Foetal loss and feminine sex ratios at birth in sub-Saharan Africa.

A wealth of demographic research has explored the determinants of sex ratios at birth, but few studies have considered the role of foetal loss (spontaneous abortion), in producing feminine sex ratios. One challenge is measuring the occurrence of foetal loss, which is difficult to recognize and report in survey research. This study uses the length of the birth interval as a proxy for foetal loss; foetal loss restarts the clock on time to conception and lengthens the birth interval. We use Demographic and Health Survey data on second births to women in 17 sub-Saharan African countries. Results show that longer second birth intervals are significantly related to lower odds of a male second birth and to feminine sex ratios at birth. These findings suggest that high levels of foetal loss, which could signal underlying poor maternal health in a population, have dramatic effects on the sex ratio at birth.

Exploring Multiple Dimensions of Young Women's Fertility Preferences in Malawi.

INTRODUCTION: Standard survey measures of fertility preferences, such as the desire for and preferred timing of future births, do not capture the complexity of individuals' preferences. New research focuses on additional dimensions of emotions and expectations surrounding childbearing. Few quantitative studies, however, consider the influence of all three dimensions of fertility preferences concurrently. METHODS: Using longitudinal survey data from the Tsogolo la Thanzi project (2009-2012) in Malawi, this study employed logistic regression analysis to investigate the influence of young women's emotions, expectations, and a standard measure of fertility preferences on pregnancy and modern contraceptive use. RESULTS: Young women experienced high unmet need; across survey waves, over three-quarters of women who desired a child in more than 2 years were not currently using modern contraceptives and over three-quarters of women who thought a pregnancy in the next month would be bad news (garnered from a measure of emotions surrounding pregnancy) were not currently using modern contraceptives. In regression models including all three measures of fertility preferences, each was significantly associated with the likelihood of a future pregnancy. The standard measure and emotions measure were significantly associated with modern contraceptive use. DISCUSSION: Emotions and expectations surrounding pregnancy and childbirth appear to be distinct and salient aspects of fertility preferences in addition to the standard measure. A better understanding of the multidimensional nature of fertility preferences will help individuals define and achieve their reproductive goals and obtain appropriate services. Furthermore, future research should incorporate new measures of fertility preferences into surveys internationally.

Happy Moms, Happier Dads: Gendered Caregiving and Parents' Affect.

Parenting is emotionally demanding and highly gendered. We use data from the American Time Use Survey to examine mothers' and fathers' momentary affect during childcare activities. We observe a gender imbalance in the emotional rewards of childcare: fathers report more happiness, less stress, and less tiredness than mothers. We introduce the "care context"-defined as the type of childcare activity, when and where it takes place, who is present, and how much care is involved-as an explanation for these gender differences in parents' affect. The analysis reveals that most dimensions of the care context vary between mothers and fathers. We also find that the care context fully accounts for differences in mothers' and fathers' happiness, partially explains differences in stress, and does little to explain differences in tiredness. Thus, the gender imbalance in the emotional rewards of childcare is partially due to parents' highly gendered engagement with their children.

Open Defecation, Livestock Ownership, and Child Nutritional Status in India.

South Asian children are among the most severely malnourished worldwide. One prominent hypothesis is that open defecation in the local area exposes children to human fecal pathogens that can cause diarrhea and malnutrition. Much of the existing research uses district-level measures of open defecation, which could mask important local-area variation. A second hypothesis is that animal fecal matter is a major source of exposure. This analysis tested these dual hypotheses using census data collected from 949 villages in Tamil Nadu, India, and a survey conducted in a random sample of 5,000 households in the same area. The final analytic sample consisted of 2,561 children aged 0-10 years. We estimated the association between the measures of village- and household-level open defecation, household livestock ownership, and child height-for-age Z-scores in a regression framework, controlling for potential confounders. Results revealed that village- and household-level open defecations are negatively associated with child height. There was an estimated difference of approximately 0.5 height-for-age Z-score between children living in villages with no open defecation and children in villages where all households practiced open defecation (P = 0.001) and a 0.2 Z-score difference between children living in households that practiced open defecation and those living in households that did not (P = 0.001). Livestock ownership was not associated with child height. Overall, the findings provide evidence on the centrality of open defecation in explaining persistent child malnutrition in India and the higher risk of exposure to human fecal pathogens compared with animal feces in the south Indian context.

