Predictors of the diets consumed by adolescent girls, pregnant women and mothers with children under age two years in rural eastern India

2020 ◽  
pp. 1-20
Author(s):  
Sayeed Unisa ◽  
Abhishek Saraswat ◽  
Arti Bhanot ◽  
Abdul Jaleel ◽  
Rabi N. Parhi ◽  
...  
Keyword(s):  
Pregnant Women ◽  
Adolescent Girls ◽  
Dietary Diversity ◽  
Baseline Survey ◽  
Food Groups ◽  
Target Groups ◽  
Indian States ◽  
Health And Nutrition ◽  
Nutrition Service ◽  
Using Data

Abstract Adolescents, pregnant women and mothers of children under 2 years of age are in stages of life characterized by higher nutritional demands. The study measured the dietary diversity of 17,680 adolescent girls, pregnant women and mothers of children under age 2 years in the eastern Indian states of Bihar, Chhattisgarh and Odisha using data from the Swabhimaan baseline survey conducted in 2016. The association of women’s mean Dietary Diversity Scores with socioeconomic, health and nutrition service indicators was assessed. The sampled population was socioeconomically more vulnerable than the average Indian population. There was not much variation in the types of foods consumed daily across target groups, with diet being predominantly cereal (98%) and vegetable (83%) based. Nearly 30% of the mothers had low Dietary Diversity Scores, compared with 25% of pregnant women and 24% of adolescent girls. In each target group, more than half of the respondents were unable to meet the Minimum Dietary Diversity score of at least five of ten food groups consumed daily. Irrespective of their background characteristics, mean Dietary Diversity Scores were significantly lower in Bihar than in Chhattisgarh and Odisha for all target groups. Having at least 6 years of education, belonging to a relatively rich household and possessing a ration card predicted mean dietary diversity. Project interventions of participatory women’s group meetings improved mean Dietary Diversity Scores for mothers and adolescent girls. Considering the association between poverty and dietary diversity, the linkage between girls and women and nutrition-focused livelihoods and supplementary nutrition programmes needs to be tested.

scholarly journals Adequacy and Sources of Protein Intake among Pregnant Women in the United States, NHANES 2003–2012

Nutrients ◽  
2021 ◽  
Vol 13 (3) ◽  
pp. 795
Author(s):  
Mary M. Murphy ◽  
Kelly A. Higgins ◽  
Xiaoyu Bi ◽  
Leila M. Barraj
Keyword(s):  
Pregnant Women ◽  
Protein Intake ◽  
First Trimester ◽  
The United States ◽  
Limited Information ◽  
Health And Nutrition ◽  
Animal Source ◽  
Usual Intake ◽  
First Trimester Of Pregnancy ◽  
Using Data

Limited information is available on protein intake and adequacy of protein intake among pregnant women. Using data from a sample of 528 pregnant women in the National Health and Nutrition Examination Surveys (NHANES) 2003–2012, usual intake of protein (g/day and g/kg body weight (bw)/day) and prevalence of intake below the Estimated Average Requirement (EAR) by trimester of pregnancy were calculated using the National Cancer Institute method. Percent contributions to protein intake by source (i.e., plant and animal, including type of animal source) were also calculated. Mean usual intake of protein was 88 ± 4.3, 82 ± 3.1, and 82 ± 2.9 g/day among women in trimester 1, 2, and 3 of pregnancy, respectively, or 1.30 ± 0.10, 1.35 ± 0.06, and 1.35 ± 0.05 g/kg bw/day, respectively. An estimated 4.5% of women in the first trimester of pregnancy consumed less protein than the EAR of 0.66 g/kg bw/day; among women in the second and third trimesters of pregnancy, 12.1% and 12.8% of women, respectively, consumed less protein than the EAR of 0.88 g/kg bw/day. Animal sources of protein accounted for approximately 66% of total protein. Findings from this study show that one in eight women in the second and third trimesters of pregnancy have inadequate intake of protein. Pregnant women should be encouraged to consume sufficient levels of protein from a variety of sources.

scholarly journals Income Level but Not Nutrition Knowledge Is Associated with Dietary Diversity of Rural Pregnant Women from Northern Ghana

