Effect of fertility health awareness strategies on fertility knowledge and childbearing in young married couples (FertStart): study protocol for an effectiveness-implementation hybrid type I multicentre three-arm parallel group open-label randomised clinical trial

IntroductionBirth rates have been declining in many advanced societies including Singapore. We designed two interventions with vastly different resource requirements, which include fertility education, personalised fertility information and a behavioural change component targeting modifiable psychological constructs to modify fertility awareness and childbearing intentions. We aim to evaluate the effect of these two interventions on knowledge, attitudes and practice around childbearing compared with a control group among young married couples in Singapore and understand the implementation factors in the setting of an effectiveness-implementation hybrid type 1 three-arm randomised trial.Methods and analysisWe will randomise 1200 young married couples to no intervention (control), Fertility Health Screening group (FHS) or Fertility Awareness Tools (FAT) in a 7:5:5 ratio. Couples in FHS will undergo an anti-Mullerian hormone test and semen analysis, a doctor’s consultation to explain the results and standardised reproductive counselling by a trained nurse. Couples in FAT will watch a standardised video, complete an adapted fertility status awareness (FertiSTAT) tool and receive an educational brochure. The attitudes, fertility knowledge and efforts to achieve pregnancy of all couples will be assessed at baseline and 6 months post-randomisation. Birth statistics will be tracked using administrative records at 2 and 3 years. The primary outcome is the change in the woman’s self-reported intended age at first birth between baseline and 6 months post-randomisation. In addition, implementation outcomes and cost-effectiveness of the two interventions will be assessed.Ethics and disseminationThis study has been reviewed and approved by the Centralized Institutional Review Board of SingHealth (2019/2095). Study results will be reported to the study funder and there are plans to disseminate them in scientific conferences and publications, where authorship will be determined by the International Committee of Medical Journal Editors guidelines.Trial registration numberNCT04647136; ClinicalTrails.gov Identifier.

Age at First Birth in Uttar Pradesh: How Much Has It Actually Changed? Over Inter-NFHS Period?

Culturally, there is always pressure among newly-wed to conceive early and have births in India. Previous studies have documented relationship between age at first birth & fertility, besides the socio-demographic factors that influence age at first birth. The current study aims answering directions and quantum of such relationships using frailty models. The successive rounds of NFHS data (1, 2, 3 & 4) from Uttar Pradesh is used in the study. Fertility in India is characterized as too-early-too-fast. By age-30 majority women would have completed the childbearing. However, the data from NFHS-4 shows some striking changes in the initiation of child bearing in Uttar Pradesh breaking away from the stereotypes of too early too fast characterization. While 44.67 percent of the women aged 30-34 had experienced first birth by age 18 in the year 1992-93 (NFHS-1), the percentages declined during 2015-16 (NFHS-4) to 28.25%. However, by ages 26 majority of women (>95%) aged 30-34 have had experienced first birth. Births at younger age are also a reflection on enforcement of child-marriage restraint act & adherence to legal minimum age at marriage which is 18 for girls & 21 for boys. The data from NFHS-4 have some quality issues. Women aged as low as 5 have shown to have experienced first birth by that age. This may not be possible. The Kaplan Meier survival Graph provided the survival probabilities with respect of each predictor sub groups. The log rank test was used to test the equality of survivor function for each sub group of the predictor variable. The survivor function was significantly different among sub groups of the predictor variables except for the categories of ever use of contraception at NFHS1 and categories of religion across rounds of NFHS data. The Cox Proportional Hazards model was used to study the risk of first birth by socio demographic characteristics. The Frailty model capturing the unobserved heterogeneity in the event time was preferred over standard survival model. For the current study, gamma frailty with Weibull-hazard is used as it fits the data well. Age at marriage and women’s literacy significantly determines the Age at First Birth. The inverse relationship with regard to ever use of contraception needs further analysis. The model also predicts significant frailty with variance parameter (theta) greater than one across the NFHS datasets.

