprivations under protracted conflict: A multi-level study in the occupied Palestinian territory.

Building on the literatures examining the impacts of deprivation and war and conflict on mental health, in this study, we investigate the impact of different forms of deprivation on mental health within a context of prolonged conflict in the occupied Palestinian territory(oPt). We expand the operationalization go deprivation while accounting for more acute exposures to conflict and political violence and spatial variations. We use multilevel modelling of data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which included a sample size of 7827 households in the West Bank(WB) and Gaza Strip(GS). We conduct the analysis for the combined sample, as for the WB and GS separately. We use a General Health Questionnaire-12 (GHQ12) score as our main outcome measure of poor health. We used various measures of deprivation including subjective deprivation, material deprivation, food deprivation, and political deprivation. In addition to the different measures of deprivation, we included acute political, health, and economic shocks in our analysis along with background socio-demographic characteristics. The results indicate significant variance at the locality level. We find a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Post-secondary education and wealth have a significant inverse association with poor mental health. Subjective deprivation is the strongest predictor of GHQ12 score in the models whereby people who feel very deprived have GHQ12 scores that are almost 4-points higher than people who do not feel deprived. Economic conditions, particularly subjective measures, are significant predictors of mental health status. Our findings confirm that political and social factors are determinants of health. Feeling deprived is an important determinant of mental health. The community effect suggests that spatial characteristics are influencing mental health, and warrant further investigation.

The psychological impact of deprivation in regions affected by conflict: a multilevel analysis of a cross-sectional survey in the occupied Palestinian territory.

BACKGROUND: Deprivation is an important determinant of poor health. Locality can be key in understanding variation in deprivation across a population. This study aimed to analyse how different forms of deprivation affect mental health among Palestinians, and how they account for locality effects in the occupied Palestinian territory. METHODS: We used multilevel modelling to analyse data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which had a sample size of 7827 adults representing the same number of households. The main outcome is a General Health Questionnaire (GHQ) score, in which a higher score signifies worse mental health. Deprivation variables include subjective deprivation, material deprivation, food deprivation, and political deprivation (which was measured by use of the human insecurity scale). For the analysis, we included data on experience of different stressors (economic, political, health-related, and weather-related stress) reported at the household level in the 6 months preceding the survey, and we controlled for demographic characteristics, including age, gender, education, wealth, and region. We also conducted a two-level random effects multilevel regression, with locality as a proxy for neighbourhood. FINDINGS: The model indicates significant variance at the locality (neighbourhood) level. There is a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Education beyond secondary school level and wealth have a significant inverse association with poor mental health. Individuals who indicated that they felt somewhat or very deprived have significantly higher GHQ scores than individuals who indicated that they did not feel deprived (ß=1·73 and 4·33 for those who felt deprived and who did not feel deprived, respectively, p<0·0001). Food consumption was inversely associated with GHQ score (ß=-0·01, p<0·0001) and food insecurity was positively associated with GHQ score (ß=0·19, p<0·0001). Political deprivation, and health-related, political, and economic stressors were significantly positively associated with GHQ scores (ß=0·043, 0·23, 0·35, and 0·19 respectively, p<0·0001). Age (ß=0·079, p<0·0001) and being a woman were positively associated with GHQ score (ß=0·26, p=0·0040), whereas education beyond secondary school level was inversely associated with GHQ score (ß=-0·54, p<0·0001). INTERPRETATION: The findings that the mental health of Palestinians is associated with various forms of deprivation and stressors, provide further evidence that political and social factors are determinants of health. Correlated factors include both subjective and objective measures, and suggest that although material conditions are important, people's subjective experiences are also important. Feeling deprived is an important correlate of mental health. The community effect suggests that services (or lack thereof), checkpoints and blockades, political situations, and other factors that vary across localities, may influence mental health issues at the neighbourhood level. FUNDING: This project is part of the study "Re-conceptualising health in wars and conflicts: a new focus on deprivation and suffering" funded by the Middle East Centre at the London School of Economics and Political Science.

Food insecurity in the context of conflict: analysis of survey data in the occupied Palestinian territory.

