Maternal mortality in Eastern Democratic Republic of Congo: a 10-year multi-zonal institutional death review

BACKGROUND

Maternal mortality (MM) remains a real scourge that hits hardest in the poorest regions of the world, particularly those affected by conflict. However, despite this worrying reality, few studies have been conducted about MM ratio in the Democratic Republic of Congo (DRC). The study aimed to describe the trends as well as the epidemiological profile and causes of reported institutional maternal deaths between 2013 and 2022 in Eastern DRC.

METHODS

A retrospective descriptive study was conducted between March 2023 and August 2023 in eight Health Zones (HZ), five in South Kivu Province (Mwana, Minova, Miti-Murhesa, Kamituga and Idjwi) and three in North Kivu Province (Kirotshe, Karisimbi and Kayna) in the eastern region of the DRC. Our study covers 242 health facilities: 168 health centers (HC), 16 referral health centers (RHCs),50 referral hospitals (RH) and 8 general referral hospitals (GRHs). Data from registers and medical records of maternal deaths recorded in these zones from 2013-2022 were extracted along with information on the number of deliveries and live births. Sociodemographic, clinical parameters, blood and ultrasound tests and suspected causes of death between provinces were assessed.

RESULTS

In total, we obtained 177 files on deceased women. Of these, 143 (80.8%) were retained for the present study, including 75 in the 3 HZs of North Kivu and 68 in the 5 HZs of South Kivu. From 2013 to 2022, study sites experienced two significant drops in maternal mortality ratio (MMR) (in 2015 and 2018), and a spike in 2016-2017. Nonetheless, the combined MMR (across study sites) started and ended the 10-year study period at approximately the same level (53 and 57 deaths per 100,000 live births in 2013 and 2022 respectively). Overall, 62,6% of the deaths were reported from secondary hospital. Most deaths were of married women in their thirties (93.5%). Almost half (47.8%) had not completed four antenatal consultations. The main direct causes of death were, in decreasing order of frequency: post-partum haemorrhage (55.2%), uterine rupture (14.0), hypertensive disorders (8.4%), abortion (7.7%) puerperal infections (2.8%) and placental abruption (0.7%). When comparing among provinces, reported abortion-related maternal mortality (14.1% vs 0%) was more frequent in North Kivu than in South Kivu.

CONCLUSION

This study imperatively highlights the need for targeted interventions to reduce maternal mortality. By emphasizing the crucial importance of antenatal consultations, intrapartum/immediate post-partum care and quality of care, significant progress can be made in guaranteeing maternal health and reducing many avoidable deaths.

Fertility Intentions During the Covid-19 Pandemic: An Analysis of Individual- and Municipality-Level Determinants

Recognizing the prolonged, uneven, and evolving nature of the Covid-19 pandemic, this study provides one of the first dynamic, multilevel perspectives of women's fertility intentions in response to the pandemic and its multifaceted impacts. We examine how evolving individual- and community-level Covid-19 risk mechanisms and socioeconomic and life-course conditions are associated with continuity and change in women's fertility intentions. We combine individual-level panel data from a population-based sample of women aged 18-34 in Pernambuco, Brazil in 2020 and 2021 with corresponding administrative data from 94 municipalities. We use multinomial logit regressions to model continuity and change in fertility intentions across waves. We then estimate fixed effect models to highlight the time-varying determinants of changing fertility intentions while accounting for unobserved, time-invariant individual factors. We find that high and/or increasing individual and community-level Covid-19 exposure is associated with a greater likelihood of abandoning initial childbearing plans and a greater likelihood to maintain intentions to forego versus to intend having additional children. We advance the literature by highlighting how individual-level Covid-19 infection risk perceptions matter for fertility intentions, net of community-level exposure, and the necessity of dynamic perspectives for understanding how fertility intentions have changed (or not) in response to the pandemic.

The Dangers of Drawing Cohort Profiles From Period Data: A Research Note

Drawing cohort profiles and cohort forecasts from grids of age-period data is common practice in demography. In this research note, we (1) show how demographic measures artificially fluctuate when calculated from the diagonals of age-period rates because of timing and cohort-size bias, (2) estimate the magnitude of these biases, and (3) illustrate how prediction intervals for cohort indicators of mortality may become implausible when drawn from Lee-Carter methods and age-period grids. These biases are surprisingly large, even when the cohort profiles are created from single-age, single-year period data. The danger is that we overinterpret deviations from expected trends that were induced by our own data manipulation.

Scars from a Previous Epidemic: Social Proximity to Zika and Fertility Intentions during the COVID-19 Pandemic

We examine whether women's social proximity to Zika during the Zika epidemic predicts intentions to avoid a pregnancy because of the COVID-19 pandemic either directly or indirectly via subjective assessments of the pandemic. We apply path models on unique microdata from Brazil, the country most affected by Zika and an epicenter of COVID-19, to understand whether a novel infectious disease outbreak left lasting imprints shaping fertility intentions during a subsequent novel infectious disease outbreak. Findings show that Zika social proximity is associated with fertility intentions through an indirect path related to subjective assessment of the COVID-19 pandemic. These findings emerged regardless of whether a woman herself had or suspected she had Zika and speak to the transformative consequences of novel infectious disease outbreaks that go beyond mortality and health.