Utilization of free maternity services among mothers aged 18-49 years in Nakuru County, Kenya

Background: In Kenya, the hope of free maternity services (FMS) is to increase the demand for maternity health care services offered by certified health professionals. Thus, this study aimed to determine and understand the utilization level of FMS among mothers aged 18-49 years living in Naivasha Sub-County, Kenya.Methods: A mixed-methods approach collected quantitative and qualitative data through structured questionnaires, health records reviews, focus group discussions, and key informant interviews. The quantitative and qualitative data were analyzed by use of Statistical package for social sciences (SPSS) 20 and content analysis, respectively. The quantitative data results were further subjected to multiple regression analysis.Results: The findings showed that over 80% utilized antenatal care, facility deliveries and postnatal care, but 68% of respondents used family planning. The mothers were found active in their first, second and third pregnancies in utilizing FMS, followed by a sudden decline. The mothers preferred the public health facilities to the private, mission and Non-Governmental Organizations (NGOs). The significant findings influencing the utilization of FMS among the mothers were age (p=0.004), the number of children (p=0.000), age at first birth (p=0.025), household income (p=0.008) and residential area (p=000). The mothers' level of knowledge on FMS had an average score of 80%, obtained by use of the Linkert scale. The radio, television, health facility and community sources were significant with (p=0.000).Conclusions: The decision-makers consider age, the number of children, age at first birth, household income and residential area in the formulation of FMS policies. Further, utilize relevant sources of information on FMS in the community.

Socio-demographic and environmental risk factors associated with multiple under-five child loss among mothers in Bangladesh

Background Despite the substantial decline in child mortality globally over the last decade, reducing neonatal and under-five mortality in Bangladesh remains a challenge. Mothers who experienced multiple child losses could have substantial adverse personal and public health consequences. Hence, prevention of child loss would be extremely desirable during women’s reproductive years. The main objective of this study was to determine the risk factors associated with multiple under-five child loss from the same mother in Bangladesh. Methods In this study, a total of 15,877 eligible women who had given birth at least once were identified from the 2014 Bangladesh Demographic and Health Survey. A variety of count regression models were considered for identifying socio-demographic and environmental factors associated with multiple child loss measured as the number of lifetime under-five child mortality (U5M) experienced per woman. Results Of the total sample, approximately one-fifth (18.9%, n = 3003) of mothers experienced at least one child’s death during their reproductive period. The regression analysis results revealed that women in non-Muslim families, with smaller household sizes, with lower education, who were more advanced in their childbearing years, and from an unhygienic environment were at significantly higher risk of experiencing offspring mortality. This study also identified the J-shaped effect of age at first birth on the risk of U5M. Conclusions This study documented that low education, poor socio-economic status, extremely young or old age at first birth, and an unhygienic environment significantly contributed to U5M per mother. Therefore, improving women’s educational attainment and socio-economic status, prompting appropriate timing of pregnancy during reproductive life span, and increasing access to healthy sanitation are recommended as possible interventions for reducing under-five child mortality from a mother. Our findings point to the need for health policy decision-makers to target interventions for socio-economically vulnerable women in Bangladesh.

Continuity of maternal healthcare services utilisation in Indonesia: analysis of determinants from the Indonesia Demographic and Health Survey

ObjectiveWHO recommends that every pregnant woman and newborn receive quality care throughout the pregnancy, delivery and postnatal periods. However, Maternal Mortality Ratio in Indonesia for 2015 reached 305 per 100 000 live births, which exceeds the target of Sustainable Development Goals (<70 per 100 000 live births). Receiving at least four times antenatal care (ANC4+) and skilled birth attendant (SBA) during childbirth is crucial for preventing maternal and neonatal deaths. The study aims to assess the determinants of ANC4 +and SBA independently, evaluate the distribution of utilisation of ANC4 + and SBA services, and further investigate the associations of two levels of continuity of services utilisation in IndonesiaDesignData from the Indonesia Demographic and Health Survey, a cross-sectional and large-scale national survey conducted in 2017 were used.SettingThis study was set in Indonesia.ParticipantsThe study involved ever-married women of reproductive age (15–49 years) and had given birth in the last 5 years prior to the survey (n=15 288). The dependent variables are the use of ANC4 + and SBA. Individual, family and community factors, such as age, age at first birth, level of education, employment status, parity, autonomy in healthcare decision-making, level of education, employment status of spouses, household income, mass media consumption residence and distance from health facilities were also measured.ResultsResults showed that 11 632 (76.1%) women received ANC4 + and SBA during childbirth. Multivariate analysis revealed that age, age at first birth, and parity have a statistically significant association with continuity of services utilisation. The odds of using continuity of services were higher among women older than 34 years (adjusted OR (aOR) 1.54; 95% CI 1.31 to 1.80) compared with women aged 15–24 years. Women with a favourable distance from health facilities were more likely to receive continuity of services utilisation (aOR 1.39; 95% CI 1.24 to 1.57).ConclusionsThe continuity of services utilisation is associated with age, reproductive status, family influence and accessibility-related factors. Findings demonstrated the importance of enhancing early reproductive health education for men and women. The health system reinforcement, community empowerment and multisectoral engagement enhance accessibility to health facilities, reduce financial and geographical barriers, and produce strong quality care.