BACKGROUND: Conflict impacts food security and decreases household dietary diversity. However, few studies have explored the routes by which prolonged conflict and social stressors affect food insecurity experience and food diversity. This study examines the influence of political, economic, and agricultural stressors on food insecurity and food diversity, and evaluates variations in food insecurity and food diversity with location of residence for households in the occupied Palestinian territory. METHODS: A secondary data analysis with structural equation modelling was carried out on data from the Socio-Economic & Food Security Survey 2014 of the Palestinian Central Bureau of Statistics. The survey was completed by a representative sample of the Palestinian population in the occupied Palestinian territory at governorate and locality levels, and consisted of 4215 households in the West Bank and 2916 households in the Gaza Strip. The primary outcomes were food diversity (measured with a food consumption score) and food insecurity (assessed with a composite experience-based measure of food security). We used structural equation models to examine the relationships between location of residence (in the West Bank, living in Area C versus not Area C; in the Gaza Strip, proximity of residence to the buffer zone), the number of political stressors, economic stressors, and agricultural stressors (eg, restricted access to land), and the primary outcomes. We controlled for demographic characteristics, including education, governorate, and wealth. FINDINGS: In the West Bank, there was no statistically significant direct association between living in Area C and food insecurity. Living in Area C is associated with a higher number of agricultural stressors than not Area C (p=0·032), and a higher number of agricultural stressors is in turn associated with lower food diversity (p=0·0080) and higher food insecurity (p=0·040). In the Gaza Strip, proximity to the buffer zone is directly associated with higher food insecurity (p=0.041) and lower food diversity (p=0·019) and a higher number of political stressors (p=0·057). A higher number of political stressors is associated with a higher number of economic stressors (p=0·026) and higher food insecurity (p=0·034). INTERPRETATION: The findings suggest that political, economic, and agricultural factors contribute to food insecurity and food diversity, and that their interactions are complex. Conflict and occupation affect food availability through both direct and indirect channels. In the Gaza Strip, living in close proximity to the buffer zone is associated with lower food diversity and higher food insecurity. In the West Bank, although residing in Area C may not directly increase food insecurity, the hardship generated by the conditions in Area C contributes to higher food insecurity. FUNDING: The Emirates Foundation.

Depends Who's Asking: Interviewer Effects in Demographic and Health Surveys Abortion Data.

Responses to survey questions about abortion are affected by a wide range of factors, including stigma, fear, and cultural norms. However, we know little about how interviewers might affect responses to survey questions on abortion. The aim of this study is to assess how interviewers affect the probability of women reporting abortions in nationally representative household surveys: Demographic and Health Surveys (DHS). We use cross-classified random intercepts at the level of the interviewer and the sampling cluster in a Bayesian framework to analyze the impact of interviewers on the probability of reporting abortions in 22 DHS conducted worldwide. Household surveys are the only available data we can use to study the determinants and pathways of abortion in detail and in a representative manner. Our analyses are motivated by improving our understanding of the reliability of these data. Results show an interviewer effect accounting for between 0.2% and 50% of the variance in the odds of a woman reporting ever having had an abortion, after women's demographic characteristics are controlled for. In contrast, sampling cluster effects are much lower in magnitude. Our findings suggest the need for additional effort in assessing the causes of abortion underreporting in household surveys, including interviewers' skills and characteristics. This study also has important implications for improving the collection of other sensitive demographic data (e.g., gender-based violence and sexual health). Data quality of responses to sensitive questions could be improved with more attention to interviewers-their recruitment, training, and characteristics. Future analyses will need to account for the role of interviewer to more fully understand possible data biases.

Web-based searching for abortion information during health emergencies: a case study of Brazil during the 2015/2016 Zika outbreak.

Sexual and reproductive health needs and access are often neglected during health emergencies. The 2015/2016 Zika epidemic is an example of priorities shifting to the detriment of women's health needs. The internet is a key tool for abortion knowledge sharing and seeking in countries where abortion is not legally available and it is also a key resource for tele-health. Yet, we know very little about how people use the internet, and the type of information searched for, to access abortion information and services. The aim of this study is to analyse to what extent and how the internet was used as a resource for abortion information during the Zika outbreak and its aftermath in Brazil in 2015/2016. Using Google Trends and Analytics data, we analyse contextually-specific abortion searches using standardised terms that reflect the overall representation of searches at that time alongside weekly levels of Zika incidence. The results show a heightened use of combined search terms for abortion and Zika, as well as abortion and microcephaly, suggesting a rise in abortion information searching linked to the epidemic. These searches were highly correlated with the level of Zika incidence. This study confirms the use of the internet for information seeking during a public health emergency. It demonstrates the need for appropriate internet resources to improve access to abortion information, especially in countries where abortion is highly restricted and stigmatised.