2021 ◽  
Vol 2021 ◽  
pp. 1-7
Author(s):  
Emmanuel Amoako Agyei ◽  
Stephen Kofi Afrifa ◽  
Adam Munkaila ◽  
Patience Kanyiri Gaa ◽  
Eugene Dogkotenge Kuugbee ◽  
...  
Keyword(s):  
Vitamin A ◽  
Pregnant Women ◽  
Low Birthweight ◽  
Dietary Diversity ◽  
Nutrition Knowledge ◽  
Rural District ◽  
Leafy Vegetables ◽  
Northern Ghana ◽  
Food Groups ◽  
Essential Nutrients

Essential nutrients are necessary for reducing the risk of maternal mortality, prenatal mortality, and low-birthweight infants. Dietary diversity can play an important role in supplying essential nutrients to both the mother and the foetus. We evaluated nutrition knowledge, attitudes, and dietary diversity of pregnant women. In addition, we investigated the sociodemographic determinants of dietary diversity among pregnant women from a rural district in Ghana. Participants were pregnant women receiving antenatal care from a rural district hospital in Ghana. Dietary diversity was measured using a 24-hour dietary recall questionnaire. Multiple linear regression was used to determine the sociodemographic characteristics of dietary diversity. About 85% of the pregnant women knew that they should eat more in comparison to nonpregnant women, and only 16.9% knew the importance of folic acid supplementation during pregnancy. Mean (SD) dietary diversity score of the participants was 5.27 (1.35), 85.4% did not consume any fruits, and 82.3% did not take milk and milk products. Almost all participants took at least one food item in the starchy staples and green leafy vegetables food groups. Moreover, 53% consumed vitamin A-rich fruits, vegetables, and tubers; 7.7% organ meats; and 30.8% eggs. Those who earned a monthly income of ≥GHC 500 or US$ 87 (B = 1.82; 0.90–2.73; p < 0.001 ) significantly had higher dietary diversity scores compared to those who earned less. Dietary diversity of the pregnant women was suboptimal. The consumption of vitamin A- and iron-rich foods was inadequate. Income was an important determinant of the dietary diversity of pregnant women from Northern rural Ghana.

scholarly journals Inadequate Dietary Diversity and Its Determinants Among Adolescent Girls and Boys: Evidence from the National Nutrition Surveillance Study in Bangladesh

2020 ◽  
Vol 4 (Supplement_2) ◽  
pp. 502-502
Author(s):  
Fahmida Akter ◽  
Md Mokbul Hossain ◽  
Abu Ahmed Shamim ◽  
Mehedi Hasan ◽  
Abu Abdullah Mohammad Hanif ◽  
...  
Keyword(s):  
Adolescent Girls ◽  
Television Viewing ◽  
Dietary Diversity ◽  
Vegetable Consumption ◽  
Family Welfare ◽  
Viewing Time ◽  
Processed Food ◽  
Food Groups ◽  
Adolescent Boys ◽  
Adolescent Girls And Boys

Abstract Objectives Bangladesh is experiencing triple burden of malnutrition among adolescents, which may be associated with inadequate dietary diversity (IDD). In the recently completed round of the national nutrition surveillance (NNS 2018–2019), we explored the prevalence of IDD and its determinants among adolescent girls and boys. Methods A total of 4808 adolescent girls and 4761 adolescent boys were interviewed. We used minimum dietary diversity for women (MDD-W) questionnaire to collect dietary data. IDD was defined as consumption of &lt;5 food groups out of 10 food groups in the past 24 hours. Bivariate and multivariable logistic regression were performed to identify risk factors for IDD among adolescent girls and boys. Results The prevalence of IDD was 55.5% and 50.6% among the adolescent girls and boys. Prevalence of IDD decreased with an increase of educational attainment among girls (no education 77.8% and grade 10 completed education 49.2%) and boys (no education 68.2% and grade 10 completed education 44.2%). The prevalence of IDD in slum, urban and rural areas was 66.4%, 55.6%, and 51.9% among girls and 61.4%, 50.5% and 52.6% among boys, respectively. Prevalence of IDD was lowest among the richest wealth quintile (girls: 45.4% and boys: 43.1%). Among adolescent girls education (e.g., for grade 10 completed, AOR: 3.42, P = 0.002), marital status (AOR: 1.24, P = 0.046), processed food consumption (AOR: 1.66, P &lt; 0.001), television viewing time (e. g. for ≤60 min/day, AOR: 1.37, P &lt; 0.001), and sex of household head (AOR: 0.81, P = 0.003) were significantly associated with IDD. Among the adolescent boys age (AOR: 0.82, P = 0.024), education (e.g., for grade 10 completed, AOR: 2.36, P &lt; 0.001), sex of household heads (AOR: 0.80, P = 0.002), livestock ownership (AOR: 1.22, P = 0.012), fruits and vegetable consumption (AOR: 1.38, P = 0.004), processed food intake (AOR: 1.74, P &lt; 0.001), physical activity (AOR: 0.76, P = 0.001), and television viewing time (e. g. for ≤60 min/day, AOR: 1.19, P = 0.021) were significantly associated with IDD. Conclusions About more than half of the adolescent girls and boys consume inadequately diversified diet in Bangladesh. The study identified a number of factors associated with IDD, which should be addressed through comprehensive and sustainable public health interventions. Funding Sources Ministry of Health and Family Welfare, Bangladesh.

