Emerging changes in reproductive behaviour among married adolescent girls in an urban slum in Dhaka, Bangladesh

Socio-sexual norms and young people's sexual health in urban Bangladesh, India, Nepal and Pakistan: A qualitative scoping review

In South Asia, young people face myriad challenges and opportunities regarding their sexual lives relating to varied experiences of norms and restrictions; gender norms and socio-sexual taboos limit communication around sexual health which in turn can affect sexual health outcomes. In this article we focus on norms affecting young people's sexual health experiences in urban settings in Bangladesh, India, Nepal, and Pakistan. We conducted a scoping review of peer reviewed empirical studies based on qualitative data pertaining to young people's experiences of sexuality and sexual health in Bangladesh, India, Nepal, and Pakistan. We searched four electronic databases for articles published (2010-2022), using terms relating to sexual health, young people, and South Asia. Sixteen articles met the inclusion criteria with sample size ranging from 9 to 180. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines for the design and analysis of this study. We synthesised the included articles using thematic analysis. The studies covered topics such as sexual health services and contraceptive use; sexuality education and communication; and gender and sexual violence. Recurring findings included: parental and societal expectations around premarital 'sexual purity' through abstinence; limited communication around sexuality between young people and parents/adults; gender norms limiting young women's sexual and reproductive decision making; and an absence of research on experiences of sexual and gender minorities. We identified common themes as well as prominent gaps which must be addressed if we are to capture diverse experiences and build a better evidence base to improve sexual health services for young people in the region. The body of research fails to include experiences of young people with diverse gender, sexual orientation, and sex characteristics.

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

Multilevel Control Over Sexuality of Unmarried Adolescent Girls and Related Violence: A Qualitative Exploration in Slums of Dhaka, Bangladesh

High concerns about sexuality of unmarried adolescent girls (UAGs) in patriarchal societies and perceived links between sexuality and honor are likely to trigger controlling behavior and underlie a range of violence perpetrated against them. These concerns are heightened in the urban slums of Bangladesh, where economic and social changes challenge traditional gender roles and behaviors. Little is, however, known about control of and violence against UAGs perpetrated by families, romantic partners, and community. Using 12 key informant interviews, 15 focus group discussions, and 27 in-depth interviews carried out between June and November 2011 in Dhaka slums, this study explores the sociocultural expectations around sexuality of UAGs, how they interact with ground reality, control, resultant conflicts, violence against UAGs, and the ways UAGs grapple with controlling behavior and violence. The findings show that perceptions, attitudes, and expectations about the behavior of these girls remain patriarchal despite changes in economic and social circumstances reshaping gender roles and practices. Patriarchy finds new ways of controlling the girls by imposing dress codes, setting new boundaries for mobility and interaction with the opposite sex, and inflicting different forms of violence at different levels of the society. Some girls attempt to avoid violence by conforming to the new rules, while many negotiate the new boundaries with the family, romantic partner, and community. UAGs sometimes make compromises in one domain or level, while they resist control and violence in another. The findings lend support to the patriarchal bargain theory. Promotion of nonpatriarchal norms is expected to reduce vulnerability of these girls to violence.

Gender Norms and Beliefs, and Men's Violence Against Women in Rural Bangladesh

Prevention of violence against women requires understanding men's controlling attitudes and behaviors toward women. In Bangladesh, while the incidence of men's violence against women is alarmingly increasing, existing research to understand the determinants of men's violent behavior resulted in contradictory findings. The current study explores rural Bangladeshi men's support for gender norms, beliefs, and attitudes concerning violence against women, and looks at how these are influenced by men's age, marital status, education, and affiliation with organizations that promote gender equality. The study also attempts to understand men's bystander attitudes and responses to incidents of violence against women. Using the theoretical framework of hegemonic masculinity, the study was conducted among a sample of 1,200 men and women. Results indicate that in the study areas, young, unmarried men are less supportive to gender norms, beliefs, and attitudes that promote violence against women. Positive association was observed with men's educational attainment and affiliation with nongovernmental organization (NGO) interventions. Regardless of age, marital status, or education, men's bystander response toward intervening to prevent violence against women was found to be low. Women showed similar level of support for inequitable gender norms, beliefs, and attitudes. Analysis of the findings using a hegemonic masculinity lens reveals more complicated dynamics of power and hegemonic control at work that perpetuate men's violence against women. Based on the findings, the study also identifies possible strategies for violence prevention interventions in Bangladesh.

