The association between early in marriage fertility pressure from in-laws' and family planning behaviors, among married adolescent girls in Bihar and Uttar Pradesh, India

Life skills and reproductive health empowerment intervention for newly married women and their families to reduce unintended pregnancy in India: protocol for the TARANG cluster randomised controlled trial

INTRODUCTION

In South Asia, younger women have high rates of unmet need for family planning and low empowerment. Life skills interventions can equip young women with agency, but the effectiveness of these interventions in reproductive and sexual autonomy and contraception has not been examined.

METHODS AND ANALYSIS

A two-arm, parallel, cluster randomised controlled trial will evaluate the impact of TARANG (Transforming Actions for Reaching and Nurturing Gender Equity and Empowerment), a life skills and reproductive health empowerment group-based intervention for newly married women, compared with usual services in the community in rural and tribal Rajasthan, India. TARANG will also provide light-touch sessions to husbands and mothers-in-law of newly married women. We will test the impact of TARANG in 80 village clusters among 800 eligible households comprising newly married women aged 18-25 years who are at risk of pregnancy but do not want a pregnancy within 1 year at the time of enrolment, their husbands and mothers-in-law who consent to participate. Women in the intervention villages will receive 14 sessions over a 6-month period, while husbands and mothers-in-law will receive 1 and 4 sessions (respectively) each. Three rounds of surveys will be collected over 18 months. Control villages will receive the intervention after the endline surveys. Primary outcomes include rate of unintended pregnancy and modern contraceptive use. We plan to start recruitment of participants and data collection in April 2024. We will estimate unadjusted and adjusted intention-to-treat effects using survival analysis and mixed models.

ETHICS AND DISSEMINATION

Study protocols have been reviewed and approved by the human subjects review boards at the University of California, San Francisco, and the Centre for Media Studies, India (IRB00006230) and ACE Independent Ethics Committee, Bangalore (NET0062022). Results will be disseminated in international peer-reviewed journals and conferences, to stakeholders including local government and non-governmental organisations, and directly to the communities and individuals that participated in the intervention.

TRIAL REGISTRATION NUMBER

NCT06024616.

Residential and wealth-related disparities of high fertility preferences in Ethiopia: A decomposition analysis

BACKGROUND

Fertility preference significantly influences contraceptive uptake and impacts population growth, especially in low and middle-income countries. In the previous pieces of literature, variations in fertility preference across residence and wealth categories and its contributors were not assessed in Ethiopia. Therefore, we decomposed high fertility preferences among reproductive-aged women by residence and wealth status in Ethiopia.

METHODS

We extracted individual women's record (IR) data from the publicly available 2016 Ethiopian Demographic Health Survey (EDHS) dataset. A total of 13799 women were included in the study. Multivariate decomposition analysis was conducted to identify the factors that contributed to the differences in the percentage of fertility preferences between rural and urban dwellers. Furthermore, we used an Erreygers normalized concentration index and curve to identify the concentration of high fertility preferences across wealth categories. The concentration index was further decomposed to identify the contributing factors for the wealth-related disparities in high fertility preference. Finally, the elasticity of wealth-related disparity for a change in the socioeconomic variable was estimated.

RESULTS

The weighted percentage of women with high fertility preference among rural and urban residents was 42.7% and 19%, respectively, reflecting a 23.7 percentage point difference. The variations in fertility preference due to the differences in respondents' characteristics accounted for 40.9%. Being unmarried (8.4%), secondary (14.1%) and higher education (21.9%), having more than four children (18.4%), having media exposure (6.9%), middle (0.4%), richer (0.2%) and richest (0.1%) wealth were the positive and city administration (-30.2%), primary education (-1.3%) were the negative contributing factors for the variations in high fertility preferences due to population composition. Likewise, about 59% of the variations in fertility preference were due to variations in coefficients. City administration (22.4%), primary (7.8%) and secondary (7.4%) education, poorer wealth (0.86%) were the positive and having media exposure (-6.32%) and being unmarried (-5.89%), having more than four children (-2.1%) were the negative factors contributing to the difference in high fertility preferences due to the change in coefficients across residents. On the other hand, there was a pro-poor distribution for high fertility preferences across wealth categories with Erreygers normalized concentration index of ECI = -0.14, SE = 0.012. Having media exposure (17.5%), primary (7.3%), secondary (5.4%), higher (2.4%) education, being unmarried (8%), having more than four children (7.4%), rural residence (3%) and emerging (2.2%) were the positive and city administration (-0.55) was the negative significant contributor to the pro-poor disparity in high fertility preference.