Contraceptive choice as risk reduction? The relevance of local violence for women's uptake of sterilization in Colombia

Altered childbearing behaviour has been observed in many settings of violent conflict, but few studies have addressed fertility control. This is the first study to investigate empirically the relationship between local conflict and uptake of sterilization, the only contraceptive method that reflects a definitive stop to childbearing. The study is based on Colombia, a middle-income, low-fertility, and long-term conflict setting. It builds on a mixed methods approach, combining survey and conflict data with expert interviews. Fixed effects regressions show that local conflict is generally associated with an increased sterilization uptake. The interviews suggest that women may opt for sterilization when reversible methods become less accessible because of ongoing violence. Since sterilization is a relatively available contraceptive option in Colombia, it may represent a risk-aversion strategy for women who have completed their fertility goals. These findings can enlighten research and programmes on fertility and family planning in humanitarian contexts.

Life After Loss: A Prospective Analysis of Mortality Exposure and Unintended Fertility

The relationship between mortality and fertility is a key component of demographic transition theory, placing it at the center of extensive inquiry. Among other linkages, mortality in women's communities and social networks influences their subsequent fertility. Existing demographic research assumes this is principally due to volitional mechanisms, implying that exposure to mortality consolidates women's desire to become pregnant, leading to intended fertility. Yet, insights from other disciplines suggest that mortality exposure could also increase women's unintended fertility through psychological, relational, and behavioral mechanisms. This study examines the relationships between network mortality exposure and women's hazard of pregnancy, and of unintended pregnancy specifically. We analyze two years (2009-2011) of closely spaced panel data on young Malawian women (N=1,272) enrolled in the Tsogolo la Thanzi study. Our data include information on funeral attendance and fertility desires measured weeks before conception, which is confirmed through frequent pregnancy testing. Hazard models show that the number of funerals women attend corresponds with a higher hazard of pregnancy and of unintended pregnancy specifically. These findings make clear that mortality exposure can influence fertility not by shaping women's desires but by disrupting the realization of those desires.

Stressor Effects on Sex Ratios and Births in the Maltese Population during the First Half of the 20th Century

Background: The sex ratio at birth (male/total = M/F) is expected to approximate 0.515. Stress is known to reduce livebirth M/F. In the first half of the 20th century, Malta was stressed by two World Wars. Objectives: This study was carried out in order to analyse changes in reproductive performance and M/F of stillbirths and livebirths in Malta during this period. Methods: Livebirth and stillbirth data (1910–1951) were obtained from official published Maltese government reports. Stillbirths were defined as any antenatal loss after 28 weeks of gestation. Results: This analysis studied 347,562 live and 11,662 stillbirths. For 1919–1951, M/F at birth was 0.517, stillbirth M/F was 0.664, implying 28/40 M/F = 0.522. Assuming conceptional M/F = 0.5, estimated M/F for fetal wastage before 28 weeks was approximately 0.434. There was a decrease in the overall birth rate starting after 1911 to 1921, more marked for 1941–1943 followed by an overshoot in 1943–48. There was a statistically significant drop in M/F livebirths during the periods 1916–21 and 1934–45. Stillbirths decreased significantly after 1935 (M>F). A stillbirth M/F drop in 1937–45 and rise in 1946–51 were statistically significant. Conclusions: Birth rate drops in both wars were ascribed to conscription, adverse living conditions and decreased fertility from nutritional restrictions. Both conflicts resulted in short post-war baby booms. The decrease in stillbirths is attributed to increase in antenatal attendances, hospital births and special food rations for pregnant women. The M/F observations suggest that the selective survival of both healthier female and male foetuses is favoured during times of stress.

Disease and fertility: Evidence from the 1918-19 influenza pandemic in Sweden

What are the consequences of a severe health shock like an influenza pandemic on fertility? Using rich administrative data and a difference-in-differences approach, we evaluate fertility responses to the 1918-19 influenza pandemic in Sweden. We find evidence of a small baby boom following the end of the pandemic, but we show that this effect is second-order compared to a strong long-term negative fertility effect. Within this net fertility decline there are compositional effects: we observe a relative increase in births to married women and to better-off families. Several factors - including disruptions to the marriage market and income effects - contribute to the long-term fertility reduction. The results are consistent with studies that find a positive fertility response following natural disasters, but we show that this effect is short-lived.

The link between climate change, food security and fertility: The case of Bangladesh

Climate change is likely to worsen the food security situation through its impact on food production, which may indirectly affect fertility behaviour. This study examines the direct and indirect effects of climate change (e.g., temperature and precipitation) via the production of major crops, as well as their short- and long-term effects on the total fertility rate (TFR) in Bangladesh. We used structural equation modelling (SEM) to perform path analysis and distinguish the direct influence of climate change on fertility and its indirect influence on fertility through food security. We also applied the error correction model (ECM) to analyze the time-series data on temperature and precipitation, crop production and fertility rate of Bangladesh from 1966 to 2015. The results show that maximum temperature has a direct effect and indirect negative effect–via crop production–on TFR, while crop production has a direct positive effect and indirect negative effect–via infant mortality–on TFR. In the short term, TFR responds negatively to the maximum temperature but positively in the long term. The effect of rainfall on TFR is found to be direct, positive, but mainly short-term. Although indicators of economic development play an important part in the fertility decline in Bangladesh, some climate change parameters and crop production are non-negligible factors.