Currently married women's present experiences of male intimate partner physical violence in Bangladesh: An intercategorical intersectional approach

In Bangladesh, one in five currently married women (CMW) presently experience male intimate partner physical violence (MIPPV). While previous studies analysed women's individual-level multiple locations-younger age, lower education, income, and poverty in an additive manner, we took an intersectional approach to look at the effects of their multiple intersectional locations on MIPPV. Using McCall's intercategorical intersectional approach, we examine how women's intersectional locations are associated with their odds of experiencing MIPPV. Our sample from a 2015 nationally representative survey comprised 14,557 CMW living with their spouses. Thirty-four percent of CMW are young, 49% below primary educated, 19% income earning, 23% poor, and 25% experience MIPPV. We found that CMW in their dual disadvantaged younger age-lower education and single disadvantaged higher education-poor locations have 13.57% (95% CI, 9.25, 17.89) and 12.02% (95% CI, 6.87, 17.17) (respectively) higher probabilities of experiencing MIPPV than their counterparts in the corresponding dual privileged older age-higher education and higher education-nonpoor locations. Consistent with intersectionality theory, instead of prioritising a few groups over others (i.e. Oppression Olympics), we recommend building intersectional solidarity with women, men and communities to disrupt the underlying socio-economic-educational-legal-political structures and processes that have sustained these marginalised locations.

Predictors of teenage pregnancy among girls aged 13-19 years in Uganda: a community based case-control study

BACKGROUND

Teenage pregnancy is a serious public health and social problem, with 95% occurring in developing countries. The aim of the study was to investigate the behavioural, familial and social factors associated with teenage pregnancy among girls aged 13-19 years in Lira District, Uganda.

METHODS

Primary data from a case-control study of teenage girls (aged 13-19 years) in Lira District, Uganda was analysed. A Structured questionnaire was administered using face-to-face interviews to collect data on 495 participants, identified through simple random sampling from 32 villages in two counties in Lira District. Data analyses were done using SPSS Statistics 23 for descriptive, bivariate (i.e. Chi-square tests) and multivariable analyses (i.e. logistics regression) used for determining independent associations.

RESULTS

A total of 495 teenage girls participated in the study, however, final analyses were undertaken for 480 respondents. At bivariable analysis, all variables except alcohol consumption were significantly associated with teenage pregnancy. Among the behavioural factors assessed, multivariable analyses showed that having multiple sexual partners, frequent sex and irregular contraceptive use increased the likelihood of teenage pregnancy. Among familial factors, being married was found to increase the likelihood of teenage pregnancy. Peer pressure, sexual abuse and lack of control over sex was observed to increase the likelihood of teenage pregnancy.

CONCLUSIONS

Demographic, behavioural, familial and social factors are important predictors of teenage pregnancy in Lira District. Interventions focussing on: retaining pregnant and married girls at school, information on sexual and reproductive health of teenage girls, improving access to and information about contraceptive use among teenage girls, improving socio-economic status of households, and law enforcement on sexual abuse among girls may come a long way to improving adolescent sexual and health services in the low-income settings.

Using a gender lens to understand eating behaviours of adolescent females living in low-income households in Bangladesh