“Counting those never bubble over” Estimated prevalence and its determinants of obstetric fistula among childbearing women in 14 African countries: Multilevel Analysis

Background Obstetric fistula is a leakage between genital tract and urinary tract and/or between genital tract and rectum. The commonest cause of obstetric fistula is prolonged labour which magnify in the areas of poor prenatal and emergency obstetric care. In Africa, there is poor of quality of obstetric care and poor social support for those who faced fistula. Obstetric fistula shatters the life of the women and the consequence is nasty while multicounty level estimate on the magnitude and determinates of fistula were nil. Multicounty level of estimate of the magnitude of fistula is important to design and fill the gaps of quality of obstetric care and design the appropriate corrective intervention mechanisms of obstetric fistula. Therefore, this study aimed the estimate the magnitude of obstetric fistula and its determinants among childbearing women in 14 Africa countries based on recent demographic and health survey data. Methods Secondary data were used from 14 African demographic and health survey database. The data were extracted based on the objective the study and previous literatures. Data were weighted using sampling weight before any statistical analysis to account the sampling design. STATA version 15 was used for extracting, recoding, and for further multilevel analysis. The appropriateness of multilevel analysis were checked by Median odds ratio (MOR), proportional change in Variance (PCV), Intraclass correlation coefficient (ICC), and Akaike Information Criteria (AIC). Four model was build and the best model was selected based on the smallest Akaike Information Criteria (AIC). Both bivariable and multivariable multilevel analysis was done accordingly. Variables with p-value ≤0.05 declared as statistical significant with outcome variable for the study. The adjusted odds ratio with 95% confidence interval was used as measure of association. Results The magnitude of obstetric fistula was 0.84 [95%CI: 0.79, 0.88]. Maternal age >=41 years [AOR=1.38; 95% CI:1.01,1.93], urban residence [AOR=0.69; 95%CI: 0.53,0.89], women who attended secondary education [AOR=0.59; 95% CI: 0.45,0.77], women who attended higher education [AOR=0.40; 95% CI: 0.25,0.65], female household head [AOR=0.78; 95% CI: 0.64,0.95], husbands who attended primary education [AOR=0.80; 95% CI: 0.65, 0.98], women who give their first birth 16-20years [AOR=0.78; 95% CI: 0.66,0.92], 21-25 years [AOR=0.66; 95% CI: 0.53,0.84], ≥26 years [AOR=0.67; 95% CI: 0.48, 0.92], history of terminating pregnancy [AOR=1.51; 95% CI: 1.29, 1.77] and awareness on fistula [AOR=0.35; 95% CI: 0.26,0.45) were the determinants of obstetric fistula identified in this study. Conclusion The magnitude of obstetric fistula in 14 African countries were high as compared with the world health organization estimate. Maternal age, residence, educational status, husband’s educational status, sex of household head, age at first birth, history of terminating pregnancy and awareness on obstetric fistula were the determinants identified in this study. Therefore, health interventions that reduce the occurrence of obstetric fistula could be designed to address the women who lives in rural area, no formal education, male-headed household, husbands who never attended formal education, and women who had terminated pregnancy should be addressed in advance. Policies and programs of fistula should be tailored the women which characterized as living in rural area, non-educated, young age at first birth and no awareness on fistula as well as male headed households. Evidence based multicounty interventions were highly recommended to eliminate obstetric fistula and to achieve sustainable development goal.

