Savings/credit group formation and change in contraception

An experiment of health services and additional microcredit in 128 villages of Bangladesh

Background

Studies in the literature have found mixed results on the effect of microcredit on health outcomes. Of the five previous experimental studies that included microcredit and a health intervention, three reported no significant changes in health status or behaviors. The purpose of this study was to test for marginal and interactive effects of increased microcredit and provision of basic health services.

Methods

This study had a 4-celled experimental design in 128 villages in rural Bangladesh. For villages in one cell, an additional microcredit worker was assigned. For those in a second cell, a health assistant visited households each month, provided simple medicines and announced a satellite clinic held monthly in each village. For a third cell, both interventions were combined, and villages in a fourth cell served as control. A baseline survey was completed and a follow-up survey was done three years later. Outcome measures were food security, contraceptive use, having a trained birth attendant at last birth, and measles immunization.

Results

Comparison of follow-up with baseline levels of the four outcome measures (for 3787 households (96% completeness) and 3687 women (94% completeness)) showed significant improvement in food security in all study arms and a significant increase in trained birth attendant at last birth in the health services villages. Due to confusion within Grameen Bank about which workers would provide the additional microcredit work, that intervention was poorly implemented so in multivariate analyses, the data for that intervention arm were grouped with data from the control arm. Logistic regression with values of the outcomes at follow-up as dependent variable and study arm and women’s schooling as covariates showed no significant effects of either separate or grouped study arms.

Conclusion

Two of the three health behaviors showed no significant changes over time but having a trained birth attendant at last delivery did increase significantly in the health services arm. Therefore, community health education can sometimes be effective in promoting healthy behaviors.

Trial registration

This was a field trial rather than a clinical trial, so trial registration was unnecessary.

More than credit: Exploring associations between microcredit programs and maternal and reproductive health service utilization in India

Microcredit programs are increasingly popular interventions aimed at enabling women's economic empowerment in low- and middle-income countries. Resultant improved income, and social support from co-members of microcredit programs, may lead to increased utilization of health services. But existing research is inconclusive. This study investigates the association of microcredit program awareness and participation, with maternal and postpartum reproductive health service utilization in India. We use data from a nationally representative survey, the National Family Health Survey (2015-16), and assess three indicators of maternal health service utilization: receipt of four or more antenatal check-ups, institutional delivery, and postnatal check-up among women who had a child less than 5 years of age (N = 32,880). Reproductive health service utilization is assessed via postpartum contraceptive use within 12 months of childbirth, among women who had a live birth in the 12-59 months preceding the survey (N = 24,258). We use binomial and multinomial logistic regression models to examine associations. Additionally, we use propensity score matching to account for self-selection bias. One-third of women are aware of microcredit programs in their community/village, but only 6% have ever taken a loan from these programs. Both microcredit program awareness and participation are associated with higher odds of antenatal care, postnatal check-ups, as well as use of a modern method of contraceptive within 12 months of childbirth, even after accounting for self-selection bias. Stratified analysis by household wealth show that significant associations seen in our primary analyses are significant only for the poorest women. Findings highlight the potential value of microcredit programs in improving health service utilization during and after pregnancy, particularly among poor women. Microcredit program benefits extend beyond their participants. Non-participants living close to the programs also have greater odds of maternal and reproductive health service utilization, suggesting a spillover effect of these programs at the community level.

Is microfinance associated with changes in women's well-being and children's nutrition? A systematic review and meta-analysis

BACKGROUND

Microfinance is the provision of savings and small loans services, with no physical collateral. Most recipients are disadvantaged women. The social and health impacts of microfinance have not been comprehensively evaluated.

OBJECTIVE

To explore the impact of microfinance on contraceptive use, female empowerment and children's nutrition in South Asia, Sub-Saharan Africa and Latin America and the Caribbean.

DESIGN

We conducted a systematic search of published and grey literature (1990-2018), with no language restrictions. We conducted meta-analysis, where possible, to calculate pooled ORs. Where studies could not be combined, we described these qualitatively.

DATA SOURCES

EMBASE, MEDLINE, LILACS, CENTRAL and ECONLIT were searched (1990-June 2018).

ELIGIBILITY CRITERIA

We included controlled trials, observational studies and panel data analyses investigating microfinance involving women and children.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. The methodological quality of included studies was assessed using the Cochrane risk-of-bias tool for controlled trials and quasi-experimental studies and a modified Newcastle Ottawa Scale for cross-sectional surveys and analyses of panel data. Meta-analyses were conducted using STATA V.15 (StataCorp).