Adolescence is a critical period characterized by rapid physical, psychological, and social development and growth. In Bangladesh, high rates of undernutrition persist among adolescent females living in low‐income households. Prevalence of adolescent marriage and pregnancy is extremely high, with almost half of Bangladeshi women giving birth by 18 years of age. Qualitative research was carried out from April to June 2017 to examine individual, social, and environmental factors influencing eating behaviours of female adolescents between 15 and 19 years of age living in low‐income families in urban and rural settings in Bangladesh. Methods included freelisting exercises (33), key informant interviews (11), in‐depth interviews (24), direct observations (16), and focus group discussions (12). Findings show that household food insecurity necessitates adjustments in meal food quality and frequency. Gender norms prescribe that females receive small meal portions and make sacrifices in food consumption so that male family members can eat more. Work and school schedules cause long breaks between meal consumption, restricting food intake of adolescent females for extended periods. Gender discrimination and its manifestations likely amplify susceptibility to psychological stresses in adolescent females. An inferior social position makes adolescent females living in food insecure households vulnerable to undernutrition, with factors affecting food deprivation increasing as they approach childbearing. Policies to increase age of marriage and reduce adolescent pregnancy must continue. Programmes must ensure that school‐going adolescents eat adequately during the school day. Prolonging school education and strengthening the economic viability of women should alter cultural expectations regarding marriage age and normative female roles.

Perceptions and behavior related to noncommunicable diseases among slum dwellers in a rapidly urbanizing city, Dhaka, Bangladesh: a qualitative study

The increasing burden of noncommunicable diseases (NCDs) in Bangladesh can be attributable to rapid urbanization and coinciding changes in lifestyle accompanied by nutrition transition. The objective of this study is to explore respondents' lived experiences and perceptions relating to NCDs and nutrition change in an urban slum community in Dhaka. Qualitative methods were employed to explore a general understanding of behavior related to NCDs among residents of the slum community. We conducted key informant interviews of six men and seven women of various backgrounds and five focus group discussions to focus salient topics emerged from the interviews. The transcriptions of the audio-recordings were thematically analyzed, using the constant comparison method. Four major themes emerged: (1) financial hardship influencing health; (2) urbanized lifestyle affecting diet; (3) tobacco and sweetened tea as cornerstones of social life; and (4) health-seeking behavior utilizing local resources. One notable finding was that even with general economic improvement, respondents perceived poverty to be one of the major causes of NCDs. A promising finding for potentially curbing NCDs was the current trend for women to walk for exercise contrary to the commonly held notion that urban dwellers generally lead sedentary lifestyles. This study described how urban slum dwellers in Dhaka, experiencing a transition from a traditional to urbanized lifestyle, perceived their daily practices in relation to NCDs and nutrition. Our research revealed both adverse and encouraging elements of perceptions and behavior related to NCDs, which may contribute to the optimal design of NCD prevention and health promotion programs.

Factors influencing the use of contraceptives through the lens of teenage women: a qualitative study in Iran

BACKGROUND

One out of seven teenage girls in developing countries marries before the age of 15. While the fertility rate of teenage girls is high, the rate of contraceptive use remains low; therefore, this group of teenagers needs reproductive healthcare. This study was undertaken to explore factors influencing the use of contraceptives from the perspective of teenage women living in the city of Ardabil in Iran.

METHODS

This qualitative study was conducted with 14 married women aged 13-19 years who attended in urban-rural healthcare centers in Ardabil. Eligible women were recruited using purposive sampling and were invited to take part in individual in-depth semi-structured interviews. The duration of the interviews varied from 45 to 90 min with an average of 55 min. Sampling continued until data saturation was reached and no new data was collected. Each interview was tape-recorded after obtaining the participant's permission, transcribed verbatim and analyzed for identifying categories and themes using conventional content analysis.

RESULTS

Three themes and eight subthemes were developed. The themes were as follows: "insufficient familiarity with contraceptive methods", "pressure to become pregnant" and "misconceptions".

CONCLUSION

Despite the high prevalence of early marriage in Iranian society, teenage women are not empowered or prepared for marriage and birth control. Sexual and reproductive healthcare services to teenage women should be improved to meet their needs.

Patterns of marriage and reproductive practices: is there any relationship?

Today, a transition from traditional to modern marriages can be observed in many countries. This shift in patterns of marriage has evidently affected childbearing and reproductive practices. This study aimed to examine the relationship between patterns of marriage and reproductive practices in Iran. Hence, 880 married women, aged 15-49 years old, living in the North of Iran were selected using a multi-stage cluster sampling strategy and their patterns of marriage and reproductive practices were cross sectionally studied. The results revealed that there were no significant differences in the reproductive practices by three main patterns of marriage in Babol, Iran. The study also indicated that there were no significant differences in reproductive practices in three patterns of marriage after controlling for socio-economic variables. It seems that apart from the patterns of marriage, other influencing factors are the determinants of fertility in women, and the policy-makers of Iran need to pay attention to these determinants before making any decisions in this area.