scholarly journals Maternal minimum dietary diversity and associated factors among pregnant women, Southwest Ethiopia, 2021

BMC Nutrition ◽  
2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Abel Girma Tilahun ◽  
Abebaw Molla Kebede
Keyword(s):  
Logistic Regression ◽  
Antenatal Care ◽  
Pregnant Women ◽  
Nutrition Education ◽  
Associated Factors ◽  
Dietary Diversity ◽  
Systematic Sampling ◽  
Age Group ◽  
Food Groups ◽  
Minimum Dietary Diversity

Abstract Background Inadequate dietary diversity intake during pregnancy increases risks of intrauterine growth restriction, abortion, low birth weight, preterm birth, prenatal and infant mortality,and morbidity and has long-lasting health impacts. Dietary diversity during pregnancy promotes the health status of the mother and her fetus. This study aimed to assess the magnitude of minimum dietary diversity and associated factors among pregnant women attending antenatal care. Methods A facility-based cross-sectional study was conducted among 274 pregnant women who attended antenatal care at Wacha primary hospital from January to February 2021. A systematic sampling method was used to select the study participants. The data were collected through face-to-face interviews using a structured and semi-structured questionnaire. Bivariate logistic regression was done to identify factors associated with maternal dietary diversity. Finally, multivariate logistic regression was done, and variables that showed P values of < 0.05 were considered statistically significant. Result The magnitude of minimum dietary diversity was 51% (95% CI: 44.5, 56.7). The mean (±SD) minimum dietary diversity score was 4.5 (± 1.268) with a minimum of 1 anda maximum of 8 food groups consumed out of ten food groups. Age fewer than 25 years (AOR 4.649; 95% CI; 1.404, 15.396), and the age group between 25 to 34 years (AOR 3.624; 95% CI: 1.315, 10.269), husband age group of 26 to 34 years (AOR 2.238; 95% CI; 1.028,4.873), and 35 to 44 years (AOR 3.555; 95% CI; 1.228,10.292) and nutrition awareness of women (AOR 2.182; 95% CI; 1.243, 3.829) were significantly associated with minimum dietary diversity. Conclusion The consumption of minimum dietary diversity of the pregnant mothers was found to be low. Women aged less than 25 and age between 25 to 34 years, husband’s age between 26 to 34 and 35 to 44 years, and nutrition awareness were the factors significantly associated with minimum dietary diversity. Therefore, providing nutrition education and counseling service warranted to promote maternal dietary diversity.

scholarly journals Maternal dietary diversity during lactation and associated factors in Palghar district, Maharashtra, India

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0261700
Author(s):  
Sunil Rajpal ◽  
Abhishek Kumar ◽  
Ruby Alambusha ◽  
Smriti Sharma ◽  
William Joe
Keyword(s):  
Dietary Diversity ◽  
Outcome Variable ◽  
Lactation Period ◽  
Food Groups ◽  
Lactating Women ◽  
Marginalized Communities ◽  
Food Items ◽  
Health And Nutrition ◽  
Lactating Mothers ◽  
Daily Diet