CONCLUSION

The variations in high fertility preferences between rural and urban women were mainly attributed to changes in women's behavior. In addition, substantial variations in fertility preference across women's residences were explained by the change in women's population composition. In addition, a pro-poor distribution of high fertility preference was observed among respondents. As such, the pro-poor high fertility preference was elastic for a percent change in socioeconomic variables. The pro-poor high fertility preference was elastic (changeable) for a percent change in each socioeconomic variables. Therefore, women's empowerment through education and access to media will be important in limiting women's desire for more children in Ethiopia. Therefore, policymakers should focus on improving the contributing factors for the residential and wealth-related disparities in high fertility preferences.

Adolescent Sexual Behavior in Rural Central India: Challenges and Interventions

Adolescence is a crucial life stage marked by significant physical, psychological, and societal changes. With India projected to have the highest population of teenagers by 2025, understanding adolescent sexual behavior in rural central India is essential due to its unique social and cultural contexts. This article reviews existing literature to explore the prevalence, risk factors, and consequences of teenage sexual behavior in rural central India. It highlights the challenges posed by societal taboos, limited access to sexual health information and services, and the impact of poverty on adolescents' sexual behavior and health outcomes. To address these issues, comprehensive sex education, improved access to contraception and reproductive health services, and efforts to overcome cultural and societal norms are crucial. The article discusses the initiatives undertaken by the government and non-governmental organizations (NGOs) to tackle adolescent sexual behavior and emphasizes the need for a multifaceted approach that addresses systemic issues while empowering adolescents. It concludes by suggesting future research directions and policy recommendations aimed at promoting safe sexual behavior among rural adolescents in central India. This article will discuss the complexity of adolescent sexual behavior in rural central India, its origins, and the challenges faced by medical decision-makers.

Role of marriage, motherhood, son preference on adolescent girls' and young women's empowerment: Evidence from a panel study in India

BACKGROUND

Marriage is a key determinant of health and well-being of adolescent girls and young women (AGYW) in India. It is a key life event in which girls move to their marital households, often co-residing with their in-laws and begin childbearing. The change in the normative environment in conjunction with cultural norms surrounding son preference influences women's overall life course. However, there is scant research about the association between these life transitions and changes in empowerment among AGYW in India.

METHODS

Using two waves of data from prospective cohort panel dataset that followed unmarried (6,065 observations in each wave) and married AGYW (3,941 observations from each wave) over a three-year period from Uttar Pradesh and Bihar, we examined how marriage, childbearing, and having a son is associated with changes in AGYW's empowerment, especially considering whether AGYW marry into patrilocal households (household with in-laws) as an effect modifier. Empowerment indicators included freedom of movement or mobility, decision-making power, access to economic using Kabeer's framework as our theoretical approach.

RESULTS

Marriage was associated with lower freedom of movement with a pronounced effect on those who co-resided with their in-laws. Marriage was associated with greater decision-making power for AGYW who did not co-reside with the in-laws. Motherhood was positively correlated with greater freedom of movement, marginally higher intrahousehold decision-making power, and better access to economic resources. No statistically significant evidence that having at least one son compared to having daughters only (or no daughters) conferred additional changes in girls' freedom of movement, intrahousehold decision-making power, and access to economic resources.

CONCLUSION

Findings highlight the importance of understanding the vulnerabilities of being newly married in adolescence and emphasize the need for having interventions that target newly married AGYW along with mothers-in-law to empower them.

The development of pressure scale toward marriage and fertility in social structure

In some cultures, giving birth and marriage adds value to women, while being single can cause women to be exposed to social and individual pressures. There are currently no instruments available in the literature for assessing how pressure women feel to be married and have children. This study aimed to develop the Marriage and Fertility Pressure Scale (PSMF) by measuring the marriage and fertility pressure on single women. The study contacted 360 single women via women's health and social groups on social networking sites. Cronbach's alpha values of the marriage pressure and fertility pressure were 0.94 and 0.82, respectively. The factor analysis of the marriage and fertility pressure subscales revealed a six-dimensional structure explaining 59.26 percent and 60.54 percent of the total variance, respectively. In conclusion, this study was important in developing a highly reliable and valid PSMF measurement tool to measure the pressure on women in terms of marriage and fertility. The widespread use of the scale in public health research will increase the sensitivity and awareness of the people about the pressure on single women. Moreover, this scale will contribute to the evaluation of the social and individual pressure differences in the research to be carried out on marriage and childbirth between societies.