Marriage Patterns and Childbearing: Results From a Quantitative Study in North of Iran

Social changes have rapidly removed arranged marriages and it seems the change in marriage pattern has played a role in childbearing. On the other hand, there is a great reduction in population in many countries which requires a comprehensive policy to manage the considerable drop in population. To achieve this goal, initially, the factors affecting fertility must be precisely identified. This study aims to examine the role of marriage patterns in childbearing. In this cross-sectional quantitative study, 880 married women 15-49 years old, living in the north of Iran were studied using a cluster sampling strategy. The results showed that there are no significant differences in reproductive behaviors of three patterns of marriage in Bobol city of Iran. It seems there is a convergence in childbearing due to the different patterns of marriage and Policymakers should pay attention to other determinants of reproductive behaviors in demographic planning.

Reproductive practices by patterns of marriage among Iranian women: study protocol for an explanatory sequential mixed methods design

Background

Nowadays, nearly half of the world population lives in societies with low fertility or the below-replacement fertility. This potentially grounds the critical situation of reduction in the workforce and causes the aging of population due to an overall increase in life expectancy and standard of living. Hence, population and its transitions including the issue of fertility decline has become a topic of intense debate in the agenda-setting and policy-making processes in both the developed and developing countries. In this view, what can practically be done to respond to the fertility decline that entails effectively addressing the determinants of fertility change? In line with the literature, how people form their marriages or patterns of marriage is amongst influencing factors which potentially affect their reproductive practices as diverse societies recognize different conventions for marriage. This study is to examine women’s reproductive practices by the various patterns of marriage using the explanatory sequential mixed methods design.

Methods/design

This study has an explanatory sequential mixed methods design, the follow-up explanations variant model, with two strands. This design will be implemented in two distinct phases. In the first phase, a cross-sectional quantitative study will be done using a cluster sampling strategy on 850 married women 15–49 years old living in Babol city, Iran. In order to obtain a deeper understanding of the results of the quantitative phase, researchers will implement a qualitative research in the second phase of this study. This design will provide an explanation of the quantitative research results using the qualitative evidence.

Discussion

As patterns of marriage have implications for the status of women, their health and fertility, the result of this study can provide a rich source of information for the required health-related interventions and policies are required to put the demographic changes on the right track at micro and macro level and improve the reproductive practices of women at micro level.

Factors associated with pregnancy among adolescents in low-income and lower middle-income countries: a systematic review

BACKGROUND

Pregnancy-related morbidity and mortality is much more prevalent among adolescents than adults. Adolescent pregnancy is therefore a significant public health problem. Most births to adolescents (95%) occur in resource-constrained countries.

OBJECTIVE

The aim was to review the available evidence about the factors associated with adolescent pregnancy in low-income and lower middle-income countries.

METHODS

The review used the PRISMA procedure of identification, screening and eligibility of publications. PubMed, OVID MEDLINE, SCOPUS and CINAHL plus were searched systematically for peer-reviewed English language papers published before December 2013.

FINDINGS

In total, 2005 articles were identified and 12 met the inclusion criteria and were reviewed. Despite varied methods, there was substantial consistency in the findings. Limited education, low socioeconomic position, insufficient access to and non-use of contraception were consistently found to be risks for pregnancy among adolescents. There was some evidence that early marriage, living in a rural area, early sexual initiation, belonging to an ethnic and religious minority group also increased the risk of adolescent pregnancy. Higher education, access to income-generating work and family support were found to protect against adolescent pregnancy.

CONCLUSIONS

In resource-constrained countries, as in well-resourced countries, low socioeconomic position appears to increase the risk of pregnancy among adolescents. Additional risks specific to these contexts include cultural traditions such as early marriage and inaccurate beliefs about contraception. It is unlikely that strategies to reduce pregnancy among women aged less than 20 years will be effective unless these are addressed directly.