Dietary adequacy and diversity during the lactation period are necessary to ensure good health and nutrition among women and children. Behavioral interventions pertaining to health and nutrition counselling during pregnancy and lactation are critical for awareness about dietary diversity. The issue assumes salience for marginalized communities because of the Covid-19 pandemic and associated economic and societal disruptions. This paper assesses the dietary patterns among 400 lactating mothers in the tribal-dominated district of Palghar in Maharashtra, India in 2020. The study is based on primary data regarding consumption of 10 food groups among women across 10 food groups based on 24-hour recall period. The primary outcome variable was binary information regarding Minimum Dietary Diversity defined as consumption from at least 5 food groups. Econometric analysis based on multilevel models and item-response theory is applied to identify food groups that were most difficult to be received by mothers during the early and late lactation period. We find that the daily diet of lactating mothers in Palghar primarily consists of grains, white roots, tubers, and pulses. In contrast, the intake of dairy, eggs, and non-vegetarian food items is much lower. Only Half of the lactating women (56.5 percent; 95% CI: 37.4; 73.8) have a minimum diversified diet (MDD). The prevalence of lactating women with MDD was higher among households with higher income (73.1 percent; 95% CI: 45.2; 89.9) than those in lower income group (50.7 percent; 95% CI: 42.3; 58.9). Lactating Women (in early phase) who received health and nutrition counseling services are more likely (OR: 2.37; 95% CI: 0.90; 6.26) to consume a diversified diet. Food groups such as fruits, meat, poultry, fish, nuts, and seeds were among the rare food items in daily diet. The dietary pattern lacking in fruits, nuts, and heme (iron) sources indicates more significant risks of micronutrient deficiencies. The findings call for improving dietary diversity among lactating mothers, particularly from the marginalized communities, and are driven by low consumption of dairy products or various fruits and vegetables. Among the different food items, the consumption of micronutrient-rich seeds and nuts is most difficult to be accessed by lactating mothers. Also, diet-centric counseling and informing lactating mothers of its benefits are necessary to increase dietary diversity for improving maternal and child nutrition.

scholarly journals Home Food Availability, Food Insecurity and Nutrition Knowledge Are Key Factors Influencing Dietary Diversity Among Adolescent Girls in Southern Ethiopia

2020 ◽  
Vol 4 (Supplement_2) ◽  
pp. 536-536
Author(s):  
Sunny Kim ◽  
Celeste Sununtnasuk ◽  
Amare Tadesse ◽  
Abdulaziz Oumer ◽  
Tamirrat Walissa ◽  
...  
Keyword(s):  
Food Insecurity ◽  
Food Availability ◽  
Adolescent Girls ◽  
Dietary Diversity ◽  
Nutrition Knowledge ◽  
Average Score ◽  
Southern Ethiopia ◽  
Food Groups ◽  
Adolescent Nutrition ◽  
The Past

Abstract Objectives In Ethiopia, where 40% of the population is under 15 years, evidence on adolescent nutrition is limited. We examined the dietary diversity and its determinants among in-school adolescent girls in 2 regions in southern Ethiopia. Methods We used household survey data from 162 in-school adolescent girls aged 10–14 y across 54 primary schools in one agrarian region (SNNP) and one pastoralist region (Somali), collected in October-November 2019. Multiple regression models were used to examine factors such as nutrition knowledge, food availability and food insecurity associated with the dietary diversity score, adjusted for age and geographic clustering. Results All of the adolescent girls were currently enrolled in school (grades 4–8), and most resided with their mothers (96.9%) and fathers (80.2%). Prevalence of thinness was 11.7% (body mass index (BMI)-for-age Z-score &lt; −2SD), and 35.2% were mildly thin (BMI-for-age Z-score &lt; -1SD). Dietary diversity was low, with 3.7 food groups (out of 10) consumed in the last 24 h. Also, 48.8% reported consuming sweets and sugar-sweetened beverages in the last 24 h. Nutrition knowledge among adolescents was moderate, with an average score of 4.8 out of 8 knowledge items. On occurrences of food insecurity in the past 30 days, they reported an average score of 1.1 (out of 9 items). However, household surveys revealed a high degree of food insecurity (56.2%). Adolescents also reported that only 3.6 food groups (out of 10) were available at home some/most/all of the time (that is, 3–7 days) over the past 7 days. Unsurprisingly, food availability at home (β = 0.30, P = 0.000) and food insecurity (β = −0.12, P = 0.013) followed by nutrition knowledge (β = 0.11, 0 = 0.031) were significantly associated with dietary diversity score. Conclusions Understanding the factors influencing poor diets among adolescents will help to enhance the design of educational interventions to improve adolescent nutrition outcomes, a critical priority in Ethiopia. However, household food insecurity and household food availability are serious concerns in this context. Funding Sources Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360; and CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the International Food Policy Research Institute.