Analysing the intersection between health emergencies and abortion during Zika in Brazil, El Salvador and Colombia.

The Zika outbreak of 2015-7 is a lens to analyse the positioning of abortion within in global health security. The sequelae of the virus almost exclusively affected newborn children, manifested through Congenital Zika Syndrome (CZS), and a focus on women at risk of, planning or being pregnant. At the global level, debate considered whether Zika would provide impetus for regulatory change for reproductive rights in Latin America, a region with some of the most restrictive abortion regulation in the world. However, regulatory change for abortion did not occur. We analyse why the Zika health emergency did not lead to any changes in abortion regulation through multi-method analysis of the intersection between Zika, health emergencies and abortion in Brazil, Colombia and El Salvador. These case study countries were purposefully selected; each had Zika infected women (albeit with differing incidence) yet represent diverse regulatory environments for abortion. Our comparative research is multi-method: framework analysis of key informant interviews (n = 49); content analysis of women's enquiries to a medical abortion telemedicine provider; and, policy analysis of (inter)national-level Zika response and abortion policies. We consider this within literature on global health security, and the prioritisation of a particular approach to epidemic control. Within this securitized landscape, despite increased public debate about abortion regulatory change, no meaningful change occurred, due to a dominant epidemiological approach to the Zika health emergency in all three countries and prominent conservative forces in government and within anti-abortion rights movements. Simultaneously, we demonstrate that regulation did not deter all women from seeking such service clandestinely.

Timing and determinants of age at menarche in low-income and middle-income countries.

INTRODUCTION: Understanding the timing and determinants of age at menarche is key to determining potential linkages between onset of puberty and health outcomes from a life-course perspective. Yet, we have little information in low-income and middle-income countries (LMICs) mainly due to lack of data. The aim of this study was to analyse trends in the timing and the determinants of menarche in LMICs. METHODS: Using 16 World Fertility Survey and 28 Demographic and Health Surveys (DHS) from 27 countries, we analysed cohort trends and used fixed-effects models for DHS surveys to investigate sociodemographic and regional effects in the timing of age at menarche. RESULTS: Trends of the mean age at menarche across time within and between countries show a declining or stalling path. Results of the determinant modelling show the relationship with wealth changes over time although not consistently across countries. We see a shift from poorer women having earlier menarche in earlier surveys to richer women having earlier menarche in later surveys in Indonesia, the Philippines and Yemen, while in Egypt, the reverse pattern is evident. CONCLUSIONS: There is a considerable gap in both literature and data on menarche. We see a trend which is declining rapidly (from 14.66 to 12.86 years for the 1932 and 2002 cohorts, respectively), possibly at a faster pace than high-income countries and with a strong link to socioeconomic status. This study calls for menarche questions to be included in more nationally representative surveys and greater use of existing data because of its impact on life-course health in fast-ageing settings. Further studies will need to investigate further the use of the age at menarche as an indicator of global health.

Under 10 mortality patterns, risk factors, and mechanisms in low resource settings of Eastern Uganda: An analysis of event history demographic and verbal social autopsy data.