Dimensions of Rural-to-Urban Migration and Premarital Pregnancy in Kenya.

Rural-to urban migration is increasingly common among youth and could affect sexual activities. We use life history calendar data collected in Kisumu, Kenya, to investigate how the timing and number of rural-to-urban moves are associated with premarital pregnancy. Among sexually experienced young women aged 18-24 (N=226), 39 percent have experienced a premarital pregnancy and 60 percent experienced a move in the last 10 years. Results of the event history analysis show that those who experienced one or two moves or whose most recent move occurred in the last seven to 12 months are at increased risk of premarital pregnancy compared to nonmovers. Those whose last move occurred at age 13 or younger were also at an elevated risk. Migration brings about specific needs for youth, including the need for sexual and reproductive health education and services, which should be made available and accessible to new urban residents.

Dimensions of poverty and inconsistent condom use among youth in urban Kenya.

To date, research on the link between poverty and unsafe sexual behaviors has utilized limited measures of socioeconomic status and has overlooked key dimensions of poverty at the individual level. This study explored how various dimensions of socioeconomic status are associated with inconsistent condom use and how these associations vary by gender. We analyzed unique life history survey data from 261 young men and women in Kisumu, Kenya, and conducted analyses based on 959 person-months in which respondents had been sexually active in nonmarital relationships. Dependent variables were inconsistent condom use (not always using a condom) and never use of condoms. Condoms were used inconsistently in 57% of months and were never used in 31%. Corroborating existing literature, lower household wealth and lower educational attainment were associated with inconsistent condom use. Lower individual economic status (lower earned income, food insufficiency, and larger material transfers from partners) were also important determinants of inconsistent condom use. There were no significant differences in these associations by gender, with the exception of food insufficiency, which increased the risk of inconsistent condom use for young women but not for young men. None of these individual measures of socioeconomic status were associated with never use of a condom. The findings suggest that both household- and individual-level measures of socioeconomic status are important correlates of condom use and that individual economic resources play a crucial role in negotiations over the highest level of usage. The results highlight the importance of poverty in shaping sexual behavior, and, in particular, that increasing individual access to resources beyond the household, including ensuring access to food and providing educational and work opportunities, could prove to be effective strategies for decreasing the risk of HIV among youth.

Local hierarchies and distributor (non) compliance: a case study of community-based distribution in rural north India.

Community-based distribution of family planning services is particularly appropriate for South Asia, which has hard-to-reach rural populations. In Uttar Pradesh (UP), India, local status hierarchies of gender, caste, and generation shape the nature of relationships that community-based distributors (CBDs) create with their clients. In this case study of an "ideal" distributor, we uncover the conflicting expectations that many CBDs experience: to comply with project objectives without violating local social norms that limit interactions across status boundaries. Our CBD responded to these dual pressures with varying strategies, often perpetuating social distance and restricting information and services for men, adolescents, and other marginalized populations.

Women as agents of change: Female income and mobility in India.

Economic globalization will give many women in developing countries access to steady and relatively remunerative employment for the first time, potentially shifting bargaining power within their households and changing the choices that are made for their children. This paper exploits a unique setting - a group of tea plantations in South India where women are employed in permanent wage labor and where incomes do not vary by caste - to anticipate the impact of globalization on mobility across social groups in the future. The main result of the paper is that a relative increase in female income weakens the family's ties to the ancestral community and the traditional economy, but these mobility enhancing effects are obtained for certain historically disadvantaged castes alone. Although the paper provides a context-specific explanation for why the women from these castes emerge as agents of change, the first general implication of the analysis is that the incentive and the ability of women to use their earnings to influence household decisions depends importantly on their social background. The second implication is that historically disadvantaged groups may, in fact, be especially responsive to new opportunities precisely because they have fewer ties to the traditional economy to hold them back.

Exploring the meaning of context for health: Community influences on child health in South India.

Much research attention has been devoted to community context and health. Communities are often defined as residential spaces, such as neighborhoods, or as social groupings, such as caste in India. Using data from a group of tea estates in South India, we attempt to address important methodological challenges in the identification of neighborhood effects on child health. We find significant neighborhood effects for weight for age at age one, including a protective role for community-level women's education, but none for birth weight. In contrast to the usual pattern in rural India, caste disparities in child health are also eliminated in this setting.

Women's Political Leadership and Adult Health: Evidence from Rural and Urban China.