Examining the influence of Mother-in-law on family planning use in South Asia: insights from Bangladesh, India, Nepal, and Pakistan

BACKGROUND

Contraceptive use contributes to improved maternal and child health, education, empowerment of women, slow population growth, and economic development. The role of the family in influencing women's health and health-seeking behavior is undergoing significant changes, owing to higher education, media exposure, and numerous government initiatives, in addition to women's enhanced agency across South Asia. Against this backdrop, this study assesses the relationship between women's living arrangements and contraceptive methods used in selected south Asian countries (India, Pakistan, Nepal, and Bangladesh).

METHODS

Data of currently married women aged 15-49 from the recent round of Demographic and Health Survey (DHS) of four South Asian countries, i.e., Nepal (2016), Pakistan (2017-18), Bangladesh (2017-18), and India (2019-21) had been used. Bivariate and multinomial logistic regression was performed using Stata with a 5% significance level.

RESULTS

Living arrangement of women had a significant association with contraceptive use in South Asia. The Mother-in-law (MIL) influenced the contraceptive method used by the Daughter-in-law (DIL), albeit a country-specific method choice. Modern limiting methods were significantly higher among women living with MIL in India. The use of the modern spacing method was considerably high among women co-residing with husband and/or unmarried child(ren) and MIL in Nepal and India. In Bangladesh, women living with husband and other family member including MIL were more likely to use modern spacing methods.. Women co-residing with the MIL had a higher likelihood of using any traditional contraceptive method in India.

CONCLUSIONS

The study suggests family planning program to cover MIL for enhancing their understanding on the benefits of contraceptive use and modifying norms around fertility. Strengthening the interaction between the grassroots level health workers and the MIL, enhancing social network of DIL may help informed choice and enhance the use of modern spacing methods. Women's family planning demands met with modern contraception, and informed contraceptive choices, must also be achieved to reach the 2030 Agenda for Sustainable Development.

Factors that provide protection against intimate partner physical violence among married adolescents in Bangladesh

Background

Intimate partner violence (IPV), and especially intimate partner physical violence (IPPV), perpetrated by husbands, and within adolescence marriage are pervasive in Bangladesh. Younger women are more vulnerable to IPPV.

Objectives

We examined factors associated with IPPV experienced by married adolescents ages 15–19 and tested four hypotheses: (1) adolescent girls married to relatively older husbands, (2) adolescents living in extended families with parents or parents-in-law, (3) adolescents who are minimally controlled by husbands, and (4) adolescents who have a child after marriage are protective of IPPV.

Methods

We analyzed IPPV data from 1,846 married girls ages 15–19 obtained from a national adolescent survey conducted in 2019–20. IPPV is defined as the respondent having physical violence perpetrated by her husband at least once in the last 12 months. We implemented logistic regression models to test our hypotheses.

Results

Sixteen percent of married adolescent girls experienced IPPV. Girls living with parents-in-law or parents had adjusted odds ratio (AOR) of 0.56 (p < 0.001) of IPPV compared to those girls who lived with husband alone. Girls with husbands ages 21–25 years and 26 years or older had AORs of 0.45 (p < 0.001) and 0.33 (p < 0.001) of IPPV compared to those girls with their husband ages 20 and younger. Married adolescent girls who did not own a mobile phone (an indicator of spousal power dynamics) had an AOR of 1.39 (p < 0.05) compared to those girls who had a phone. IPPV risk increases with an increased duration of marriage for those with no living children (p < 0.001) but not for those with at least one living child; the risk was higher among those who had a child within the 1st year of marriage than those who had not yet had a child. At a duration of 4 years and longer, IPPV risk was higher among those with no living children than those with children.

Discussion

Findings related to those living with parents-in-law or parents, girls married to relatively older boys/men, having the ability to communicate with outside world, and having a child are protective of IPPV in Bangladesh are new, to our knowledge. Strictly adhering to the law that requires men waiting until the age of 21 to marry can reduce married girls' risk of IPPV. Raising girls' legal marriage age can minimize adolescents' IPPV and other health risks associated with adolescent childbearing.