The effects of armed conflict on the health of women and children

Women and children bear substantial morbidity and mortality as a result of armed conflicts. This Series paper focuses on the direct (due to violence) and indirect health effects of armed conflict on women and children (including adolescents) worldwide. We estimate that nearly 36 million children and 16 million women were displaced in 2017, on the basis of international databases of refugees and internally displaced populations. From geospatial analyses we estimate that the number of non-displaced women and children living dangerously close to armed conflict (within 50 km) increased from 185 million women and 250 million children in 2000, to 265 million women and 368 million children in 2017. Women's and children's mortality risk from non-violent causes increases substantially in response to nearby conflict, with more intense and more chronic conflicts leading to greater mortality increases. More than 10 million deaths in children younger than 5 years can be attributed to conflict between 1995 and 2015 globally. Women of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings. Current research provides fragmentary evidence about how armed conflict indirectly affects the survival chances of women and children through malnutrition, physical injuries, infectious diseases, poor mental health, and poor sexual and reproductive health, but major systematic evidence is sparse, hampering the design and implementation of essential interventions for mitigating the harms of armed conflicts.

How Assad changed population growth in Sweden and Norway: Syrian refugees' impact on Nordic national and municipal demography

In an increasingly interconnected world, the demographic effects of wars are not confined only to war zones and neighbouring areas; wars and conflicts may also change populations far away. Without the war in Syria under President Assad and the associated mass exodus of Syrian refugees, the population trends in distant countries like Sweden and Norway over the last few years would have been different. We create hypothetical scenarios of the population developments in Sweden and Norway without a war in Syria from 2011 onwards, where excess immigration due to the war and associated excess births are removed. The results indicate that population growth in 2016 would have been roughly 36% lower in Sweden and 26% lower in Norway without the Syrian war. The number of births in 2017 would have been about 3% lower in Sweden and 1% lower in Norway. One in ten municipalities would have had a population decline in 2016 instead of a population increase, and the largest immigrant group in Sweden by January 2019 would still be of Finnish origin.

Evaluation of animal models to explore the influence of maternal genetic and maternal permanent environment effect on reproductive performance of Jersey crossbred cattle

The present study was conducted on 1,002 reproductive records of 430 Jersey crossbred cattle, descended from 57 sires and 198 dams, maintained at the Eastern Regional Station of ICAR-National Dairy Research Institute, Kalyani, Nadia, West Bengal, India to investigate the influence of direct genetic, maternal genetic and maternal permanent environmental effect on three most important reproductive traits viz., number of service per conception (NSPC), days open (DO) and calving interval (CI) of Jersey crossbred cattle. Six single-trait animal models (including or excluding maternal genetic or permanent environmental effects) were fitted to analyse these traits, and the best model was chosen after testing the significant increase in the log-likelihood values when additional parameters were added in the model. Direct heritability estimates for NSPC, DO and CI from the best model were 0.10, 0.14 and 0.20, respectively. The maternal permanent environmental (c² ) effects on reproductive traits accounted for almost negligible fraction of the total phenotypic variance in this study. The maternal genetic effects (m² ) also contributed very little (0%-3%) to the total phenotypic variance except for CI where it was important and accounted for 20% of phenotypic variance. A significantly large negative genetic correlation was observed between direct and maternal genetic effects for all traits, suggesting the presence of antagonistic relationship between dam's direct additive component and daughter's additive genetic component. Results suggest that both direct and maternal effects were important only for CI but not for other traits. Therefore, both direct additive effects and maternal genetic effect need to be considered for improving this trait by selection.

Exposure to Armed Conflict and Fertility in Sub-Saharan Africa

Changes in fertility patterns are hypothesized to be among the many second-order consequences of armed conflict, but expectations about the direction of such effects are theoretically ambiguous. Prior research, from a range of contexts, has also yielded inconsistent results. We contribute to this debate by using harmonized data and methods to examine the effects of exposure to conflict on preferred and observed fertility outcomes across a spatially and temporally extensive population. We use high-resolution georeferenced data from 25 sub-Saharan African countries, combining records of violent events from the Armed Conflict Location and Event Data Project (ACLED) with data on fertility goals and outcomes from the Demographic and Health Surveys (n = 368,765 women aged 15-49 years). We estimate a series of linear and logistic regression models to assess the effects of exposure to conflict events on ideal family size and the probability of childbearing within the 12 months prior to the interview. We find that, on average, exposure to armed conflict leads to modest reductions in both respondents' preferred family size and their probability of recent childbearing. Many of these effects are heterogeneous between demographic groups and across contexts, which suggests systematic differences in women's vulnerability or preferred responses to armed conflict. Additional analyses suggest that conflict-related fertility declines may be driven by delays or reductions in marriage. These results contribute new evidence about the demographic effects of conflict and their underlying mechanisms, and broadly underline the importance of studying the second-order effects of organized violence on vulnerable populations.