This study examined the role of women's political leadership at the community level in China, a context that has experienced recent political and socioeconomic change and has a distinctive rural-urban divide. Drawing on longitudinal data from the China Family Panel Studies (N range = 40,918-52,406 person-year observations), we found that female community directors outnumbered male directors in urban China but were much less common in rural areas. Female community directors had higher levels of human capital regardless of rural or urban location. Residents living in female-directed communities reported better mental health but not physical health or life satisfaction compared to those living in male-directed communities, and this association was most robust among rural women. For rural women, the mental health benefit of living in female-directed communities was partially explained by reduced personal experience of gender discrimination, suggesting that female leadership fosters ideational change toward women that lowers discriminatory behaviors among constituents.

The correlates of HIV testing and impacts on sexual behavior: evidence from a life history study of young people in Kisumu, Kenya.

BACKGROUND: HIV counseling and testing is considered an important component of HIV prevention and treatment. This paper examines the characteristics of young males and females at the time of first reported HIV test, including the influence of recent sexual partnerships, and investigates how HIV testing and the cumulative number of tests are associated with sexual behaviors within six months of testing. METHODS: The study uses data from a random sample of youth aged 18-24 years living in Kisumu, Kenya, who were interviewed using a 10-year retrospective life history calendar. Cox regression models were used to examine the correlates of the timing of first HIV test. Variance-correction models for unordered repeated events were employed to examine whether having an HIV test in the previous six months and the cumulative number of tests predict unsafe sexual practices in a given month. RESULTS: Sixty-four percent of females and 55% of males reported at least one HIV test in the last 10 years and 40% of females were pregnant the month of first test. Significant correlates of first HIV test included marital aspirations among non-pregnant females, unprotected sex in the previous six months among pregnant females, and concurrency in the previous six months among males. Having a recent HIV test was associated with a decreased likelihood of unprotected sex among ever-pregnant females, an increased likelihood of unprotected sex and "risky" sexual partnerships among never-pregnant females, and an increased likelihood of concurrency among males. Repeated HIV testing was associated with a lower likelihood of concurrency among males and involvement in "risky" sexual partnerships among males and never-pregnant females. CONCLUSIONS: The high rate of pregnancy at first test suggests that promotion of HIV testing as part of prevention of mother-to-child transmission is gaining success. Further research is warranted to examine how and why behavior change is influenced by client- versus provider-initiated testing. The influence of different sexual partnership variables for males and females suggests that interventions to assess risk and promote testing should be gender- and relationship-specific. The findings also suggest that encouraging repeat or routine testing could potentially increase the uptake of safer sexual behaviors.

Concurrent sexual partnerships among youth in urban Kenya: Prevalence and partnership effects.

Research on concurrent sexual partnerships is hindered by lack of accurate partnership data. Using unique life-history calendar data from a population-based sample of youths aged 18-24 in urban Kenya, we estimated the prevalence and correlates of concurrency. In the sixth month before the survey, 3.5 per cent of females and 4.0 per cent of males were engaged in concurrent sexual partnerships. In the previous 9.5 years, males experienced more concurrent partnerships than females and they were of shorter duration. Using survival analysis, we find that the characteristics of initial partnerships affect entry into a second (concurrent) relationship. For females, geographic separation from a partner increases the risk of concurrency, while concurrency is positively associated with the duration of the initial relationship for males. For both sexes, the perception of partner infidelity increases the risk, suggesting that concurrency expands individuals' sexual networks and bridges additional networks involving partners' other sexual partners.

Men's Economic Dependency, Gender Ideology, and Stress at Midlife.

OBJECTIVE: This study investigates the association between men's economic dependency during midlife and allostatic load, an indicator of chronic stress, and how this relationship varies with men's gender ideology. BACKGROUND: Women are primary breadwinners in almost a third of heterosexual couples in the U.S. Emerging research finds that female primary breadwinning (or men's economic dependency) is a threat to masculinity that has negative implications for men's midlife health. However, there is no quantitative evidence of the mechanisms linking men's economic dependency and health, particularly the role of stress, and whether men's gender ideology moderates this relationship. METHOD: Using two waves of Midlife in the United State (MIDUS) data for men who remained with the same marital or cohabiting female partner between waves (n = 332), the authors estimate the relationship between men's economic dependency in wave 1 and allostatic load in wave 2. RESULTS: There was no evidence of an association between men's economic dependency and higher allostatic load on average. However, gender ideology had a moderating influence; men's economic dependency was associated with higher allostatic load for those who espoused more traditional gender attitudes and lower allostatic load for those with the most egalitarian attitudes. CONCLUSION: The findings underscore the existence of multiple masculinities and suggest that economic dependence has a negative or positive influence on men's health depending on the meanings men attach to female primary breadwinning.