Prevalence and factors associated with teenage pregnancy in Sierra Leone: evidence from a nationally representative Demographic and Health Survey of 2019

BACKGROUND

Globally, teenage pregnancy remains a public health concern because of the associated maternal and perinatal morbidity and mortality. To address the extensive social, political and economic effects of teenage pregnancy, there is need for current epidemiological evidence on its prevalence and associated factors, especially from low resource settings where the burden is highest.

METHODS

We used data from the 2019 Sierra Leone Demographic and Health Survey (SLDH), which included 3,427 female adolescents. Multistage stratified sampling was used to select study participants. Teenage pregnancy was defined as those who had ever either had a child, or terminated a pregnancy, or were currently pregnant. Multivariable logistic regression was conducted to determine the factors associated with teenage pregnancy using SPSS version 25(Armonk, NY: IBM Corp).

RESULTS

The prevalence of teenage pregnancy was 22.1% [758/3,427]. Of these, 17.8%, (608/3427), had ever had childbirth, 4.2%, (144/3427), were pregnant, and 1.2%, (40/3427) had ever terminated a pregnancy. After adjusting for confounders, the odds of teenage pregnancy among married girls were about 15 times more than the odds among those who were not married (aOR; 15.31, 95% CI: 11.17-20.98) while the odds of teenage pregnancy among girls from the poorest households were 2.5 times more than the odds among girls from the richest households.

CONCLUSION

The prevalence of teenage pregnancy in Sierra Leone is high. To reduce teenage pregnancy, the government of Sierra Leone and its partners should target married, older teenagers and those from poor households. Policies giving teenage mothers a second chance by encouraging them to return to school after childbirth should be encouraged as an alternative to early marriages.

Future directions for reproductive coercion and abuse research

BACKGROUND

Reproductive coercion and abuse (RCA) is a form of intimate partner violence (IPV) in which people with the capacity for pregnancy experience coercive behaviors that threaten their reproductive autonomy. Behaviors that constitute RCA include contraceptive control/sabotage, pregnancy pressure, and controlling the outcome of a pregnancy. Several areas of RCA study have emerged: associations with IPV, health outcomes resulting from RCA, and demographic and contextual factors associated with experiencing RCA. Current research in these areas is summarized and placed in a global context, including sexual and gender minority groups, use of RCA (exploring perpetration), RCA interventions, RCA in women with disabilities, and the question of whether people assigned male at birth can be RCA victims.

CONCLUSION

Areas for future exploration include evolving interpretations of pregnancy intention in the setting of fewer options for abortion, RCA in people with disabilities and multiple levels of marginalization, including sexual and gender minorities; intersections between RCA and economic abuse in the context of efforts at economic justice; and community-centered approaches to intervention and prevention.

Qualitative Examination of the Role and Influence of Mothers-in-Law on Young Married Couples' Family Planning in Rural Maharashtra, India

Unmet need for family planning (FP) continues to be high in India, especially among young and newly married women. Mothers-in-law (MILs) often exert pressure on couples for fertility and control decision making and behaviors around fertility and FP, yet there is a paucity of literature to understand their perspectives. Ten focus group discussions (FGDs) were carried out with MILs of young married women (aged 18-29 years) participating in a couple-focused FP intervention as a part of a cluster-randomized intervention evaluation trial (the CHARM2 study) in rural Maharashtra, India. FGDs included questions on their roles, attitudes, and decision making around fertility and FP. Audio-recorded data were translated/transcribed into English and analyzed for key themes using a deductive coding method. MILs reported having social norms of early fertility and son preference. They understood that family size norms are lower among daughters-in-law and that spacing can be beneficial but were not supportive of short-term contraceptives, especially before the first child. They preferred female sterilization, opposed abortion, had apprehensions around side effects from contraceptive use, and had misconceptions about the intrauterine device, with particular concerns around its coercive insertion. MILs mostly believed that decision making should be done jointly by a husband and wife, but that as elders, they should be consulted and involved in the decision-making process. These findings highlight the need for engagement of MILs for FP promotion in rural India and the potential utility of social norms interventions.

Household Structure and Contraceptive Use in Nigeria

Background

Contraceptive use in Nigeria has been consistently low despite its many benefits and several efforts by government and development partners to increase its uptake. According to the Nigeria Demographic and Health Survey, the use of any modern method staggeringly increased from 4 to 12% over 28 years (1990-2018). Studies have identified factors at the individual, household, and societal levels that affect contraceptive use. While studies have also shown that decisions such as contraceptive behavior and acquisition of family skills may vary according to the individual or societal factors, there is a dearth of knowledge on how household structure and composition influence contraceptive use in Nigeria. This article seeks to contribute to the body of knowledge by exploring contraceptive use within the household context.

