Recent fertility decline in Eritrea: Is it a conflict-led transition?

Spatial variation and associated factors of home delivery among reproductive age group women in Ethiopia, evidence from Performance Monitoring for Action Ethiopia Survey 2019, spatial and multilevel logistic regression analysis

Introduction

Home birth is described as a delivery that takes place at home without the presence of a skilled birth attendant. In 2017, nearly 295,000 mothers died from various pregnancy and childbirth-related problems, accounting for approximately 810 maternal deaths per day. Therefore, this study aims to investigate the spatial distributions of home birth and associated factors in Ethiopia using the Performance Monitoring for Action Survey (PMAS) 2019) to get information that helps to take geographic-based interventions and can assist health planners and policymakers in developing particular measures to reduce home deliveries.

Method

In PMA-ET 2019, a community-based cross-sectional study was conducted in collaboration with Addis Ababa University, Johns Hopkins University, and the Federal Ministry of Health from September 2019 to December 2019, in Ethiopia. A multi-stage cluster sampling procedure was employed to draw from the stratified 2019 PMAS sample. A weighted total of 5,796 women were included in this study. ArcGIS version 10.7 software was used to visualize the spatial analysis. In addition, STATA version 14 of the statistical software was used for multilevel analysis The Bernoulli model was applied using Kulldorff's SaTScan version 9.6 software to identify significant purely spatial clusters for home delivery in Ethiopia. Intra-class Correlation Coefficient (ICC), Likelihood Ratio (LR) test, Median Odds Ratio (MOR), and deviance (-2LLR) values were used for model comparison and fitness. Adjusted Odds Ratios (AOR) with a 95% Confidence Interval (CI) and p-value <0.05 in the multilevel logistic model were used to declare significant factors associated with home delivery.

Result

The spatial distribution of home delivery was non-random in Ethiopia. Statistically significant high hotspots of home delivery were found in Somali, Afar, Sidama, most of South Nation Nationality and People Region (SNNP), most parts of Amhara, south west Ethiopia, and Oromia region. In the multilevel logistic regression model; Women from the lowest wealth quintile were 1.68 times [AOR = 1.68; 95% CI: 1.31, 2.15] higher odds of giving birth at home as compared to their counterparts. Regarding maternal educational status, mothers who had no education, primary education, and secondary education had 9.91 times [AOR = 9.91, 95% CI: 5.44, 18.04], 6.62 times [AOR = 6.62, 95% CI: 3.65, 12.00] and 2.99 times [AOR = 2.99, 95% CI: 1.59, 5.63] higher odds of giving birth at home compared to mothers who attained higher education, respectively. In addition, community-level factors were significantly associated with home delivery, women who had high community-level poverty were 1.76 times [AOR = 1.76; 95% CI: 1.14, 2.72] higher odds of home delivery compared to women who had low community-level poverty.

Conclusion

Home delivery was statistically found to be a significantly high hot spot in Somalia, Afar, Sidama, most of the South Nation Nationality and People area (SNNP), most of Amhara, southwest Ethiopia, and the Oromia region of Ethiopia. Significant factors associated with home delivery in Ethiopia were women with lower levels of education, poor wealth, living in rural areas, high levels of community poverty, divorced or separated widowed marital status, and older maternal ages. Therefore, health institutions, health professionals, National and regional policymakers health planners community leaders and all concerned should give priority to the identified hot spot clusters to design an effective intervention program to reduce home delivery.

Incidence of child marriage among refugees and internally displaced persons in the Middle East and South Asia: evidence from six cross-sectional surveys

OBJECTIVE

To examine incidence of child marriage among displaced and host populations in humanitarian settings.

DESIGN

Cross-sectional surveys.

SETTING

Data were collected in Djibouti, Yemen, Lebanon and Iraq in the Middle East and in Bangladesh and Nepal in South Asia.

PARTICIPANTS

Adolescent girls aged 10-19 in the six settings and age cohort comparators.

OUTCOME MEASURES

Cumulative incidence of marriage by age 18.

RESULTS

In Bangladesh and Iraq, the hazard of child marriage did not differ between internally displaced populations (IDPs) and hosts (p value=0.25 and 0.081, respectively). In Yemen, IDPs had a higher hazard of child marriage compared with hosts (p value<0.001). In Djibouti, refugees had a lower hazard of child marriage compared with hosts (p value<0.001). In pooled data, the average hazard of child marriage was significantly higher among displaced compared with host populations (adjusted HR (aHR) 1.3; 95% CI 1.04 to 1.61).In age cohort comparisons, there was no significant difference between child marriage hazard across age cohorts in Bangladesh (p value=0.446), while in Lebanon and Nepal, younger cohorts were less likely to transition to child marriage compared with older comparators (p value<0.001). Only in Yemen were younger cohorts more likely to transition to child marriage, indicating an increase in child marriage rates after conflict (p value=0.034). Pooled data showed a downward trend, where younger age cohorts had, on average, a lower hazard of child marriage compared with older cohorts (aHR 0.36; 95% CI 0.29 to 0.4).