Non-Parental Family Members as Brokers of Family Social Capital: Compensatory Time Use in India.

Non-parental family members are understudied but important brokers of family social capital, especially in contexts without a nuclear-family norm. We used rich time diary data from a sample of 1568 South Indian adolescents to examine the relationships between any time spent with parents, parents' residency status, and the time spent with non-parental family members. We found that adolescents with at least one non-resident parent spent significantly more time with siblings, on average, when compared to adolescents with resident parents. We further found that adolescents spent more time with siblings in educational activities, such as studying, when they had at least one non-resident parent. These findings point to the importance of considering non-parental family members in studies of family social capital, especially in low- and middle-income contexts. Our findings challenge resource dilution theories by demonstrating that siblings themselves act as resources, rather than simply competitors for parental resources.

Exposure to conflict-related violence and nutritional status of children in Iraq.

There is limited empirical evidence of the health effects of war-related violence on child nutritional status. Using unique micro-level data from Iraq, we create measures of cumulative exposure to violence since conception for children ages two to five based on their date of birth and geographic location. We examine the relationship between height-for-age z-scores, a measure of chronic malnutrition, and four indicators of violence in a regression framework, adjusting for potential confounders and trends. We find that a child exposed to the maximum number of violent incidents is likely to experience a 0.5 standard deviation reduction in height-for-age z-score compared to a child who is exposed to no incidents. Each type of attack we evaluate is negatively associated with height-for-age. Further analysis reveals that the associations are the strongest for children in the northern and central regions where the bulk of the violent incidents occurred. Contrary to our expectation, the associations are similar for boys and girls. Our findings suggest that, in addition to efforts aimed at decreasing violent conflict in Iraq in general, the government and its development partners should focus relief, recovery, and reconstruction efforts in the central and northern regions of the country.

Nutritional status, cognitive achievement, and educational attainment of children aged 8-11 in rural South India.

BACKGROUND: Malnutrition among children is one of the most pressing health concerns middle- and low-income countries face today, particularly those in Sub-Saharan Africa and South Asia. Early-life malnutrition has been shown to affect long-term health and income. One hypothesized channel linking early-life malnutrition and long-term outcomes is cognitive development. However, there is limited empirical evidence on the relationship between nutritional status and cognitive achievement in middle childhood. STUDY DESIGN: As part of the South India Community Health Study (SICHS), we collected educational attainment and anthropometric data from 1,194 children in rural Vellore district of Tamil Nadu, India, and assessed their math and reading skills. We analyzed the relationship between continuous and binary anthropometric measures of nutritional status and three measures of cognitive achievement (reading, math, and grade level), adjusting for potential confounders, using a regression framework. RESULTS: Lower height-for-age and weight-for-age and their corresponding binary measures (stunting, underweight) were associated with lower reading scores, lower math scores, and lower grade level, with the exception of the association between weight-for-age and reading, which was marginally significant. A stunted child had one-third of a grade disadvantage compared to a non-stunted counterpart, whereas an underweight child had one-fourth of a grade disadvantage compared to a non-underweight counterpart. Lower BMI-for-age was associated with grade level and marginally associated with lower math scores, and its binary measure (thinness) was marginally associated with lower math scores. CONCLUSIONS: Acute and chronic malnutrition in middle childhood were negatively associated with math scores, reading scores, and educational attainment. Our study provides new evidence that cognitive achievement during middle childhood could be an important mechanism underlying the association between early-life malnutrition and long-term wellbeing.

Diagnostic pathways and direct medical costs incurred by new adult pulmonary tuberculosis patients prior to anti-tuberculosis treatment - Tamil Nadu, India.