RESULTS

We included 27 studies. Microfinance was associated with a 64% increase in the number of women using contraceptives (OR 1.64, 95% CI 1.45 to 1.86). We found mixed results for the association between microfinance and intimate partner violence. Some positive changes were noted in female empowerment. Improvements in children's nutrition were noted in three studies.

CONCLUSION

Microfinance has the potential to generate changes in contraceptive use, female empowerment and children's nutrition. It was not possible to compare microfinance models due to the small numbers of studies. More rigorous evidence is needed to evaluate the association between microfinance and social and health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42015026018.

Men's Report of Domestic Violence Perpetration in Bangladesh: Correlates From a Nationally Representative Survey

This study provides an examination of the antecedents of domestic violence perpetration among a nationally representative sample of men in Bangladesh using an ecological model. Secondary analysis of survey data from nationally representative Bangladesh Demographic and Health Survey is used to examine potential antecedents of perpetration of domestic violence in a sample of 3,371 ever-married men between the ages of 15 and 54 years. Outcome measure is perpetration of domestic violence as measured by a modified Conflict Tactics Scale (CTS), and predictor variables include maternal domestic violence, egalitarianism, marital age, number of household members, wealth index, marital duration, and demographic variables. Men who reported maternal domestic violence had 0.13 greater probability of perpetrating domestic violence compared with men who did not report maternal domestic violence, men who were egalitarian had 0.04 greater probability of perpetrating domestic violence compared with men who were not egalitarian, men in larger households were less likely to report domestic violence. At the same time, the probability of domestic violence perpetration was 0.07 smaller for men who were married at age 36 years and older, as compared with men who were married between the ages of 16 and 20 years, as well as men who were married for more than 5 years when compared with men married for 0 to 4 years. Finally, the probability of domestic violence perpetration was 0.17 smaller for men who were married between the ages of 21 and 25 years and 0.10 smaller for men married between the ages of 26 and 35 years, compared with men who married below the legal marital age of 21. This study provides support for the use of an ecological model to explain domestic violence perpetration in the context of Bangladesh to suggest a multipronged holistic effort to address this insidious social problem and prevent its intergenerational transmission.

Familial Power and Women's Contradictory Responses to Attitudinal Questions About Intimate Partner Violence in Rural Bangladesh

Research is lacking on how power processes can influence women's reporting of their attitudes about intimate partner violence (IPV) against women. Structural elements of textual data were investigated as potential evidence of latent power. Overall, the majority of the women switched their response at least once throughout the interview, and the context of these contradictory responses provide evidence that women's reporting of attitudes about IPV against women may be understood as arising in part from latent power processes. New methodological tools are needed to better understand women's personal attitudes about IPV against women.

Increasing literate and illiterate women's met need for contraception via empowerment: a quasi-experiment in rural India

Background

Virtually all the evidence on the relationship between women’s empowerment and use of contraception comes from cross-sectional studies that have emphasized macrosocial factors.

This analysis tested whether literate and illiterate women are empowered by an intervention designed to provide information addressing technical and gender concerns and expand contraceptive choice, and evaluated the effects of women’s decision-making power on contraceptive behavior.

Methods

The data came from a three-year quasi-experiment conducted in two comparable, yet not equivalent, rural blocks in Jharkhand, India. At the intervention block, a new contraceptive method was introduced at Ministry of Health health centers, providers were trained to offer family planning information and services which took into consideration gender power dynamics, and promotional messages and information about contraception were disseminated community-wide. Married women ages 15–49 who lived in the intervention and control blocks were sampled and interviewed before and after the intervention by a professional research firm. Data analyses included generalized linear models with interactions and covariate control.

Results

Women’s normative beliefs concerning wives’ power in decisions regarding money earned and visits to relatives and friends vis-à-vis their husbands’ power were increased by the intervention; similar was the case among illiterate, but not literate, women regarding decisions related to childbearing. Concerning met need for contraception, the change for women with relatively more power who were illiterate was greater in the intervention than in the control area.

Conclusion

The findings suggest that women were empowered by outreach visits that addressed gender dynamics and that their empowerment contributed to their met need for contraception. Generalizations to other settings, however, may be limited by cultural differences.

Electronic supplementary material

The online version of this article (doi:10.1186/1742-4755-11-74) contains supplementary material, which is available to authorized users.