Unintended pregnancies among young women living in urban slums: evidence from a prospective study in Nairobi city, Kenya

BACKGROUND

Despite the significant proportion of young people residing in slum communities, little attention has been paid to the sexual and reproductive health (SRH) challenges they face during their transition to adulthood within this harsh environment. Little is known about the extent to which living in extreme environments, like slums, impact SRH outcomes, especially during this key developmental period. This paper aims to fill this research gap by examining the levels of and factors associated with unintended pregnancies among young women aged 15-22 in two informal settlements in Nairobi, Kenya.

METHODS

We use data from two waves of a 3-year prospective survey that collected information from adolescents living in the two slums in 2007-2010. In total, 849 young women aged 15-22 were considered for analysis. We employed Cox and logistic regression models to investigate factors associated with timing of pregnancy experience and unintended pregnancy among adolescents who were sexually active by Wave 1 or Wave 2.

FINDINGS

About two thirds of sexually experienced young women (69%) have ever been pregnant by Wave 2. For 41% of adolescents, the pregnancies were unintended, with 26% being mistimed and 15% unwanted. Multivariate analysis shows a significant association between a set of factors including age at first sex, schooling status, living arrangements and timing of pregnancy experience. In addition, marital status, schooling status, age at first sex and living arrangements are the only factors that are significantly associated with unintended pregnancy among the young women.

CONCLUSIONS

Overall, this study underscores the importance of looking at reproductive outcomes of early sexual initiation, the serious health risks early fertility entail, especially among out-of school girls, and sexual activity in general among young women living in slum settlements. This provides greater impetus for addressing reproductive behaviors among young women living in resource-poor settings such as slums.

Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development

By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the country's development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.

Is Young Maternal Age a Risk Factor for Sexually Transmitted Diseases and Anaemia in India? An Examination in Urban and Rural Areas

The present research work aims to study the effect of young maternal age on the prevalence of sexually transmitted diseases (STDs) and anaemia using National Family Health Survey-3 (NFHS-3) data for India. Analysis has been done for currently married women in the reproductive age group and who had their first birth in the age group 29 or below. Data have been analysed for urban and rural areas separately. The bivariate analysis showed that per cent of women who had their first birth during adolescence is higher in rural areas than urban areas. Further, women who had their first birth during adolescence reported a higher prevalence of STDs and anaemia than women who had their first birth at later ages in both settings. Logistic regression analysis has been used to examine the net influence of maternal age on the prevalence of anaemia and STDs. The multivariate findings revealed that the likelihood of prevalence of STDs and anaemia (urban areas) was higher among adolescent women than among adult women.

"Who am I? Where am I?" Experiences of married young women in a slum in Islamabad, Pakistan

BACKGROUND

In Pakistan, 16% of the women aged 15-19 years are married. Many get married shortly after they attain menarche. This study explores the preparedness for and actual experiences of married life (inter-spousal relationship, sexual activity and pregnancy) among adolescent women.

METHODS

Among married adolescent women residing in a slum of Islamabad ten were selected with the help of a community health worker and interviewed qualitatively till saturation was reached. They were interviewed three times at different occasions. Narrative structuring was used to explore how the participants represented their background, social situation, decision making and spousal communication and how they explained, understood and managed married life and bore children.

RESULTS

Two categories identifying the respondents as either submissive-accepting or submissive-victims emerged. The married young women who belonged to the accepting group lived under compromised conditions but described themselves as satisfied with their situation. They were older than the other group identifying themselves as victims. However, none of the respondents felt prepared for marriage. Women belonging to the victimized group experienced physical and verbal abuse for their inability to cope with the duties of a wife, caretaker of the home and bearer of children. Their situation was compounded by the power dynamics within the household.

CONCLUSION

Knowledge about sexuality could prepare them better for the future life and give them more control of their fertility. Adolescent development and life skills education need to be addressed at a national level. There is need for innovative interventions to reach out and provide support to young women in disadvantaged homes.