Unrealized fertility among women in low and middle-income countries.

BACKGROUND: There has been little research on women who have fewer than their ideal number of children toward the end of their childbearing years in low and middle-income countries (LMICs). We examine the level and distribution of unrealized fertility in LMICs across three geographical regions. We also examine the role of sex preference and other factors associated with unrealized fertility. DATA AND METHODS: We used Demographic and Health Survey (DHS) data for women age 44-48 in 36 countries from the three geographical regions of Western and Central Africa, Eastern and Southern Africa, and South and Southeast Asia. We conducted descriptive analysis to examine the distribution of unwanted fertility and unrealized fertility, and fit adjusted logistic regressions of unrealized fertility. The main variables are number of living children (including by sex) and the sex composition of children. Other variables included education, marital status, age at first childbirth, wealth quintile, place of residence, exposure to family planning messages, contraceptive use, and country. RESULTS: Unrealized fertility was highest in Western and Central Africa, followed by Eastern and Southern Africa. In all regions, there was a decrease in unrealized fertility with an increasing number of children. Findings for sex preference varied with little sex preference in the African regions, and some limited evidence of preference for sons in South and Southeast Asia. In most regions, higher levels of education, higher wealth quintile, and use of contraceptive methods were associated with decreased unrealized fertility. CONCLUSION: Family planning programs and messages should consider regional and socioeconomic differences in unrealized fertility in order to give women and families the right to achieve the family size they desire regardless of their status.

Evidence of Impact: iCCM as a strategy to save lives of children under five.

BACKGROUND: In 2013, the World Health Organization (WHO) launched the Rapid Access Expansion (RAcE) programme in the Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria to increase coverage of diagnostic, treatment, and referral services for malaria, pneumonia, and diarrhea among children ages 2-59 months. In 2017, a final evaluation of the six RAcE sites was conducted to determine whether the programme goal was reached. A key evaluation objective was to estimate the reduction in childhood mortality and the number of under-five lives saved over the project period in the RAcE project areas. METHODS: The Lives Saved Tool (LiST) was used to estimate reductions in all-cause child mortality due to changes in coverage of treatment for the integrated community case management (iCCM) illnesses - malaria, pneumonia, and diarrhea - while accounting for other changes in maternal and child health interventions in each RAcE project area. Data from RAcE baseline and endline household surveys, Demographic and Health Surveys, and routine health service data were used in each LiST model. The models yielded estimated change in under-five mortality rates, and estimated number of lives saved per year by malaria, pneumonia and diarrhea treatment. We adjusted the results to estimate the number of lives saved by community health worker (CHW)-provided treatment. RESULTS: The LiST model accounts for coverage changes in iCCM intervention coverage and other health trends in each project area to estimate mortality reduction and child lives saved. Under five mortality declined in all six RAcE sites, with an average decline of 10 percent. An estimated 6200 under-five lives were saved by malaria, pneumonia, and diarrhea treatment in the DRC, Malawi, Niger, and Nigeria, of which approximately 4940 (75 percent) were saved by treatment provided by CHWs. This total excludes Mozambique, where there were no estimated under-five lives saved likely due to widespread stockouts of key medications. In all other project areas, lives saved by CHW-provided treatment contributed substantially to the estimated decline in under-five mortality. CONCLUSIONS: Our results suggest that iCCM is a strategy that can save lives and measurably decrease child mortality in settings where access to health facility services is low and adequate resources for iCCM implementation are provided for CHW services.

Women's empowerment and its differential impact on health in low-income communities in Mumbai, India.

This paper examines the relationship of empowerment to women's self-reported general health status and women's self-reported health during pregnancy in low-income communities in Mumbai. The data on which this paper is based were collected in three study communities located in a marginalised area of Mumbai. We draw on two data sources: in-depth qualitative interviews conducted with 66 married women and a survey sample of 260 married women. Our analysis shows that empowerment functions differently in relation to women's reproductive status. Non-pregnant women with higher levels of empowerment experience greater general health problems, while pregnant women with higher levels of empowerment are less likely to experience pregnancy-related health problems. We explain this non-intuitive finding and suggest that a globally defined empowerment measure for women may be less useful that one that is contextually and situationally defined.