Millennium Development Goals progress report

Women's health and rights in the twenty-first century

In the twenty-first century, the complex relationship between women's health and rights has been influenced by a range of interconnected challenges, including gender inequity, reproductive health disparities, maternal mortality and morbidity, and women's inability to access life-saving, high-quality healthcare services including family planning. Going forward, the world needs to find ways to implement the unfinished agenda of the International Conference on Population and Development (ICPD) 1994 and the Sustainable Development Goals (SDGs), thus prioritizing health and rights for women and girls as essential not only to their survival but also to their progress, agency and empowerment. It is also important to consider the interconnection between women's health and rights and climate change, with its disproportionate impact on the well-being of girls and women, and to address the impact and opportunities afforded by digital technologies. By embracing a holistic approach, societies might be able to advance the cause of women's health and rights in a more inclusive and sustainable manner.

Availability and readiness of healthcare facilities and their effects on antenatal care services uptake in Bangladesh

BACKGROUND

Sustainable Development Goal (SDG) 3.7 aims to ensure universal access to sexual and reproductive healthcare services, where antenatal care (ANC) is a core component. This study aimed to examine the influence of health facility availability and readiness on the uptake of four or more ANC visits in Bangladesh.

METHODS

The 2017/18 Bangladesh Demographic and Health Survey data were linked with the 2017 Health Facility Survey and analyzed in this study. The associations of health facility-level factors with the recommended number of ANC uptakes were determined. A multilevel mixed-effect logistic regression model was used to determine the association, adjusting for potential confounders.

RESULTS

Nearly 44% of mothers reported four or more ANC uptakes, with significant variations across several areas in Bangladesh. The average distance of mothers' homes from the nearest health facilities was 6.36 km, higher in Sylhet division (8.25 km) and lower in Dhaka division (4.45 km). The overall uptake of the recommended number of ANC visits was positively associated with higher scores for the management (adjusted odds ratio (aOR) 1.85; 95% CI, 1.16-2.82) and infrastructure (aOR, 1.59; 95% CI, 1.09-2.19) of health facilities closest to mothers' homes. The odds of using the recommended number of ANC in mothers increased by 3.02 (95% CI, 2.01-4.19) and 2.36 (95% CI, 2.09-3.16) folds for each unit increase in the availability and readiness scores to provide ANC services at the closest health facilities, respectively. Every kilometer increase in the average regional-level distance between mothers' homes and the nearest health facilities reduced the likelihood of receiving the recommended number of ANC visits by nearly 42% (aOR, 0.58, 95% CI, 0.42-0.74).

CONCLUSION

The availability of healthcare facilities close to residence, as well as their improved management, infrastructure, and readiness to provide ANC, plays a crucial role in increasing ANC services uptake. Policies and programs should prioritize increasing the availability, accessibility, and readiness of health facilities to provide ANC services.

Association between maternal high-risk fertility behaviour and perinatal mortality in Bangladesh: Evidence from the Demographic and Health Survey

BACKGROUND

High-risk fertility behaviours including pregnancy early or late in the reproductive life course, higher parity and short birth intervals are ongoing concerns in Low- and Middle-Income Countries (LMICs) such as Bangladesh. Although such factors have been identified as major risk factors for perinatal mortality, there has been a lack of progress in the area despite the implementation of the Millennium and Sustatinable Development Goals. We therefore explored the effects of high-risk maternal fertility behaviour on the occurrence of perinatal mortality in Bangladesh.

METHODS

A total of 8,930 singleton pregnancies of seven or more months gestation were extracted from 2017/18 Bangladesh Demographic and Health Survey for analysis. Perinatal mortality was the outcome variable (yes, no) and the primary exposure variable was high-risk fertility behaviour in the previous five years (yes, no). The association between the exposure and outcome variable was determined using a mixed-effect multilevel logistic regression model, adjusted for covariates.

RESULTS

Forty-six percent of the total births that occurred in the five years preceding the survey were high-risk. After adjusting for potential confounders, a 1.87 times (aOR, 1.87, 95% CI, 1.61-2.14) higher odds of perinatal mortality was found among women with any high-risk fertility behaviour as compared to women having no high-risk fertility behaviours. The odds of perinatal mortality were also found to increase in line with an increasing number of high-risk behaviour. A 1.77 times (95% CI, 1.50-2.05) increase in odds of perinatal mortality was found among women with single high-risk fertility behaviour and a 2.30 times (95% CI, 1.96-2.64) increase in odds was found among women with multiple high-risk fertility behaviours compared to women with no high-risk fertility behaviour.