BACKGROUND: Globally, the under-10 years of age mortality has not been comprehensively studied. We applied the life-course perspective in the analysis and interpretation of the event history demographic and verbal autopsy data to examine when and why children die before their 10th birthday. METHODS: We analysed a decade (2005-2015) of event histories data on 22385 and 1815 verbal autopsies data collected by Iganga-Mayuge HDSS in eastern Uganda. We used the lifetable for mortality estimates and patterns, and Royston-Parmar survival analysis approach for mortality risk factors' assessment. RESULTS: The under-10 and 5-9 years of age mortality probabilities were 129 (95% Confidence Interval [CI] = 123-370) per 1000 live births and 11 (95% CI = 7-26) per 1000 children aged 5-9 years, respectively. The top four causes of new-born mortality and stillbirth were antepartum maternal complications (31%), intrapartum-related causes including birth injury, asphyxia and obstructed labour (25%), Low Birth Weight (LBW) and prematurity (20%), and other unidentified perinatal mortality causes (18%). Malaria, protein deficiency including anaemia, diarrhoea or gastrointestinal, and acute respiratory infections were the major causes of mortality among those aged 0-9 years-contributing 88%, 88% and 46% of all causes of mortality for the post-neonatal, child and 5-9 years of age respectively. 33% of all causes of mortality among those aged 5-9 years was a share of Injuries (22%) and gastrointestinal (11%). Regarding the deterministic pattern, nearly 30% of the new-borns and sick children died without access to formal care. Access to the treatment for the top five morbidities was after 4 days of symptoms' recognition. The childhood mortality risk factors were LBW, multiple births, having no partner, adolescence age, rural residence, low education level and belonging to a poor household, but their association was stronger among infants. CONCLUSIONS: We have identified the vulnerable groups at risk of mortality as LBW children, multiple births, rural dwellers, those whose mother are of low socio-economic position, adolescents and unmarried. The differences in causes of mortalities between children aged 0-5 and 5-9 years were noted. These findings suggest for a strong life-course approach in the design and implementation of child health interventions that target pregnant women and children of all ages.

Service utilization patterns for childbirth and neonatal mortality in the occupied Palestinian territory during conflict.

BACKGROUND: The global incidence of man-made crises has increased in the last decade. Evidence on deviations in service uptake during conflict is needed to better understand the link between conflict and adverse neonatal outcomes. We assessed the association between conflict intensity in the occupied Palestinian territory (oPt) at time of birth and (i) utilization patterns for childbirth across different providers; and (ii) neonatal mortality. METHODS: We combined data on conflict intensity with four demographic and health surveys (2004, 2006, 2010 and 2014) that included nationally representative samples of women of childbearing age. Our exposure variable was casualties per 100 000 population in defined sub-regions of the oPt. Our outcome specifications were a binary variable for neonatal deaths and a categorical variable for childbirth location. We used multivariate logistic and multinomial regressions to assess the associations. RESULTS: High conflict intensity was associated with fewer childbirths in the private sector (RR=0.97, P=0.04), and non-governmental organizations (RR=0.95, P=0.03) compared to public facilities. Conflict intensity was not associated with higher neonatal mortality beyond 2004. CONCLUSIONS: Policy implications include better preparedness in the public sector for childbirth during conflict and exploring reasons for the slow decline in neonatal mortality in the territory beyond conflict at time of birth.

Maternal and child access to care and intensity of conflict in the occupied Palestinian territory: a pseudo longitudinal analysis (2000-2014).

BACKGROUND: In the occupied Palestinian territory (oPt), access to maternal and child healthcare (MCH) services are constrained due to the prolonged Israeli military occupation, the Separation Wall, army checkpoints, and restrictions on the movement of people and goods. This study assesses the relationship between conflict intensity and access to Maternal and Child Health care in occupied Palestinian territory (oPt). To the best of our knowledge, the impact of conflict on access to health care has not been measured due to the lack of data. METHODS: We analyse pooled data from household surveys covering a fifteen-year period (2000-2014) of children (n = 16,793) and women (n = 8477) in five regions of the oPt. Conflict intensity was used as a continuous variable defined as the square root of non-combatant conflict mortality taken from monthly death rates of non-combatants by region. We use multilevel logistic models to explain four outputs: child vaccination schedules, antenatal care, caesarean sections, and complications during pregnancy. RESULTS: Locality is important with results showing the negative impact of conflict intensity on access to care, especially in the South West Bank for maternal health services and Central West Bank for vaccination (B - 0.161 p = 0.000 for DPT). Wealth is only significant for DPT vaccinations with poorest (B - 0.098 p = 0.005) and poor (B - 0.148 p = 0.002) individuals less likely to access services. Otherwise conflict does not show a differential effect across socio-economic conditions. CONCLUSIONS: This study shows how locality is the strongest factor when looking at the impact of conflict in the oPt. Preventative services (ANC and vaccinations) are the most affected by conflict. We recommend a greater use of community health care to improve access to maternal and child care when barriers impede access to health facilities during times of conflict.