Social and Biological Transgenerational Underpinnings of Adolescent Pregnancy

Adolescent pregnancy (occurring < age 20) is considered a public health problem that creates and perpetuates inequities, affecting not only women, but societies as a whole globally. The efficacy of current approaches to reduce its prevalence is limited. Most existing interventions focus on outcomes without identifying or addressing upstream social and biological causes. Current rhetoric revolves around the need to change girls’ individual behaviours during adolescence and puberty. Yet, emerging evidence suggests risk for adolescent pregnancy may be influenced by exposures taking place much earlier during development, starting as early as gametogenesis. Furthermore, pregnancy risks are determined by complex interactions between socio-structural and ecological factors including housing and food security, family structure, and gender-based power dynamics. To explore these interactions, we merge three complimentary theoretical frameworks: “Eco-Social”, “Life History” and “Developmental Origins of Health and Disease”. We use our new lens to discuss social and biological determinants of two key developmental milestones associated with age at first birth: age at girls’ first menstrual bleed (menarche) and age at first sexual intercourse (coitarche). Our review of the literature suggests that promoting stable and safe environments starting at conception (including improving economic and social equity, in addition to gender-based power dynamics) is paramount to effectively curbing adolescent pregnancy rates. Adolescent pregnancy exacerbates and perpetuates social inequities within and across generations. As such, reducing it should be considered a key priority for public health and social change agenda.

Factors contributing to the reduction in childhood stunting in Bangladesh: a pooled data analysis from the Bangladesh demographic and health surveys of 2004 and 2017–18

Background Over the last two decades, Bangladesh has made progress in reducing the percentage of stunted children under age 5 years from 51% in 2004 to 31% in 2017. Such reduction has created a source for new research to understand its contributing factors. The present study aims to identify such crucial factors which contributed in reducing the percentage of under-five stunting status of children from 2004 to 2017–18. Methods The study used data from the Bangladesh Demographic and Health Surveys (BDHS), conducted in 2004 and in 2017–18, focused on children under-5-years of age (U5). The sample sizes were n = 6375 children included in the 2004 survey and n = 8312 children included in the 2017–18 survey. Descriptive analysis and bivariate analysis were conducted for a general characterization of the samples. Logistic regression was used to find out the significant factors contributing to the prevalence of stunting among U5 children. Furthermore, the Fairlie decomposition technique was used to identify the crucial factors that contributed to the reduction of stunting. Results The prevalence of stunting among U5 children has declined significantly, from 49.8 to 30.7% between the two survey periods (2004 and 2017–18). Estimates of decomposition analysis show that overall, the selected variables explained 50.6% of the decrease in the prevalence of stunting. Mother’s characteristics such as age at first birth, education level, working status and BMI (body mass index) status were the primary contributors of this change. Father’s characteristics, such as education explained 9% of this change. Conclusion The results of the study highlight the importance of increasing maternal education and reducing inter-household wealth inequality to improve nutritional status of U5 children. In order to achieve further reduction in stunting, among U5 children in Bangladesh, this paper calls for policymakers to develop effective programs to improve maternal education, raise parental awareness of parents regarding children’s height and weight, and aim to significantly reduce inter-household inequalities.

Child marriage and infant mortality: causal evidence from Ethiopia

This study assesses the causal effect of child marriage on infant mortality. Using age discontinuities in exposure to a law that raised the legal age of marriage for women in Ethiopia, the study estimates that a 1-year delay in a woman’s age at cohabitation during her teenage years reduces the probability of her first-born child dying during infancy by 3.8 percentage points. This impact is closely linked to the effect of delaying cohabitation on women’s age at first birth.

Health facility delivery among women of reproductive age in Nigeria: Does age at first birth matter?

Background High maternal mortality ratio in sub-Saharan Africa (SSA) has been linked to inadequate medical care for pregnant women due to limited health facility delivery utilization. Thus, this study, examined the association between age at first childbirth and health facility delivery among women of reproductive age in Nigeria. Methods The study used the most recent secondary dataset from Nigeria’s Demographic and Health Survey (NDHS) conducted in 2018. Only women aged15-49 were considered for the study (N = 34,193). Bi-variate and multivariable logistic regression models were used to examine the association between age at first birth and place of delivery. The results were presented as crude odds ratios and adjusted odds ratios (aOR) with corresponding 95% confidence intervals (CIs). Statistical significance was set at p<0.05. Results The results showed that the prevalence of health facility deliveries was 41% in Nigeria. Women who had their first birth below age 20 [aOR = 0.82; 95%(CI = 0.74–0.90)] were less likely to give birth at health facilities compared to those who had their first birth at age 20 and above. Conclusion Our findings suggest the need to design interventions that will encourage women of reproductive age in Nigeria who are younger than 20 years to give birth in health facilities to avoid the risks of maternal complications associated with home delivery. Such interventions should include male involvement in antenatal care visits and the education of both partners and young women on the importance of health facility delivery.