CONCLUSION

Women's high-risk fertility behaviour is an important predictor of perinatal mortality in Bangladesh. Increased contraceptive use to allow appropriate birth spacing, educational interventions around the potential risks associated with high risk fertility behaviour (including short birth interval) in future pregnacies, and improved continuity of maternal healthcare service use among this population are required to improve birth outcomes in Bangladesh.

Trends and Determinants of Child Growth Indicators in Malawi and Implications for the Sustainable Development Goals

Sustainable development goals (SGD) 2 links malnutrition, morbidity and child mortality to stunting, wasting and overweight among children under-5 years of age. Sub-Saharan Africa still registers high nutritionally insecure people. In particular, Malawi has made modest progress in improving nutritional outcomes; and still experiences a number of structural challenges leading to negative nutritional outcomes. We describe trends of under nutrition and how the effect of selected determinants of child nutrition affect Malawian children under-5 from 1992 to 2015–16; and examine the changing patterns of the effect of selected socio-demographic characteristics on stunting and underweight using data from demographic and health surveys (DHS). The analysis included 31,630 children under-5 years from 1992, 2000, 2004, 2010, and 2015–16 DHS. Our outcome measures are stunting (height/length-for-age) and underweight (weight-for-age) less than -2 SD (Z-score). We perform logistic regression to assess the relationship between selected socio-demographic characteristics with the stunting and underweight variables. Underweight decreased by 14.0% from 24.7% (1992) to 10.7% (2015–16). Stunting decreased by 23.0% from 55.6% (1992) to 32.6% (2015–16). Underweight was more prevalent among children from central and southern regions; among male children; and children above 6 months of age or more. Later surveys were associated with reduced likelihood of underweight than the earliest surveys. Similar trends were observed between socioeconomic factors and stunting. The observed underweight and stunting prevalence is 2.2% and 1.9% lower than expected, respectively. Despite modest declines in underweight and stunting among young children in Malawi, underweight and stunting remain significant public health challenges particularly in southern and central Malawi which constitute about 85% of the total population. Interventions to address the critical malnutrition challenges in Malawi are inevitable within the context of SDG 2 on health.

Maternal care mediates the effects of nutrition and responsive stimulation interventions on young children's growth

BACKGROUND

Undernutrition contributes to at least half the estimated six million annual childhood deaths worldwide. Furthermore, one in three children fails to meet their developmental potential because of risks including stunting, illness, under-stimulation, poor responsive interactions and maternal depressive symptoms. Our study investigates the role of caregiving processes on children's height-for-age at 2 and 4 years.

METHODS

The Pakistan Early Child Development Scale-up study assessed the longitudinal effectiveness of early nutrition and responsive stimulation interventions on growth and development at 4 years of age. In total, 1302 children were followed up from birth to 4 years. We leveraged path analyses to explore potential mediators of early intervention effects on children's height-for-age at 4 years, including maternal depressive symptoms, mother-child interaction quality, diarrhoeal illness and height-for-age at 2 years.

RESULTS

Our final model had excellent model fit (comparative fix index = 0.999, Tucker-Lewis index = 0.998, root mean square error of approximation = 0.008) and showed that mother-child interaction quality mediated the effects of both enhanced nutrition and responsive stimulation interventions on height-for-age at 4 years via its longitudinal stability from 2 years of age (β = 0.016, p = 0.005; β = 0.048, p < 0.001, respectively). Further, diarrhoeal illness mediated the effects of maternal depressive symptoms at 1 year post partum on children's height-for-age at 4 years via the longitudinal stability of height-for-age z-score from 2 years of age onwards (β = -0.007, p = 0.019).

CONCLUSIONS

The quality of early caregiving experience mediated the association between both interventions and height-for-age. The effect of maternal depressive symptoms on growth was mediated by diarrhoeal illness. Programmatic approaches to child nutrition and growth must address all these potentially modifiable factors.