Brazil's Missing Infants: Zika Risk Changes Reproductive Behavior

Zika virus epidemics have potential large-scale population effects. Controlled studies of mice and nonhuman primates indicate that Zika affects fecundity, raising concerns about miscarriage in human populations. In regions of Brazil, Zika risk peaked months before residents learned about the epidemic and its relation to congenital anomalies. This spatiotemporal variation supports analysis of both biological effects of Zika infection on fertility and the effects of learning about Zika risk on reproductive behavior. Causal inference techniques used with vital statistics indicate that the epidemic caused reductions in birth cohort size of approximately one-quarter 18 months after Zika infection risk peaked but 10 months after public health messages advocated childbearing delay. The evidence is consistent with small but not statistically detectable biological reductions in fecundity, as well as large strategic changes in reproductive behavior to temporally align childbearing with reduced risk to infant health. The behavioral effects are larger for more-educated and older women, which may reflect facilitated access to information and to family planning services within high-risk, mosquito-infested urban locations as well as perceptions about the opportunity costs of risks to pregnancy and infant survival.

The Effects of Conflict on Fertility: Evidence From the Genocide in Rwanda

Our study analyzes the fertility effects of the 1994 genocide in Rwanda. We study the effects of violence on both the duration time to the first birth in the early post-genocide period and on the total number of post-genocide births per woman up to 15 years following the conflict. We use individual-level data from Demographic and Health Surveys, estimating survival and count data models. This article contributes to the literature on the demographic effects of violent conflict by testing two channels through which conflict influences fertility: (1) the type of violence exposure as measured by the death of a child or sibling, and (2) the conflict-induced change in local demographic conditions as captured by the change in the district-level sex ratio. Results indicate the genocide had heterogeneous effects on fertility, depending on the type of violence experienced by the woman, her age cohort, parity, and the time horizon (5, 10, and 15 years after the genocide). There is strong evidence of a child replacement effect. Having experienced the death of a child during the genocide increases both the hazard of having a child in the five years following the genocide and the total number of post-genocide births. Experiencing sibling death during the genocide significantly lowers post-genocide fertility in both the short-run and the long-run. Finally, a reduction in the local sex ratio negatively impacts the hazard of having a child in the five years following the genocide, especially for older women.

Design and measurement in a study of war exposure, health, and aging: protocol for the Vietnam health and aging study

BACKGROUND

Survivors of war throughout the world experience illnesses and injuries that are crucial to understand, given the ongoing treatment and adaptation they demand. In developing countries like Vietnam, where population aging and chronic disease burdens are rapidly rising, aging populations have seen a disproportionate share of armed conflict and related casualties. This paper describes the Vietnam Health and Aging Study (VHAS), a unique resource for investigating mechanisms of association between diverse exposures to armed conflict during the Vietnam War and multiple dimensions of older adult health among survivors of that war.

METHODS

The VHAS utilizes a longitudinal design, the first wave of data collection conducted in 2018 among 2447 older adults. A second wave of follow-up data collection, scheduled to take place in 2021, will examine life course, social relational and health and mortality transitions. The VHAS was conducted in four northern Vietnamese districts purposively selected to represent a spectrum of war exposure as indicated by intensity of bombings. Additionally, VHAS uses random sampling within gender and military service subdomains to permit unique gender-specific analyses of military service, trauma exposure and health. The VHAS' face-to-face interviews include modules detailing war and military service experiences; warzone stressors; and multiple dimensions of health such as chronic disease, functional limitation, disability, health behaviors, cognition and psychological health. Biomarker data collected for the full VHAS sample includes anthropometric and functional tests such as grip strength and blood pressure, hair samples for cortisol assay, and capillary blood samples to assay C-reactive protein, cholesterol, HbA1c, and other markers of interest for cardiovascular and other disease risks and for testing the impact of early life stressors on later life health. Blood samples will also permit epigenetic analysis of biological aging.

DISCUSSION

Future VHAS investigations will examine dynamic linkages between war exposure, mortality and morbidity, while taking into account the selective nature of each of these processes. Longitudinal analyses will examine late-life health transitions and war-related resiliency.

Spacing, Stopping, or Postponing? Fertility Desires in a Sub-Saharan Setting

A growing body of research has argued that the traditional categories of stopping and spacing are insufficient to understand why individuals want to control fertility. In a series of articles, Timæus, Moultrie, and colleagues defined a third type of fertility motivation-postponement-that reflects a desire to avoid childbearing in the short term without clear goals for long-term fertility. Although postponement is fundamentally a description of fertility desires, existing quantitative research has primarily studied fertility behavior in an effort to find evidence for the model. In this study, we use longitudinal survey data to consider whether postponement can be identified in standard measures of fertility desires among reproductive-age women in rural Mozambique. Findings show strong evidence for a postponement mindset in this population, but postponement coexists with stopping and spacing goals. We reflect on the difference between birth spacing and postponement and consider whether and how postponement is a distinctive sub-Saharan phenomenon.

