Unique and shared risk factors for early childhood victimisation and polyvictimisation in a Brazilian population-based birth cohort.

Background: Identifying modifiable risk factors for child victimisation and polyvictimisation (exposure to multiple types of victimisation) is critical for informing prevention efforts, yet little evidence is available in low- and middle-income countries. The authors aimed to estimate the prevalence of child victimisation and polyvictimisation, and examine unique and shared risk factors in a population-based cohort in Southern Brazil. Methods: Lifetime child victimisation was based on maternal report when children were aged 4 years old (N∼3900) and included five types of victimisation (conventional crime, child maltreatment, peer/sibling victimisation, sexual victimisation, and witnessing/indirect victimisation) and polyvictimisation. Based on a socioecological model, possible risk factors were examined in four levels: community, maternal and family, parent, and child. Findings: Conventional crime and peer/sibling victimisation were the most common types of victimisation (46.0 and 46.5%, respectively), followed by witnessing/indirect victimisation (27.0%), and child maltreatment (11.3%). Sexual victimisation had the lowest prevalence (1.4%). One in 10 (10.1%) children experienced polyvictimisation. In general, boys had higher victimisation rates than girls. There were few risk factors related only to specific types of victimisation (e.g., child disability was uniquely associated with child maltreatment and peer/sibling victimisation). Instead, most risk factors were shared across nearly all victimisation types and also associated with polyvictimisation. These shared risk factors were: violent neighbourhood and low social cohesion, maternal adverse childhood experiences, younger maternal age, parental antisocial behaviour, intimate partner violence against mothers, and maternal depression. Interpretation: These findings reveal a general pattern of accumulative risk effects for different types of victimisation and polyvictimisation, rather than unique risk profiles in children aged four year Prevention efforts should target risk factors at multiple levels (e.g.,: community, maternal and family and parent) during early childhood. Funding: Wellcome Trust grant 10735_Z_18_Z.

Health effects associated with exposure to intimate partner violence against women and childhood sexual abuse: a burden of proof study.

The health impacts of intimate partner violence against women and childhood sexual abuse are not fully understood. Here we conducted a systematic review by comprehensively searching seven electronic databases for literature on intimate partner violence-associated and childhood sexual abuse-associated health effects. Following the burden of proof methodology, we evaluated the evidence strength linking intimate partner violence and/or childhood sexual abuse to health outcomes supported by at least three studies. Results indicated a moderate association of intimate partner violence with major depressive disorder and with maternal abortion and miscarriage (63% and 35% increased risk, respectively). HIV/AIDS, anxiety disorders and self-harm exhibited weak associations with intimate partner violence. Fifteen outcomes were evaluated for their relationship to childhood sexual abuse, which was shown to be moderately associated with alcohol use disorders and with self-harm (45% and 35% increased risk, respectively). Associations between childhood sexual abuse and 11 additional health outcomes, such as asthma and type 2 diabetes mellitus, were found to be weak. Although our understanding remains limited by data scarcity, these health impacts are larger in magnitude and more extensive than previously reported. Renewed efforts on violence prevention and evidence-based approaches that promote healing and ensure access to care are necessary.

E. coli contamination of drinking water sources in rural and urban settings: an analysis of 38 nationally representative household surveys (2014-2021).

The world is not on track to achieve universal access to safely managed water by 2030, and access is substantially lower in rural areas. This Sustainable Development Goal target and many other global indicators rely on the classification of improved water sources for monitoring access. We aimed to investigate contamination in drinking water sources, comparing improved and unimproved sources in urban and rural settings. We used data from Multiple Indicator Cluster Surveys, which tested samples from the household water source and a glass of water for Escherichia coli contamination across 38 countries. Contamination was widespread and alarmingly high in almost all countries, settings, and water sources, with substantial inequalities between and within countries. Water contamination was found in 51.7% of households at the source and 70.8% in the glass of water. Some improved sources (e.g., protected wells and rainwater) were as likely to be contaminated as unimproved sources. Some sources, like piped water, were considerably more likely to be contaminated in rural than urban areas, while no difference was observed for others. Monitoring water contamination along with further investigation in water collection, storage, and source classification is essential and must be expanded to achieve universal access to safely managed water.

Intimate partner violence victimisation and its association with maternal parenting (the 2015 Pelotas [Brazil] Birth Cohort): a prospective cohort study.