Intimate partner violence and utilization of maternal health care services in Addis Ababa, Ethiopia

Background

Despite its prominence, intimate partner violence (IPV) against women has received little attention in Ethiopia. And as many of sub-Saharan African countries, maternal health care services utilization remains poor. Full access and utilization of maternal health care services is a key to significant reduction in maternal and child mortality, and eliminate new HIV infection in infants. Identifying the factors that contribute to the poor access and utilization should aid the design of appropriate policy and intervention strategies. Thus the objective of this study was to examine the association between IPV and use of maternal health care services in Addis Ababa, Ethiopia.

Methods

A cross sectional study on couples (N = 210; male/female pairs) with an infant less than 6 months of age was conducted. The dependent variable was use of maternal health care services and the main independent variable was IPV. Data was collected using face-to-face self-reported questionnaires and analyzed using SPSS version 20.0. Bivariate and multivariate logistic regression models were used to examine the relationship between the dependent and independent variables.

Results

The mean age of the women was 28.7 years (SD = 5.4), on average women were 7.4 years (SD = 7.4) younger than their partners. Although most of the women (95.2%) had at least one antenatal care (ANC), only 35 (2%) had ≥4 ANC visits and about half (49.0%) had their first ANC visit within the first trimester. Women who experienced emotional IPV in their relationship were less likely to have their 1^st ANC within three months of pregnancy (AOR = 0.69; 95%CI = 0.49–0.96). Women who reported physical IPV in their relationship were less likely to use ≥4 ANC (AOR = 0.48; 95%CI = 0.21–0.71), be tested for HIV (AOR = 0.26; 95%CI = 0.09–0.79), have skilled delivery attendant (AOR = 0.31; 95%CI = 0.12–0.98), and deliver in a health facility (AOR = 0.35; 95%CI = 0.14–0.88). Likewise, women experienced sexual IPV or partner control in their relationship were less likely to use ANC ≥4 times (AOR_sexual-IPV = 0.91; 95%CI = 0.84–0.98 and AOR_{partner-control} = 0.38; 95%CI = 0.17–0.85 respectively).

Conclusions

IPV is prevalent among couples in Addis Ababa, Ethiopia where three out of four women reported having experienced one or more type of IPV in their current relationship. And all types of IPV showed significant association with poor utilization of one or more maternal health care services. Thus efforts to sustain the recent success in maternal health and further improvement should give due consideration to IPV.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2121-7) contains supplementary material, which is available to authorized users.

Breaking the cycles of poverty: Strategies, achievements, and lessons learned in Los Cuatro Santos, Nicaragua, 1990-2014

Background: In a post-war frontier area in north-western Nicaragua that was severely hit by Hurricane Mitch in 1998, local stakeholders embarked on and facilitated multi-dimensional development initiatives to break the cycles of poverty.

Objective: The aim of this paper is to describe the process of priority-setting, and the strategies, guiding principles, activities, achievements, and lessons learned in these local development efforts from 1990 to 2014 in the Cuatro Santos area, Nicaragua.

Methods: Data were derived from project records and a Health and Demographic Surveillance System that was initiated in 2004. The area had 25,893 inhabitants living in 5,966 households in 2014.

Results: A participatory process with local stakeholders and community representatives resulted in a long-term strategic plan. Guiding principles were local ownership, political reconciliation, consensus decision-making, social and gender equity, an environmental and public health perspective, and sustainability. Local data were used in workshops with communities to re-prioritise and formulate new goals. The interventions included water and sanitation, house construction, microcredits, environmental protection, school breakfasts, technical training, university scholarships, home gardening, breastfeeding promotion, and maternity waiting homes. During the last decade, the proportion of individuals living in poverty was reduced from 79 to 47%. Primary school enrolment increased from 70 to 98% after the start of the school breakfast program. Under-five mortality was around 50 per 1,000 live births in 1990 and again peaked after Hurricane Mitch and was approaching 20 per 1,000 in 2014. Several of the interventions have been scaled up as national programs.

Conclusions: The lessons learned from the Cuatro Santos initiative underline the importance of a bottom-up approach and local ownership of the development process, the value of local data for monitoring and evaluation, and the need for multi-dimensional local interventions to break the cycles of poverty and gain better health and welfare.