Organized Violence and Institutional Child Delivery: Micro-Level Evidence From Sub-Saharan Africa, 1989-2014

The conditions under which a mother gives birth greatly affect the health risk of both the mother and the child. This article addresses how local exposure to organized violence affects whether women give birth in a health facility. We combine geocoded data on violent events from the Uppsala Conflict Data Program with georeferenced survey data on the use of maternal health care services from the Demographic and Health Surveys. Our sample covers 569,201 births by 390,574 mothers in 31 countries in sub-Saharan Africa. We use a mother fixed-effects analysis to estimate the effect of recent organized violence events within a radius of 50 km of the home of each mother on the likelihood that her child is born in a health facility. The results indicate that geographical and temporal proximity to organized violence significantly reduces the likelihood of institutional births. Although the level of maternal health care overall is lower in rural areas, the negative effect of violence appears to be stronger in urban areas. The study further underscores the importance of household and individual resilience, indicating that the effect of organized violence on institutional child delivery is greater among poor and less-educated mothers.

Fear of violence during armed conflict: Social roles and responsibilities as determinants of fear

This article investigates the prevalence and determinants of fear as a consequence of living through armed conflict. We use survey data from Nepal during the armed conflict (1996-2006) to examine how trauma, sex and gender, age, marriage, and household size affect fear of violence. We also disaggregate types of worry, and find substantial variance on whether respondents were more concerned about livelihood consequences of conflict than physical danger. We supplement quantitative analyses with discussion of in-depth interviews from the study area on these same topics. Overall, our results highlight the enduring impact of gender roles in Nepal and that conflict might disproportionately affect those who are already vulnerable and have greater social responsibilities. This article provides a unique comparison between fear of violence during armed conflict in a low-income country to the fear of crime literature based in high-income countries.

Death Is Not the End: A Register-Based Study of the Effect of Parental Death on Adult Children's Childbearing Behavior in Sweden

Macro-level studies have shown that rapid increases in mortality can affect fertility rates. Parental death has also been linked to negative psychological and physical outcomes, reduced relationship quality, and making bereaved children attach more importance to their families. No prior study has examined whether parental death influences adult children's fertility at the microlevel. This study applies event history techniques to Swedish multigeneration registers listing 1.5 million individuals with micro data on mortality and fertility to investigate short-term (first birth risk) and long-term (childlessness at age 45) effects of parental death on adult children's fertility. The principal finding is that parental death during reproductive age affects children's fertility and this effect is mainly short term. The effects differ to some degree between men and women and depend on the stage of the life course in which the bereavement occurs. Younger individuals experiencing a parental death have a significantly higher first birth risk after the parental death compared with peers who did not experience a parental death. Individuals older than 23 who experience a parental death have no or lower first birth risk after the parental death compared with baseline. Men, compared with women, are more likely to end childless if they experience a parental death.

Fertility after natural disaster: Hurricane Mitch in Nicaragua

This investigation evaluates the effect of Hurricane Mitch on women's reproductive outcomes throughout Nicaragua. This research aim is achieved by analyzing a unique Nicaraguan Living Standards Measurement Study panel dataset that tracks women's fertility immediately before and at two time points after Hurricane Mitch, combined with satellite-derived municipality-level precipitation data for the 10-day storm period. Results show higher odds of post-disaster fertility in municipalities receiving higher precipitation levels in the immediate post-Hurricane Mitch period. However, fertility normalizes between disaster and non-disaster areas four to six years after the storm. These findings suggest that the disruptive effects of a natural disaster such as Hurricane Mitch can have an initial stimulative effect on fertility but the effect is ephemeral.

The effect of war on infant mortality in the Democratic Republic of Congo

Background

The Democratic Republic of Congo (DRC) has suffered from war and lingering conflicts in East DRC and has one of the highest infant mortality rates in the world. Prior research has documented increases in infant and child mortality associated with war, but the empirical evidence is limited in several respects. Measures of conflict are quite crude or conflict is not tightly linked to periods of exposure to infant death. Few studies have distinguished between the effects of war on neonatal versus post-neonatal infants. No study has considered possible differences between women who give birth during wartime and those who do not that may be related to greater infant mortality.

Methods

The analysis used the nationally representative sample of 15,103 mothers and 53,768 children from the 2007 and 2013/2014 Demographic Health Survey in the DRC and indicators of conflict events and conflict deaths from the 2013 Uppsala Conflict Data. To account for unobserved heterogeneity across women, a multi-level modeling approach was followed by grouping all births for each woman and estimating random intercepts in discrete time event history models.

Results

Post-neonatal mortality increased during the Congolese wars, and was highest where conflict events and deaths were extreme. Neonatal mortality was not associated with conflict levels. Infant mortality was not higher in East DRC, where conflicts continued during the post Congolese war period. Models specifying unobserved differences between mothers who give birth during war and those who have children in peacetime did not reduce the estimated effect of war, i.e., no support was found for selectivity in the sample of births during war.

Conclusion

Differences in effects of the Congolese war on neonatal versus post-neonatal mortality suggest that conflict influences the conditions of infants’ lives more than the aspects of mothers’ pregnancy conditions and delivery that are relevant for infant mortality. These differences may, however, be specific to the nature of conflict and prior conditions in the DRC. Because of continued political instability, violent conflict may be expected to continue in contexts such as the DRC; we must therefore continue to document, analyze and monitor the mechanisms through which war influences infant mortality.