Microcredit and domestic violence in Bangladesh: an exploration of selection bias influences

This article explores the relationship between women's participation in microcredit groups and domestic violence in Bangladesh. Several recent studies have raised concern about microcredit programs by reporting higher levels of violence among women who are members. These results, however, may be attributable to selection bias because members might differ from nonmembers in ways that make them more susceptible to violence to begin with. Using a sample of currently married women from the 2007 Bangladesh Demographic Health Survey (BDHS) (N = 4,195), we use propensity score matching (PSM) as a way of exploring selection bias in this relationship. Results suggest that the previously seen strong positive association between membership and violence does not hold when an appropriate comparison group, generated using PSM, is used in the analyses. Additional analyses also suggest that levels of violence do not differ significantly between members and nonmembers and instead could depend on context-specific factors related to poverty. Members for whom a match is not found report considerably higher levels of violence relative to nonmembers in the unmatched group. The background characteristics of members and nonmembers who do not match suggest that they are more likely to be younger and from relatively well-to-do households.

Predicting contraceptive use from an egalitarian model of women's overall household power vis-à-vis conventional power models and third variables

Research on gender power in contraceptive use has focused on whether women have an active role in household decision-making (the participation model) or on the extent of their control of domestic decisions (the control model); it has also addressed the joint effects of power, age, education and work. Findings published in this journal (Woldemicael, 2009) suggest a third power model according to which wives make joint decisions with their husbands on important domestic areas and autonomous decisions on secondary matters (the egalitarian model). In analyses of Demographic and Health Survey data sets from 46 countries, the egalitarian model explained contraceptive use better than the control and participation models in 19 out of 20 countries outside sub-Saharan Africa; its superiority was less overwhelming in this sub-continent. Power effects on contraceptive use that depend on women's education, age and work for cash are larger in sub-Saharan Africa than in other world regions, whereas independent power effects differ little regionally, suggesting the action of a personality factor. Situational specification of decision importance and direct measurement of women's assertiveness are needed to improve the explanation of contraceptive behaviour.

Measurement of Women's Empowerment in Rural Bangladesh

Women's empowerment is a dynamic process that has been quantified, measured and described in a variety of ways. We measure empowerment in a sample of 3500 rural women in 128 villages of Bangladesh with five indicators. A conceptual framework is presented, together with descriptive data on the indicators. Linear regressions to examine effects of covariates show that a woman's exposure to television is a significant predictor of three of the five indicators. A woman's years of schooling is significantly associated with one of two self-esteem indicators and with freedom of mobility. Household wealth has a significant and positive association with a woman's resource control but a significant negative association with her total decision-making score.

What works in family planning interventions: a systematic review

This study presents findings from a systematic review of evaluations of family planning interventions published between 1995 and 2008. Studies that used an experimental or quasi-experimental design or used another approach to attribute program exposure to observed changes in fertility or family planning outcomes at the individual or population levels were included and ranked by strength of evidence. A total of 63 studies met the inclusion criteria. The findings from this review are summarized in tabular format by the type of intervention (classified as supply-side or demand-side). About two-thirds of the studies found were evaluations of programs focusing on demand generation. Findings from all programs revealed significant improvements in knowledge, attitudes, discussion, and intentions. Program impacts on use of contraceptives and use of family planning services were less consistently found, and fewer than half of the studies that measured fertility or pregnancy-related outcomes found an impact. Based on the review findings, we identify promising programmatic approaches and propose directions for future evaluation research of family planning interventions.

Microcredit, Family Planning Programs, and Contraceptive Behavior: Evidence From a Field Experiment in Ethiopia

The impact of community-based family planning programs and access to credit on contraceptive use, fertility, and family size preferences has not been established conclusively in the literature. We provide additional evidence on the possible effect of such programs by describing the results of a randomized field experiment whose main purpose was to increase the use of contraceptive methods in rural areas of Ethiopia. In the experiment, administrative areas were randomly allocated to one of three intervention groups or to a fourth control group. In the first intervention group, both credit and family planning services were provided and the credit officers also provided information on family planning. Only credit or family planning services, but not both, were provided in the other two intervention groups, while areas in the control group received neither type of service. Using pre- and post-intervention surveys, we find that neither type of program, combined or in isolation, led to an increase in contraceptive use that is significantly greater than that observed in the control group. We conjecture that the lack of impact has much to do with the mismatch between women’s preferred contraceptive method (injectibles) and the contraceptives provided by community-based agents (pills and condoms).

WIFE ABUSE IN RURAL BANGLADESH

Intimate partner violence (IPV) is a global public health and gender problem, especially in low-income countries. The study focused on verbal abuse, physical abuse and abuse by restricting food provision to wives by their husbands by victim and perpetrator characteristics, emphasizing the socioeconomic context of rural Bangladesh. Using a cross-sectional household survey of 4411 randomly selected married women of reproductive age, the study found that a majority of the respondents are exposed to verbal abuse (79%), while 41% are exposed to physical abuse. A small proportion (5%) of the women had suffered food-related abuse. Risk factors observed were age of the wife, illiteracy (of both victims and perpetrators), alcohol misuse, dowry management, husband's monetary greed involving parents-in-law, and wife's suspicions concerning husband's extramarital affairs. Well-established risk factors for wife abuse, along with dowry and husband's monetary greed, have a relatively high prevalence in rural Bangladesh.