Zika, abortion and health emergencies: a review of contemporary debates.

BACKGROUND: The Zika outbreak provides pertinent case study for considering the impact of health emergencies on abortion decision-making and/or for positioning abortion in global health security debates. MAIN BODY: This paper provides a baseline of contemporary debates taking place in the intersection of two key health policy areas, and seeks to understand how health emergency preparedness frameworks and the broader global health security infrastructure is prepared to respond to future crises which implicate sexual and reproductive rights. Our paper suggests there are three key themes that emerge from the literature; 1) the lack of consideration of sexual and reproductive health (SRH) services in outbreak response 2) structural inequalities permeate the landscape of health emergencies, epitomised by Zika, and 3) the need for rights based approaches to health. CONCLUSION: Global health security planning and response should specifically include programmatic activity for SRH provision during health emergencies.

Women's mid-life health in Low and Middle Income Countries: A comparative analysis of the timing and speed of health deterioration in six countries.

BACKGROUND: Mid-life is a neglected stage of women's lives, particularly in Low and Middle Income Countries (LMICs). Birth injuries, menopause and manual labour can contribute to health problems in the mid-life. OBJECTIVES: This study analyses the relationship between women's health deterioration and age across socio-economic groups in 6 countries (China, Ghana, Mexico, Russia, South Africa and India). METHODS: Using constrained cubic splines, I analysed data from the WHO SAGE survey to examine age and wealth patterns in the onset of deterioration in objective proxies of ageing. RESULTS: Results show a clear pattern of deterioration in health in middle-aged women. Ageing processes differ dramatically between rich and poor strata within countries and between countries. DISCUSSION: This study clearly shows that the onset of ageing in women in LMICs begins in the early forties. The paper highlights the need to focus more on mid-life health of women, in particular poorer ones.

Priorities and Challenges Accessing Health Care Among Female Migrants.

Women's ability to access health care requires access to and control of resources as well as the ability to make personal health decisions. Female migrants may experience additional challenges in accessing health care due to marginalization and vulnerability resulting from both their gender and their migrant status. Rural-to-urban migrant women working in the informal sector, such as Ghana's head porters (kayayei), experience exclusion from the health system, risk of being uninsured, and poor health outcomes. Kayayei's survival needs (eg, food, water) and a need to provide for their families can mean that migrant kayayei avoid health care expenses for illnesses or injuries. To ensure equal access to health care for migrant and non-migrant populations, health insurance is crucial. Yet, improving access to health care and service uptake requires more than health insurance. Incorporating culturally appropriate care into the provision of health services, or even developing specific migrant-friendly health services, could improve health service uptake and health awareness among migrants. Public health systems should also take account of migrants' financial situations and priorities in the design and delivery of health services.

Maternal and child health outcomes and intensity of conflict in the occupied Palestinian territory in 2000-14: a pseudo longitudinal analysis.

BACKGROUND: Armed conflicts can undermine a country's health-care capacity and disrupt the delivery of basic health services. Yet the public health consequences of war remain difficult to quantify, mainly because adequate data do not exist. We hypothesised that the ongoing conflict in the occupied Palestinian territory (including the restrictions on free movement and the strain on health-care services) have had detrimental effects on maternal and child health outcomes. METHODS: We reconstructed data on delivery by caesarean section and diphtheria, pertussis, and tetanus vaccination with pooled data from Demographic and Health Surveys for 2000-14. We use probit regression for binary outcomes to explain changes in caesarean sections (using data on the last pregnancy of 8700 woman aged 15-45 years) and child vaccination (using 12 600 schedules). All-age mortality of non-combatants was used to measure the intensity of conflict (the explanatory variable). Excess mortality is commonly used as a proxy for conflict intensity in the absence of more detailed data. FINDINGS: There is a general increase in the prevalence of all indicators (less so for caesarean sections, which increased from 10% to 20% between 2002 and 2014). Intensity of conflict is negatively associated with vaccination (ß=-0·2; p<0·0001). A visual examination shows that vaccination is more susceptible to peaks in conflict intensity-prevalence increased from 65% to 80% in the years after the Second Intifada. Boys were more likely than girls to be vaccinated (ß=0·31; p<0·0001). The negative association between conflict intensity and delivery by caesarean section is weaker but significant (ß=-0·04; p=0·007). Education and wealth are not significant predictors for caesarean section. INTERPRETATION: The conflict spares no one: women are affected irrespective of their socioeconomic status. The closer association between vaccination and intensity of conflict might result from their dependency on specialised resources and infrastructure. The slight negative correlation with caesarean delivery during conflict could be due to the difficulty of accessing health centres that provide caesarean section. It is also possible that the rates of planned caesarean section increases during calm periods. The most acute effects occurred when conflict intensity increased or decreased sharply, which suggests that these periods are crucial for health-care provision. FUNDING: Emirates Foundation through the London School of Economics Middle East Centre.

