Nonviolent civil insecurity is negatively associated with subsequent height-for-age in children aged <5 y born between 1998 and 2014 in rural areas of Africa

The impact of armed conflicts on the nutritional status of children: Evidence from Northern Nigeria

Armed conflicts often significantly exacerbate the magnitude and severity of malnutrition by increasing food insecurity. Evidence shows that malnutrition is among the leading causes of morbidity and mortality among children during conflicts. This study examines the impact of the armed conflicts in Northern Nigeria on nutritional status of children under the age of five. Three waves (2008, 2013, and 2018) of individual-level birth records data from the Nigeria Demographic and Health Survey (NDHS) dataset are spatially merged with information on conflict events drawn from the Armed Conflict Location and Events Dataset. All fatal incidents in the study region during the 5-year intervals 2004-2008, 2009-2013 and 2014-2018 are aggregated and mapped to the 2008, 2013 and 2018 NDHS clusters, respectively. A cluster is classified to be exposed to conflict if located within 5-10 km radius of an incident with at least 1 fatality. We use matching analysis in a difference-in-differences approach to estimate the effects of the conflicts on stunting, wasting, and underweight. We find that the impact of conflict exposure differs by the dimension of child nutritional status. While it significantly lowers the risk of stunting, it has no discernible significant effect on the likelihood of wasting or being underweight among under-fives. Though nutritional support/interventions in the conflict-affected areas are crucial and must be prioritised, an all-inclusive strategy for a long-term resolution of the conflict is needed to engender development, improve food security, reduce vulnerability to malnutrition, and improve the health and wellbeing of the residents of the region.

Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000-2019

BACKGROUND

Armed conflicts have major indirect health impacts in addition to the direct harms from violence. They create enduring political instability, destabilise health systems, and foster negative socioeconomic and environmental conditions-all of which constrain efforts to reduce maternal and child mortality. The detrimental impacts of conflict on global maternal and child health are not robustly quantified. This study assesses the association between conflict and maternal and child health globally.

METHODS AND FINDINGS

Data for 181 countries (2000-2019) from the Uppsala Conflict Data Program and World Bank were analysed using panel regression models. Primary outcomes were maternal, under-5, infant, and neonatal mortality rates. Secondary outcomes were delivery by a skilled birth attendant and diphtheria, pertussis, and tetanus (DPT) and measles vaccination coverage. Models were adjusted for 10 confounders, country and year fixed effects, and conflict lagged by 1 year. Further lagged associations up to 10 years post-conflict were tested. The number of excess deaths due to conflict was estimated. Out of 3,718 country-year observations, 522 (14.0%) had minor conflicts and 148 (4.0%) had wars. In adjusted models, conflicts classified as wars were associated with an increase in maternal mortality of 36.9 maternal deaths per 100,000 live births (95% CI 1.9-72.0; 0.3 million excess deaths [95% CI 0.2 million-0.4 million] over the study period), an increase in infant mortality of 2.8 per 1,000 live births (95% CI 0.1-5.5; 2.0 million excess deaths [95% CI 1.6 million-2.5 million]), a decrease in DPT vaccination coverage of 4.9% (95% CI 1.5%-8.3%), and a decrease in measles vaccination coverage of 7.3% (95% CI 2.7%-11.8%). The long-term impacts of war were demonstrated by associated increases in maternal mortality observed for up to 7 years, in under-5 mortality for 3-5 years, in infant mortality for up to 8 years, in DPT vaccination coverage for up to 3 years, and in measles vaccination coverage for up to 2 years. No evidence of association between armed conflict and neonatal mortality or delivery by a skilled birth attendant was found. Study limitations include the ecological study design, which may mask sub-national variation in conflict intensity, and the quality of the underlying data.

CONCLUSIONS

Our analysis indicates that armed conflict is associated with substantial and persistent excess maternal and child deaths globally, and with reductions in key measures that indicate reduced availability of organised healthcare. These findings highlight the importance of protecting women and children from the indirect harms of conflict, including those relating to health system deterioration and worsening socioeconomic conditions.

Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline

BACKGROUND

Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development.

OBJECTIVE

This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries.

METHODS

We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time.

RESULTS

Among the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height.

CONCLUSIONS

Unique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.

Estimating indirect mortality impacts of armed conflict in civilian populations: panel regression analyses of 193 countries, 1990-2017

BACKGROUND

Armed conflict can indirectly affect population health through detrimental impacts on political and social institutions and destruction of infrastructure. This study aimed to quantify indirect mortality impacts of armed conflict in civilian populations globally and explore differential effects by armed conflict characteristics and population groups.

METHODS

We included 193 countries between 1990 and 2017 and constructed fixed effects panel regression models using data from the Uppsala Conflict Data Program and Global Burden of Disease study. Mortality rates were corrected to exclude battle-related deaths. We assessed separately four different armed conflict variables (capturing binary, continuous, categorical, and quintile exposures) and ran models by cause-specific mortality stratified by age groups and sex. Post-estimation analyses calculated the number of civilian deaths.

RESULTS

We identified 1118 unique armed conflicts. Armed conflict was associated with increases in civilian mortality-driven by conflicts categorised as wars. Wars were associated with an increase in age-standardised all-cause mortality of 81.5 per 100,000 population (β 81.5, 95% CI 14.3-148.8) in adjusted models contributing 29.4 million civilian deaths (95% CI 22.1-36.6) globally over the study period. Mortality rates from communicable, maternal, neonatal, and nutritional diseases (β 51.3, 95% CI 2.6-99.9); non-communicable diseases (β 22.7, 95% CI 0.2-45.2); and injuries (β 7.6, 95% CI 3.4-11.7) associated with war increased, contributing 21.0 million (95% CI 16.3-25.6), 6.0 million (95% CI 4.1-8.0), and 2.4 million deaths (95% CI 1.7-3.1) respectively. War-associated increases in all-cause and cause-specific mortality were found across all age groups and both genders, but children aged 0-5 years had the largest relative increases in mortality.

CONCLUSIONS

Armed conflict, particularly war, is associated with a substantial indirect mortality impact among civilians globally with children most severely burdened.

Contextual Data in IPUMS DHS: Physical and Social Environment Variables linked to the Demographic and Health Surveys

The Demographic and Health Surveys (DHS) are the most important source of comparative information on the health of women and young children in low- and middle-income countries and are well-suited for studies of the relationship between environmental factors and health. However, barriers have limited the use of the DHS for these purposes. IPUMS DHS, an online data dissemination tool, overcomes these barriers, simplifying comparative analyses with DHS. IPUMS DHS recently incorporated environmental variables that can easily be attached to individual or household records, facilitating the use of DHS data for the study of population and environment issues. We provide a brief introduction to IPUMS DHS, describe the current and anticipated environmental variables and how to use them, and provide an example of the novel research possibilities facilitated by this latest IPUMS DHS development. IPUMS-DHS is available free online at dhs.ipums.org.