The impact of armed conflict on adolescent transitions: a systematic review of quantitative research on age of sexual debut, first marriage and first birth in young women under the age of 20 years

Background

Young women in conflict-affected regions are at risk of a number of adverse outcomes as a result of violence, economic deterioration and the breakdown of community structures and services. This paper presents the findings of a systematic review of quantitative literature reporting how key sexual and reproductive health (SRH) outcomes among young women under the age of 20 years are affected by exposure to armed conflict; namely, sexual debut, first marriage and first birth. Increases in these outcomes among young women are all associated with potential negative public health consequences. It also examines and documents possible causal pathways for any changes seen.

Methods

To fit with our inclusion criteria, all reviewed studies included outcomes for comparable populations not exposed to conflict either temporally or spatially. A total of 19 studies with results from 21 countries or territories met our inclusion criteria; seven presented findings on marriage, four on fertility and eight on both of these outcomes. Only one study reporting on sexual debut met our criteria.

Results

Findings show clear evidence of both declines and increases in marriage and childbirth among young women in a range of conflict-affected settings. Several studies that showed increases in marriage below the age of 20 years reported that such increases were concentrated in the younger teenagers. Trends in fertility were predominantly driven by marriage patterns. Suggested causal pathways for the changes observed could be grouped into three categories: involuntary, gender and psycho-social and economic and material factors.

Conclusion

The review reveals a paucity of literature on the impact of conflict on SRH outcomes of young women. Further quantitative and qualitative studies are needed to explore how conflict influences SRH events in young women over both the short- and longer-term.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2868-5) contains supplementary material, which is available to authorized users.

Ethnic Dimensions of Guatemala's Stalled Transition: A Parity-Specific Analysis of Ladino and Indigenous Fertility Regimes

In some contemporary populations, fertility levels appear to plateau, with women maintaining a consistently high level of fertility for a relatively extended period. Because this plateau does not reflect the historical patterns observed in Europe, the focus of most studies on fertility patterns, mechanisms underlying the plateau and the reinstatement of a decline have not been fully explored and are not fully understood. Through the construction of fertility histories of 25,000 women using multiple years of health survey data, we analyze some of the components of stalled fertility as they pertain to Guatemala, the only Central American country to have experienced a stalled fertility decline.

Estimating Post-Emergency Fertility Among Disaster-Affected Adolescents: Findings From a Case-Control Study in Aceh Province, Indonesia

OBJECTIVE

We aimed to retrospectively estimate adolescent fertility rates before and after a large-scale natural disaster.

METHODS

A case-control study was conducted in Aceh Province, Indonesia, 2 years after the Indian Ocean tsunami in 2004. The age-specific fertility rates of 15-19-year-old-women (ASFR 15-19) was estimated each year from 2004 to 2006 by creating hypothetical age cohorts. The results were compared with data from the closest edition of the Indonesian Demographic Health Survey (IDHS).

RESULTS

The pre-disaster ASFR 15-19 (4.4% in 2004) was not significantly different from the 2002-2003 IDHS data (P=0.49), whereas the post-disaster ASFR 15-19 (1.1% in 2005-2006) was significantly lower than the provincial estimation in the 2007 IDHS (P<0.01). ASFR 15-19 was reduced by 76% in the post-disaster period compared with the pre-disaster period (rate ratio: 0.24, P=0.02).

CONCLUSIONS

The creation of hypothetical age cohorts enabled valid and useful estimation of the ASFR in disaster-affected areas where reliable vital statistics are not available. For pre-disaster fertility estimation, however, we suggest excluding data from the 40-week period preceding the disaster, because the data may be biased by excess mortality in childbearing mothers and newborn babies in the disaster.

The effects of mortality on fertility: population dynamics after a natural disaster

Understanding how mortality and fertility are linked is essential to the study of population dynamics. We investigate the fertility response to an unanticipated mortality shock that resulted from the 2004 Indian Ocean tsunami, which killed large shares of the residents of some Indonesian communities but caused no deaths in neighboring communities. Using population-representative multilevel longitudinal data, we identify a behavioral fertility response to mortality exposure, both at the level of a couple and in the broader community. We observe a sustained fertility increase at the aggregate level following the tsunami, which was driven by two behavioral responses to mortality exposure. First, mothers who lost one or more children in the disaster were significantly more likely to bear additional children after the tsunami. This response explains about 13 % of the aggregate increase in fertility. Second, women without children before the tsunami initiated family-building earlier in communities where tsunami-related mortality rates were higher, indicating that the fertility of these women is an important route to rebuilding the population in the aftermath of a mortality shock. Such community-level effects have received little attention in demographic scholarship.