scholarly journals Dietary diversity practice and associated factors among adolescent girls in Dembia district, northwest Ethiopia, 2017

2020 ◽  
Vol 41 (1) ◽  
Author(s):  
Kedir Abdela Gonete ◽  
Amare Tariku ◽  
Sintayehu Daba Wami ◽  
Temesgen Yihunie Akalu
Keyword(s):  
Adolescent Girls ◽  
Technical Assistance ◽  
Dietary Diversity ◽  
Public Health Problem ◽  
Sampling Technique ◽  
Northwest Ethiopia ◽  
Major Public Health Problem ◽  
Food Groups ◽  
Binary Logistic Regression Model ◽  
Cross Sectional

Abstract Background Dietary diversity is defined as the number of food groups or items consumed over a reference period, and usually, it is a problem in developing countries including Ethiopia. Inadequate dietary diversity is one of a major public health problem and can result in physical, emotional, and psychological changes among adolescents. However, studies on dietary diversity among school children were very limited. Hence, this study aimed at determining dietary diversity practices and factors among adolescents in Dembia district. Methods A school-based cross-sectional study was conducted from March 1 to April 15, 2017, at Dembia district, northwest Ethiopia. A total of 474 study subjects were selected using the multi-stage sampling technique. A structured and pre-tested questionnaire was used to collect the data. Dietary diversity was measured through standard tool adopted from Food and Nutrition Technical Assistance (FANTA) 2016 using the 24-h recall method. A multivariable binary logistic regression model was employed to identify factors associated with a diversified diet. Result This study illustrated that 32.3% (95% CI 27.9–36.8) of the adolescents had adequate dietary diversity. Inadequate dietary diversity was significantly associated with being Muslim (AOR = 0.3; 95% CI 0.1–0.7), self-employment (AOR = 0.3; 95% CI 0.1–0.9), middle (AOR = 0.5; 95% CI 0.3–0.8) and high wealth category (AOR = 0.3; 95% CI 0.2–0.6), and underweight (AOR = 3.5; 95% CI 1.3–9.5). Conclusion The findings of this study showed that only one-third of adolescent girls have adequate dietary diversity. Low level of dietary diversification suggested points to the need for strengthening efforts targeting to improve the healthy dietary practice of adolescents by giving due attention to poor households and undernourished adolescents.

scholarly journals Household food insecurity is associated with low dietary diversity among pregnant and lactating women in rural Malawi

2018 ◽  
Vol 22 (4) ◽  
pp. 697-705 ◽  
Author(s):  
Yunhee Kang ◽  
Kristen M Hurley ◽  
Julie Ruel-Bergeron ◽  
Assumpta Bou Monclus ◽  
Rachel Oemcke ◽  
...  
Keyword(s):  
Food Insecurity ◽  
Pregnant Women ◽  
Dietary Diversity ◽  
Cross Sectional Study ◽  
Household Food Insecurity ◽  
Food Groups ◽  
Cross Sectional ◽  
Lactating Women ◽  
Rural Districts ◽  
Household Food