Women's health in the occupied Palestinian territories: Contextual influences on subjective and objective health measures.

The links between two commonly used measures of health-self-rated health (SRH) and self-reported illness (SRI)-and socio-economic and contextual factors are poorly understood in Low and Middle Income Countries (LMICs) and more specifically among women in conflict areas. This study assesses the socioeconomic determinants of three self-reported measures of health among women in the occupied Palestinian territories; self-reported self-rated health (SRH) and two self-reported illness indicators (acute and chronic diseases). Data were obtained from the 2010 Palestinian Family Health Survey (PFHS), providing a sample of 14,819 women aged 15-54. Data were used to construct three binary dependent variable-SRH (poor or otherwise), and reporting two SRI indicators-general illness and chronic illness (yes or otherwise). Multilevel logistic regression models for each dependent variable were estimated, with individual level socioeconomic and sociodemographic predictors and random intercepts at the governorate and community level included, to explore the determinants of inequalities in health. Consistent socioeconomic inequalities in women's reports of both SRH and SRI are found. Better educated, wealthier women are significantly less likely to report an SRI and poor SRH. However, intra-oPt regional disparities are not consistent across SRH and SRI. Women from the Gaza Strip are less likely to report poor SRH compared to women from all other regions in the West Bank. Geographic and residential factors, together with socioeconomic status, are key to understanding differences between women's reports of SRI and SRH in the oPt. More evidence is needed on the health of women in the oPt beyond the ages currently included in surveys. The results for SRH show discrepancies which can often occur in conflict affected settings where a combination of ill-health and poor access to health services impact on women's health. These results indicate that future policies should be developed in a holistic manner by targeting physical and mental health and well-being in programmes addressing the health needs of women, especially those in conflict affected zones.

Double burden or double counting of child malnutrition? The methodological and theoretical implications of stuntingoverweight in low and middle income countries.

BACKGROUND: There is increasing concern at research and policy levels about the double burden of child malnutrition (DBCM)-with stunting and overweight found across different groups of children. Despite some case studies suggesting that stunting and overweight can occur concurrently in children, here known as 'stuntingoverweight', and major drives to reduce all forms of malnutrition in low and middle income countries (LMICs), stuntingoverweight is continually overlooked. This research evidences the prevalence of stuntingoverweight across LMICs, exploring the theoretical and methodological implications of failing to acknowledge this form of malnutrition. METHODS: Prevalence estimates of stuntingoverweight are constructed from 79 LMICs with nationally representative anthropometric survey data. Stunting and overweight estimates are amended to exclude stuntedoverweight children. These estimates are compared with those published in the Joint Child Malnutrition Estimates (JMEs)-evidencing overestimation and double counting of stuntedoverweight children. RESULTS: Children can be concurrently stunted and overweight. Stuntedoverweight children are found in all LMICs, from 0.3% to 11.7% of under-fives and are included in both stunting and overweight rates. Analysed together, this leads to double counting of stuntedoverweight children. This artificial inflation of stunting and overweight rates can give a false impression of a DBCM, obscuring the true diversity of malnutrition present. Over 10 million children are stuntedoverweight in the world. CONCLUSIONS: Stuntingoverweight is a newly recognised, understudied phenomenon. Affected children are included in both stunting and overweight prevalence estimates, introducing unobserved heterogeneity to both individual-level and population-level research and double counting to population-level research. Overlooking stuntedoverweight children has great implications for methodology, theory, policies, programmes and the health of affected children.