Early-life nutritional effects on the female reproductive system

There is now considerable epidemiological and experimental evidence indicating that early-life environmental conditions, including nutrition, affect subsequent development in later life. These conditions induce highly integrated responses in endocrine-related homeostasis, resulting in persistent changes in the developmental trajectory producing an altered adult phenotype. Early-life events trigger processes that prepare the individual for particular circumstances that are anticipated in the postnatal environment. However, where the intrauterine and postnatal environments differ markedly, such modifications to the developmental trajectory may prove maladaptive in later life. Reproductive maturation and function are similarly influenced by early-life events. This should not be surprising, because the primordial follicle pool is established early in life and is thus vulnerable to early-life events. Results of clinical and experimental studies have indicated that early-life adversity is associated with a decline in ovarian follicular reserve, changes in ovulation rates, and altered age at onset of puberty. However, the underlying mechanisms regulating the relationship between the early-life developmental environment and postnatal reproductive development and function are unclear. This review examines the evidence linking early-life nutrition and effects on the female reproductive system, bringing together clinical observations in humans and experimental data from targeted animal models.

The Effect on Fertility of the 2003-2011 War in Iraq

This article provides the first detailed account of recent fertility trends in Iraq, with a particular focus on the changes resulting from the 2003-2011 war and the factors underlying them. The study is based on retrospective birth history data from the 2006 and 2011 Iraq Multiple Indicator Cluster Surveys (I-MICS). Estimates from the two surveys indicate that total fertility remained stable from 1997 to 2010, at about 4.5 children per woman. However, examination of the age patterns of fertility reveals an abrupt shift in the timing of births, with adolescent fertility rising by over 30 percent soon after the onset of the war. A decomposition analysis shows that the rise in early childbearing is due to an increased prevalence of early marriage among less-educated women. The prevalence of early marriage and childbearing among women with secondary or higher education is relatively low and has not increased after 2003.

Power outages, power externalities, and baby booms

Determining whether power outages have significant fertility effects is an important policy question in developing countries, where blackouts are common and modern forms of family planning are scarce. Using birth records from Zanzibar, this study shows that a month-long blackout in 2008 caused a significant increase in the number of births 8 to 10 months later. The increase was similar across villages that had electricity, regardless of the level of electrification; villages with no electricity connections saw no changes in birth numbers. The large fertility increase in communities with very low levels of electricity suggests that the outage affected the fertility of households not connected to the grid through some spillover effect. Whether the baby boom is likely to translate to a permanent increase in the population remains unclear, but this article highlights an important hidden consequence of power instability in developing countries. It also suggests that electricity imposes significant externality effects on rural populations that have little exposure to it.

How community organizations moderate the effect of armed conflict on migration in Nepal

This study analyses micro-level variability in migration during armed conflict in Nepal. The analysis is based on a multi-dimensional model of individual out-migration that examines the economic, social, and political consequences of conflict and how community organizations condition the experience of these consequences and systematically alter migration patterns. Detailed data on violent events and individual behaviour during the Maoist insurrection in Nepal and multi-level event-history analysis were used to test the model. The results indicate that community organizations reduced the effect of conflict on out-migration by providing resources that helped people cope with danger, as well as with the economic, social, and political consequences of the conflict. The evidence suggests that the conflict caused the population to be systematically redistributed in a way that will probably affect its future socio-demographic composition--the extent of the redistribution depending on the resources available in each community.

A micro-level event-centered approach to investigating armed conflict and population responses

In this article, we construct and test a micro-level event-centered approach to the study of armed conflict and behavioral responses in the general population. Event-centered approaches have been successfully used in the macro-political study of armed conflict but have not yet been adopted in micro-behavioral studies. The micro-level event-centered approach that we advocate here includes decomposition of a conflict into discrete political and violent events, examination of the mechanisms through which they affect behavior, and consideration of differential risks within the population. We focus on two mechanisms: instability and threat of harm. We test this approach empirically in the context of the recent decade-long armed conflict in Nepal, using detailed measurements of conflict-related events and a longitudinal study of first migration, first marriage, and first contraceptive use. Results demonstrate that different conflict-related events independently shaped migration, marriage, and childbearing and that they can simultaneously influence behaviors in opposing directions. We find that violent events increased migration, but political events slowed migration. Both violent and political events increased marriage and contraceptive use net of migration. Overall, this micro-level event-centered approach yields a significant advance for the study of how armed conflict affects civilian behavioral responses.

Fertility Transitions and Schooling: From Micro- to Macro-Level Associations

Research on the schooling implications of fertility transitions often faces an aggregation problem: despite policy interest in macro-level outcomes, empirical studies usually focus on the micro-level effects of sibsize on schooling. This article proposes an aggregation framework for moving from micro- to macro-level associations between fertility and schooling. The proposed framework is an improvement over previous aggregation methods in that it considers concurrent changes in the effects of sibsize, socioeconomic context, and family structure. The framework is illustrated with data from six sub-Saharan countries. Possible extensions are discussed.

The Phoenix population: demographic crisis and rebound in Cambodia

The study of mortality crises provides an unusual and valuable perspective on the relationship between mortality and fertility changes, a relationship that has puzzled demographers for decades. In this article, we combine nationally representative survey and demographic-surveillance system data to study fertility trends around the time of the Khmer Rouge (KR) regime, under which 25% of the Cambodian population died. We present the first quantitative evidence to date that attests to a one-third decline of fertility during this regime, followed by a substantial "baby boom" after the fall of the KR. Further analyses reveal that the fertility rebound was produced not only by a two-year marriage bubble but also by a surge in marital fertility that remained for nearly a decade above its precrisis level. Our results illustrate the potential influence of mortality on fertility, which may be more difficult to identify for more gradual mortality declines. To the extent that until recently, Cambodian fertility appears to fit natural fertility patterns, our findings also reinforce recent qualifications about the meaning of this core paradigm of demographic analysis.