AbstractObjectiveTo examine the association between household food insecurity and dietary diversity in the past 24h (dietary diversity score (DDS, range: 0–9); minimum dietary diversity (MDD, consumption of three or more food groups); consumption of nine separate food groups) among pregnant and lactating women in rural Malawi.DesignCross-sectional study.SettingTwo rural districts in Central Malawi.SubjectsPregnant (n 589) and lactating (n 641) women.ResultsOf surveyed pregnant and lactating women, 66·7 and 68·6 %, respectively, experienced moderate or severe food insecurity and only 32·4 and 28·1 %, respectively, met MDD. Compared with food-secure pregnant women, those who reported severe food insecurity had a 0·36 lower DDS (P<0·05) and more than threefold higher risk (OR; 95 % CI) of not consuming meat/fish (3·19; CI 1·68, 6·03). The risk of not consuming eggs (3·77; 1·04, 13·7) was higher among moderately food-insecure pregnant women. Compared with food-secure lactating women, those who reported mild, moderate and severe food insecurity showed a 0·36, 0·44 and 0·62 lower DDS, respectively (all P<0·05). The risk of not achieving MDD was higher among moderately (1·95; 1·06, 3·59) and severely (2·82; 1·53, 5·22) food-insecure lactating women. The risk of not consuming meat/fish and eggs increased in a dose–response manner among lactating women experiencing mild (1·75; 1·01, 3·03 and 2·81; 1·09, 7·25), moderate (2·66; 1·47, 4·82 and 3·75; 1·40, 10·0) and severe (5·33; 2·63, 10·8 and 3·47; 1·19, 10·1) food insecurity.ConclusionsAddressing food insecurity during and after pregnancy needs to be considered when designing nutrition programmes aiming to increase dietary diversity in rural Malawi.

scholarly journals Dietary Diversity and Associated Factors among Pregnant Women Attending Antenatal Clinic in Shashemane, Oromia, Central Ethiopia: A Cross-Sectional Study

2019 ◽  
Vol 2019 ◽  
pp. 1-7 ◽  
Author(s):  
Melaku Desta ◽  
Mohammed Akibu ◽  
Mesfin Tadese ◽  
Meskerem Tesfaye
Keyword(s):  
Pregnant Women ◽  
Associated Factors ◽  
Dietary Diversity ◽  
Antenatal Clinic ◽  
Cross Sectional Study ◽  
Food Groups ◽  
Sectional Study ◽  
Cross Sectional ◽  
Central Ethiopia ◽  
Pregnant Mothers

Background. Maternal dietary diversity is a proxy indicator of maternal nutrient adequacy and improves health outcomes for both mothers and babies. However, little is documented on dietary diversity among pregnant mothers. Therefore, this study assessed diet diversity and associated factors among pregnant mothers attending the antenatal clinic in Shashemane, Oromia, Central Ethiopia.Methods. An institution-based cross-sectional study was conducted on 315 systematically selected pregnant women attending antenatal clinic of Shashemane town in April 2017. Dietary diversity was assessed using a 24 h dietary recall method, and the dietary diversity score was computed for ten food groups. Bivariate and multivariate logistic regressions were computed to identify associated factors of dietary diversity.Result. In this study, only a quarter (25.4%) of pregnant mothers consumed adequate dietary diversity. Mother’s tertiary (AOR 3.18; 95% CI: 1.8, 6.35) and secondary (AOR 2.13; 95% CI: 2.32, 8.72) education, household monthly income above 3500 ETB (AOR = 2.24; 95% CI: 1.47, 7.78), livestock ownership (AOR = 4.15; 95% CI: 2.07, 9.86), women who got emotional support from the husband (AOR = 3.49; 95% CI: 1.12, 8.23), and women who participated in the shooping (AOR = 2.54; 95% CI: 3.27, 9.83) were more likely to attain the adequate dietary diversity.Conclusion. The study revealed that the overall consumption of adequate dietary diversity was found to be low. Developing the educational level of women, increasing household income and owning of livestock, increasing husbands’ support, and improving women’s participation in the shopping are recommended to improve women’s adequate dietary diversity.

Fertility levels and trends in Arsi and Shoa regions of Central Ethiopia

1991 ◽  
Vol 23 (4) ◽  
pp. 387-400
Author(s):  
Assefa Hailemariam
Keyword(s):  
Population Health ◽  
Baseline Survey ◽  
High Fertility ◽  
Ministry Of Health ◽  
Central Ethiopia ◽  
Health And Nutrition ◽  
Using Data

SummaryLevels and trends of fertility in the Arsi and Shoa regions of Central Ethiopia are examined, using data from the 1986 Population, Health and Nutrition baseline survey of the Ministry of Health of Ethiopia. The population has high fertility. Total fertility of six children per woman in the late 1960s increased to eight children per woman in the early 1980s, then declined to seven children per woman in the mid-1980s. Urban fertility declined by a substantial amount during the 15 years before the survey while rural fertility increased during the same period.The implications of high fertility are considered.

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