BACKGROUND: Tuberculosis (TB) patients face substantial delays prior to treatment initiation, and out of pocket (OOP) expenditures often surpass the economic productivity of the household. We evaluated the pre-diagnostic cost and health seeking behaviour of new adult pulmonary TB patients registered at Primary Health Centres (PHCs) in Vellore district, Tamil Nadu, India. METHODS: This descriptive study, part of a randomised controlled trial conducted in three rural Tuberculosis Units from Dec 2012 to Dec 2015, collected data on number of health facilities, dates of visits prior to the initiation of anti-tuberculosis treatment, and direct OOP medical costs associated with TB diagnosis. Logistic regression analysis examined the factors associated with delays in treatment initiation and OOP expenditures. RESULTS: Of 880 TB patients interviewed, 34.7% presented to public health facilities and 65% patients sought private health facilities as their first point of care. The average monthly individual income was $77.79 (SD 57.14). About 69% incurred some pre-treatment costs at an average of $39.74. Overall, patients experienced a median of 6 days (3-11 IQR) of time to treatment initiation and 21 days (10-30 IQR) of health systems delay. Age ≤ 40 years (aOR: 1.73; CI: 1.22-2.44), diabetes (aOR: 1.63; CI: 1.08-2.44) and first visit to a private health facility (aOR: 17.2; CI: 11.1-26.4) were associated with higher direct OOP medical costs, while age ≤ 40 years (aOR: 0.64; CI: 0.48-0.85) and first visit to private health facility (aOR: 1.79, CI: 1.34-2.39) were associated with health systems delay. CONCLUSION: The majority of rural TB patients registering at PHCs visited private health facilities first and incurred substantial direct OOP medical costs and delays prior to diagnosis and anti-tuberculosis treatment initiation. This study highlights the need for PHCs to be made as the preferred choice for first point of contact, to combat TB more efficiently.

Exploring couple attributes and attitudes and marital violence in Vietnam.

Using a couple-centered approach, this study focuses on the relative attributes and attitudes of spouses as predictors of marital violence. Analysis of data from Vietnam showed that 37% of married women have ever been hit by their husbands. Regression results found that husbands with lower resources or status than their wives were more likely to have abused. Results also found that the association between husbands' gender attitudes and marital violence depends on the level of equity of wives'attitudes. The decline in violence among couples in which husbands expressed gender equitable attitudes was greater when wives also expressed equitable attitudes.

Social Affiliation and the Demand for Health Services: Caste and Child Health in South India.

This paper assesses the role of social affiliation, measured by caste, in shaping investments in child health. The special setting that we have chosen for the analysis - tea estates in the South Indian High Range - allows us to control nonparametrically for differences in income, access to health services, and patterns of morbidity across low caste and high caste households. In this controlled setting, low caste households spend more on their children's health than high caste households, reversing the pattern we would expect to find elsewhere in India. Moreover, health expenditures do not vary by gender within either caste group, in contrast once again with the male preference documented throughout the country. A simple explanation, based on differences in the returns to human capital across castes in the tea estates is proposed to explain these striking results.

Confronting the 'sugar daddy' stereotype: age and economic asymmetries and risky sexual behavior in urban Kenya.

CONTEXT: "Sugar daddy" relationships, which are characterized by large age and economic asymmetries between partners, are believed to be a major factor in the spread of HIV in Sub-Saharan Africa. Information is needed about sugar daddy partnerships-and about age and economic asymmetries more generally-to determine how common they are and whether they are related to unsafe sexual behavior. METHODS: The sample comprised 1,052 men aged 21-45 who were surveyed in Kisumu, Kenya, in 2001. Data on these men and their 1,614 recent non-marital partnerships were analyzed to calculate the prevalence of sugar daddies and sugar daddy relationships, as well as a range of age and economic disparities within non-marital partnerships. Logistic regression models were constructed to assess relationships between condom use at last sexual intercourse and various measures of age and economic asymmetry. RESULTS: The mean age difference between non-marital sexual partners was 5.5 years, and 47% of men's female partners were adolescents. Fourteen percent of partnerships involved an age difference of at least 10 years, and 23% involved more than the mean amount of male-to-female material assistance. Men who reported at least one partnership with both these characteristics were defined as sugar daddies and made up 5% of the sample; sugar daddy relationships accounted for 4% of partnerships. Sugar daddy partnerships and the largest age and economic asymmetries we constructed were associated with decreased odds of condom use. CONCLUSIONS: Although sugar daddy relationships are not as pervasive as generally assumed, age and economic asymmetries in non-marital partnerships are relatively common. All these types of asymmetries are associated with nonuse of condoms. Increasing women's power within asymmetric sexual relationships could improve their ability to negotiate safer sexual behaviors, such as condom use.