Method

We used data from the 2018 Nigeria Demographic and Health Survey to examine the relationship between household structure and contraceptive use. We excluded pregnant and non-married women at the time of the survey from the sample and used multinomial regression analysis to examine the likelihood of using traditional or modern methods of contraception.

Results

Results show that having a large household size, and the presence of multiple wives in the household significantly reduces the likelihood of using any method of contraceptive. The result further shows a significant association between household wealth index and contraceptive use as the use of any method increases with household wealth index, with those from richest households being twice as likely as their counterparts in the poorest households to use traditional methods (OR:2.02, p < 0.05). Also, women living in households headed by older men (25 and above), households with under 5 children, and those living in rural areas have significantly reduced likelihood of using any method.

Conclusion

This study highlights the dynamics of contraceptive use among married women considering household composition. While our study serves as a primer to understanding contraceptive use in households where a woman and her spouse are usual household members, improved family planning interventions to increase uptake through demand creation will require deeper and more comprehensive work to understand the dynamics among women in more complex household settings.

Ethical implications of the widespread use of informal mHealth methods in Ghana

BACKGROUND

Informal mHealth is widely used by community health nurses in Ghana to extend healthcare delivery services to clients who otherwise might have been excluded from formal health systems or would experience significant barriers in their quest to access formal health services. The nurses use their private mobile phones or devices to make calls to their clients, health volunteers, colleagues or superiors. These phone calls are also reciprocal in nature. Besides, the parties exchange or share other health data and information through text messages, pictures, videos or voice clips. There are some ethical dimensions that are inherent in these practices that ought to be critically scrutinised by bioethicists.

OBJECTIVE

The author has argued in this paper that informal mHealth at large scale adoption in Ghana is associated with some bioethical challenges.

METHODS

This essay was largely based on an analysis of an empirical study published by Hampshire et al in 2021 on the use of informal mHealth methods in Ghana.

RESULTS

Widespread adoption of Informal mHealth in Ghana is associated with privacy invasion of both the nurses and their clients, breaches confidentiality of the parties, discredits the validity of informed consent processes and may predispose the nurses to some other significant aggregated harms.

CONCLUSION

The author affirms his partial support for a formalised adoption process of informal mHealth in Ghana but has reiterated that the current ethical challenges associated with informal mHealth in Ghana cannot escape all the debilitating bioethical challenges, even if it is formalised.

Facilitating behavioral change: A comparative assessment of ASHA efficacy in rural Bihar

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA's overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.

Women's empowerment and fertility decision-making in 53 low and middle resource countries: a pooled analysis of demographic and health surveys

OBJECTIVE

Women's empowerment and its association with fertility preference are vital for central-level promotional health policy strategies. This study examines the association between women's empowerment and fertility decision-making in low and middle resource countries (LMRCs).

DESIGN

This cross-sectional study uses the Demographic and Health Survey database.

SETTINGS

53 LMRCs from six different regions for the period ranging from 2006 to 2018.

PARTICIPANTS

The data of women-only aged 35 years and above is used as a unit of analysis. The final sample consists of 91 070 married women.

METHODS

We considered two outcome variables: women's perceived ideal number of children and their ability to achieve preferred fertility desire and the association with women empowerment. Women empowerment was measured by their participation in household decision-making and attitude towards wife-beating. The negative binomial regression model was used to assess women's perceived ideal number of children, and multivariable logistic regression was used to evaluate women's ability to achieve their preferred fertility desire.

RESULTS

Our study found that empowered women have a relatively low ideal number of children irrespective of the measures used to assess women empowerment. In this study, the measures were participation in household decision-making (incidence rate ratio (IRR): 0.92, 95% CI: 0.91 to 0.93) and attitude towards wife-beating (IRR: 0.96, 95% CI: 0.95 to 0.97). In the LMRCs, household decision-making and negative attitude towards wife-beating have been found associated with 1.12 and 1.08 times greater odds of having more than their ideal number of children.

CONCLUSION

Our findings suggest that women's perceived fertility desire can be achieved by enhancing their empowerment. Therefore, a modified community-based family planning programme at the national level is required, highlighting the importance of women's empowerment on reproductive healthcare as a part of the mission to assist women and couples to have only the number of children they desire.