Modified activity-stress paradigm in an animal model of the female athlete triad

The exercising woman with nutritional deficits and related menstrual irregularities is at risk of compromising long-term bone health, i.e., the female athlete triad. There is no animal model of the female athlete triad. The purpose of this study was to examine long-term energy restriction in voluntary wheel-running female rats on estrous cycling, bone mineral content, and leptin levels. Twelve female Sprague-Dawley rats (age 34 days) were fed ad libitum and given access to running wheels during an initial 14-wk period, providing baseline and age-related data. Daily collection included dietary intake, body weight, estrous cycling, and voluntary running distance. At 4 mo, rats were randomized into two groups, six restrict-fed rats (70% of ad libitum intake) and six rats continuing as ad libitum-fed controls. Energy intake, energy expenditure, and energy availability (energy intake - energy expenditure) were calculated for each animal. Serum estradiol and leptin concentrations were measured by RIA. Femoral and tibial bone mineral density and bone mineral content (BMC) were determined by dual-energy X-ray absorptiometry. Restrict-fed rats exhibited a decrease in energy availability during Weight Loss and Anestrous phases (P = 0.002). Compared with controls after 12 wk, restrict-fed rats showed reduced concentrations of serum estradiol (P = 0.002) and leptin (P = 0.002), lower ovarian weight (P = 0.002), and decreased femoral (P = 0.041) and tibial (P = 0.05) BMC. Decreased energy availability resulted in anestrus and significant decreases in BMC, estrogen and leptin levels, and body weight. Finally, there is a critical level of energy availability to maintain estrous cycling.

The long-term health and economic consequences of the 1959-1961 famine in China

This paper, using a difference-in-differences method, tries to quantify the long-term effects of China's 1959-1961 famine on the health and economic status of the survivors. We find that the great famine caused serious health and economic consequences for the survivors, especially for those in early childhood during the famine. Our estimates show that on average, in the absence of the famine, individuals of the 1959 birth cohort would have otherwise grown 3.03 cm taller in adulthood. The famine also greatly impacted the labor supply and earnings of the survivors with famine exposure during their early childhood.

Necessidade insatisfeita por métodos anticoncepcionais no Brasil

No Brasil, a prevalência do uso de contraceptivo é elevada e a taxa de fecundidade total está quase no nível de reposição. No entanto, ainda há um percentual significativo de gravidezes indesejadas, abortos provocados e mulheres que não querem mais ter filhos ou querem tê-los mais tarde, porém não estão usando métodos contraceptivos - ou seja, mulheres com necessidade insatisfeita por anticoncepção. O objetivo deste estudo é apresentar a magnitude da necessidade insatisfeita por método anticoncepcional entre mulheres unidas no Brasil, assim como identificar os fatores a ela associados. A fonte de dados utilizada nesse estudo é proveniente da Pesquisa Nacional Sobre Demografia e Saúde, realizada no Brasil em 1996. Para identificar os determinantes associados com a necessidade insatisfeita por anticoncepção foi utilizado o modelo multinomial, em que a variável resposta tem três categorias: necessidade para espaçar, necessidade para limitar e sem necessidade. A análise empreendida ao longo deste trabalho revelou uma forte associação entre as variáveis relativas ao ciclo de vida das mulheres (idade e número de filhos) e a necessidade insatisfeita por métodos anticoncepcionais. Com relação às variáveis socioeconômicas destaca-se a elevada probabilidade de necessidade insatisfeita de limitar entre as mulheres da região Nordeste. Observou-se ainda que mulheres com maior nível de escolaridade são menos propensas a apresentar uma necessidade insatisfeita de limitar. A análise aponta para a necessidade de adequação e universalização dos serviços de planejamento familiar com vistas a um atendimento integral à saúde da mulher.

An energy-saving development initiative increases birth rate and childhood malnutrition in rural Ethiopia

BACKGROUND

Evolutionary life history theory predicts that, in the absence of contraception, any enhancement of maternal condition can increase human fertility. Energetic trade-offs are likely to be resolved in favour of maximizing reproductive success rather than health or longevity. Here we find support for the hypothesis that development initiatives designed to improve maternal and child welfare may also incur costs associated with increased family sizes if they do not include a family planning component.

METHODS AND FINDINGS

Demographic and anthropometric data were collected in a rural Ethiopian community benefiting from a recent labour-saving development technology that reduces women's energetic expenditure (n = 1,976 households). Using logistic hazards models and general linear modelling techniques, we found that whilst infant mortality has declined, the birth rate has increased, causing greater scarcity of resources within households.

CONCLUSIONS

This study is, to our knowledge, the first to demonstrate a link between a technological development intervention and an increase in both birth rate and childhood malnutrition. Women's nutritional status was not improved by the energy-saving technology, because energy was diverted into higher birth rates. We argue that the contribution of biological processes to increased birth rates in areas of the developing world without access to modern contraception has been overlooked. This highlights the continued need for development programmes to be multisectoral, including access to and promotion of contraception.