Exploring the role of economic empowerment in HIV prevention

It has been argued that women's economic vulnerability and dependence on men increases their vulnerability to HIV by constraining their ability to negotiate the conditions, including sexual abstinence, condom use and multiple partnerships, which shape their risk of infection. In the face of escalating infection rates among women, and particularly young women, many have pointed to the potential importance of economic empowerment strategies for HIV prevention responses. Global evidence suggests that the relationship between poverty and HIV risk is complex, and that poverty on its own cannot be viewed simplistically as a driver of the HIV epidemic. Rather, its role appears to be multidimensional and to interact with a range of other factors, including mobility, social and economic inequalities and social capital, which converge in a particularly potent way for young women living in southern Africa. To date, there have been few interventions that have explicitly attempted to combine economic empowerment with the goal of HIV prevention, and even fewer that have been rigorously evaluated. This paper explores how programmes such as microfinance, livelihood training and efforts to safeguard women's food security and access to property have begun to incorporate an HIV prevention focus. Although such circumscribed interventions, by themselves, are unlikely to lead to significant impacts on a national or regional scale, they are useful for testing cross-sectoral partnership models, generating practical lessons and providing a metaphor for what might be possible in promoting women's economic empowerment more broadly. Despite numerous calls to 'mainstream AIDS' in economic development, cross-sectoral responses have not been widely taken up by government or other stakeholders. We suggest potential reasons for limited progress to date and conclude by presenting programme and policy recommendations for further exploring and harnessing linkages between economic empowerment and HIV prevention in Southern Africa.

Micro-credit, women's groups, control of own money: HIV-related negotiation among partnered Dominican women

A sample of 356 members of women's groups, aged 18-49, in the Dominican Republic were interviewed by trained female interviewers. Data among 273 partnered women were analyzed. The dependent variable, a measure of HIV-related negotiation, was examined for associations with control of own money, level of women's group participation, and ever having received a loan through a micro-credit program. Findings suggest control of own money to be significantly associated with HIV-related negotiation. Ever having received a loan and level of women's group participation, however, were not significantly associated with HIV-related negotiation. Empowerment measured as control of own money may influence HIV protective behavior among partnered women in this setting.

Physical violence by husbands: Magnitude, disclosure and help-seeking behavior of women in Bangladesh

This paper explores the magnitude of physical violence by husbands, the disclosure of it and the help-seeking behavior of abused women in urban and rural Bangladesh. The data come from a larger study on domestic violence against women conducted in Bangladesh during 2000-2004. All ever-married women covered by the population-based survey component (n=2702) conducted in 2001 were included in the current analysis. We also draw on in-depth interviews with 28 women who were physically abused by their husbands. Results show a high prevalence of lifetime physical spousal violence against women: 40% in urban and 42% in rural areas. Most of the abused women (66%) were silent about their experience. The main reasons behind this silence were high acceptance of violence, stigma and fear of greater harm. Sixty percent of urban and 51% of rural abused women never received any help from others. Only 2% ever sought help from institutional sources, from where support was not forthcoming. Women approached these sources only when they could not endure anymore or the violence became life threatening or children were at risk. The findings show that although providing appropriate services is absolutely necessary, it is also important to foster the use of such services and to help women overcome the barriers for accessing these services.

Factors associated with spousal physical violence against women in Bangladesh

Using data from a population-based survey of 2,702 women of reproductive age and from 28 in-depth interviews of abused women conducted during 2000-01, this study explores factors associated with domestic violence in urban and rural Bangladesh. Multilevel analysis revealed that in both residential areas, dowry or other demands in marriage and a history of abuse of the husband's mother by his father increased the risk of violence. Better spousal communication and husband's education beyond the tenth grade decreased the risk of violence. In the urban area, women's being younger than their husband and participating in savings and credit groups increased the risk of abuse, whereas husband's education beyond the sixth grade had a protective effect. In the rural area, women's earning an income increased the risk. These factors are important to consider when designing interventions.

Spatial variation in contraceptive use in Bangladesh: looking beyond the borders

This article promotes a more complete understanding of social change by analyzing spatial patterns of contraceptive use in Bangladesh and the contiguous state of West Bengal in India. Multilevel analyses that control for variations in individual- and household-level correlates show an important role for cross-border influences only in those districts that share a common language across the border. The districts that are positive outliers in contraception hug the Bangladesh-West Bengal border. A map of outliers shows that the positive outliers form a contiguous band in a manner suggestive of a role for contagion.