CONCLUSIONS

We did not find conclusive evidence that humanitarian crises are associated with universal increases in child marriage rates. Our findings indicate that decision-making about investments in child marriage prevention and response must be attuned to the local context and grounded in data on past and current trends in child marriage among communities impacted by crisis.

[Sexual and reproductive health in women victims of the armed conflict]

OBJETIVE

Show the main conditions in sexual and reproductive health in women victims of the conflicts and armed post-conflicts.

METHODOLOGY

An scoping systematic review was conducted, about literature in English, Spanish, and Portuguese languages, between 2000 to the present, in PubMED, EMBASE, Google Scholar, LILACS, IBECS, SciELO and was consulted key informants.

RESULTS

It was found in the international ambit, the main affectation identified referred to sexual violence, risk factors were found that perpetuate it, such as the family environment, access to education, poor infrastructure of health services among others. Other important effects derive from an increase in the rate of pregnancies and marriages. In Colombia the situation is similar: the areas with the greatest impact due to conflict have a higher fertility rate, poor access to obstetric care, and poor knowledge of STIs.

CONCLUSION

Access to sexual health services in the conflict, for disease prevention, and the right to sexual and reproductive health must be ensured.

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.

Regional Effects of Maternal Mortality Determinants in Africa and the Middle East: How About Political Risks of Conflicts?

Background

As per the United Nations Women data, the maternal mortality rate in war-affected countries is critical and more than 800 million people live in war-affected countries (ICRC). External and internal conflicts such as foreign pressure, war and cross-border, civil disorder, terrorism, and civil war, are characteristics of Middle Eastern and African countries. Therefore considering the rapid increment of political risks and internal and external conflicts in Africa and the Middle East during the last decade, and considering warfare as a key contributor to maternal mortality; This paper seeks to evaluate the factors that have caused significant rates of maternal mortality in Middle Eastern and African countries by emphasizing the contributions of a number of political risk aspects as Civil Disorder Index, Terrorism Index, Civil War Index, Foreign Pressures Index, Cross-Border Conflict Index, War Index along with other socio-economic factors.

Method

Data were collected from forty-six countries during 2011–2016 to explore the regional contributions of political risk aspects to the maternal mortality rate through spatial approaches.

Results

It was found that GDP per capita, energy intensity, and urbanization strongly impacted maternal mortality. Also, it was observed that natural resource rents and economic growth significantly influenced the reduction of mortality by expanding healthcare services. The urban expansion was found to have elevated maternal mortality. A majority of external and internal conflicts reduced the orientation of production toward healthcare services and thus raised maternal mortality. On the other hand, war and cross-border were found to pose opposite impacts.

Conclusion

The findings revealed that political risks arising from terrorism, foreign pressure, and war in the adjacent countries would elevate the rate of mortality in the original country. This implies the spillover impacts of regional conflicts on maternal mortality elevation at the regional scale.

JEL Classification Codes: C23; I10; I18; N37:

Child marriage among Somali refugees in Ethiopia: a cross sectional survey of adolescent girls and adult women

BACKGROUND

Despite child marriage receiving increased attention over the past two decades, research on child marriage in humanitarian settings remains scarce. This study sought to quantify child marriage among Somali adolescent girls residing in Kobe refugee camp in Ethiopia and to identify its correlates and consequences.

METHODS

A cross-sectional survey was conducted using multi-stage cluster-based sampling with probability proportional to size. We randomly sampled households that have at least one female aged 15-49 and at least one adolescent female aged 10-19. In addition to calculating the proportion of girls married under age 18, we used survival methods - namely Kaplan Meier graphs and Cox proportional hazard models - to identify risk factors associated with child marriage in this context. We also used descriptive statistics to describe marital age preferences among female adults and presented measures of important sexual and reproductive health indicators among married adolescent girls.

RESULTS

A total of 603 adult women were surveyed and a household roster was created with information on 3319 household members, of whom 522 were adolescent girls aged 15-19. Of those, 14% were currently married (95% Confidence Interval [CI] 0.11-0.18), and 11% were ever married under age 18 (95% CI 8-15%). Several variables were found to be significantly associated with hazard of child marriage including schooling, sex and employment status of head of household, as well as number of girls under age 18 in the childhood home.. Adult women tended to incorrectly identify minimum legal age at marriage and preferred low marital age for boys and girls - particularly in households of child brides. Among married adolescent girls, contraceptive use was very low (11%; 95% CI 4.94-22.40), and early childbearing was common (60%; 95% CI 45.56-72.89).

CONCLUSIONS

This research contributes to the evidence base on child marriage in humanitarian settings. Insights generated from this study have the potential to inform programs and interventions aiming to prevent and mitigate the impacts of this harmful practice.

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.

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.

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.

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.