BACKGROUND: Intimate partner violence (IPV) is highly prevalent in low-income and middle-income countries and has been a major obstacle towards reaching global health targets for women and children. We aimed to investigate cross-sectional and longitudinal associations between IPV victimisation and maternal parenting practices of young children in a population-based birth cohort study in Brazil. METHODS: The 2015 Pelotas Birth Cohort is an ongoing, prospective cohort, including all hospital births occurring between Jan 1 and Dec 31, 2015, in the city of Pelotas, Brazil. When children were aged 4 years, mothers reported on emotional, physical, and sexual IPV victimisation in the past 12 months. Parenting outcomes were assessed through filming the mother and child in interactive tasks at age 4 years and maternal interviews at ages 4 years and 6-7 years. Interactive tasks were filmed at the Centre for Epidemiological Research facilities. Directly observed outcomes included negative (eg, coercive) and positive (eg, sensitivity and reciprocity) parenting interactions independently coded by a team of psychologists. Self-reported parenting was measured using the subscales on quality of parent-child relationship, positive encouragement, parental consistency, and coercive behaviour of the Parenting and Family Adjustment Scales questionnaire. Unadjusted and adjusted linear regression analyses were performed to assess the associations. FINDINGS: Of the 4275 livebirths enrolled in the cohort, 3730 mother-child dyads were included in our analytical sample at age 4 years and 3292 at age 6-7 years. After adjusting for all potential confounders, emotional IPV and physical or sexual IPV were associated with the following self-reported parenting outcomes: poor parent-child relationship quality (emotional IPV: p=0·011), lower parental consistency (emotional IPV: p<0·001, physical or sexual IPV: p=0·0053), and more coercive behaviour (emotional IPV: p<0·001, physical or sexual IPV: p=0·0071) at age 4 years. Associations were not observed for self-reported positive encouragement and filmed parenting outcomes in fully adjusted models. Longitudinally, IPV at age 4 years predicted similar outcomes when children were aged 6-7 years. INTERPRETATION: In this large cohort study, maternal IPV victimisation was consistently associated with poorer parent-child relationship, decreased parental consistency, and increased harsh parenting reported by mothers of young children. As well as initiatives to prevent IPV, parenting interventions focused on supporting the capacity of caregivers to provide nurturing care delivered at key stages early in the life course are crucial. FUNDING: Wellcome Trust. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Effects of the Pelotas (Brazil) Peace Pact on violence and crime: a synthetic control analysis.

Background: City-led interventions are increasingly advocated to achieve the UN's Sustainable Development Goal to reduce violence for all. We used a new quantitative evaluation method to examine whether a flagship programme, called the "Pelotas Pact for Peace" (the Pacto), has been effective in reducing violence and crime in the city of Pelotas, Brazil. Methods: We used synthetic control methodology to assess the effects of the Pacto from August 2017 to December 2021, and separately before and during the COVID-19 pandemic. Outcomes included monthly rates of homicide and property crime, and yearly rates of assault against women and school drop-out. We constructed synthetic controls (counterfactuals) based on weighted averages from a donor pool of municipalities in Rio Grande do Sul. Weights were identified using pre-intervention outcome trends and confounders (sociodemographics, economics, education, health and development, and drug trafficking). Findings: The Pacto led to an overall 9% reduction in homicide and 7% reduction in robbery in Pelotas. These effects were not uniform across the full post-intervention period as clear effects were only seen during the pandemic period. A 38% reduction in homicide was also specifically associated with the criminal justice strategy of Focussed Deterrence. No significant effects were found for non-violent property crimes, violence against women, and school dropout, irrespective of the post-intervention period. Interpretation: City-level interventions that combine public health and criminal justice approaches could be effective in tackling violence in Brazil. Continued monitoring and evaluation efforts are increasingly needed as cities are proposed as key opportunities for reducing violence for all. Funding: This research was funded by the Wellcome Trust [grant number: 210735_Z_18_Z].

The Leading Causes of Death in Children and Adolescents in Brazil, 2000-2020.

INTRODUCTION: Despite promising reductions in mortality from infectious diseases, premature death is a still major public health problem in Brazil. However, little is known about which diseases and injury mechanisms are the main causes of premature death. This paper aimed to detail the trends in leading causes of death among children and adolescents in Brazil. METHODS: Data were extracted from medical death certificates from the Brazilian Mortality Information System for children and adolescents aged 1-19 years for 2000-2020. The 10 leading causes of death for children and adolescents were defined using primary cause of death codes, grouped by death for diseases and mechanism for injury, according to the ICD-10. All analyses were completed in 2022. RESULTS: From 2000 through 2020, there was a total of 772,729 child and adolescent deaths in Brazil. Despite an overall 34% reduction in child and adolescent mortality from 2000 to 2020, improvements were less pronounced for injury-related deaths than for communicable diseases. Therefore, by 2020, over half of deaths were from injury-related causes. Firearm-related injury was by far the leading cause, accounting for 21% of all deaths. There was a 38% reduction in firearm deaths in the last 4 years against a previously increasing trend, and homicide accounted for over 90% of all firearm deaths because suicide by firearm was rare. CONCLUSIONS: Injury-related deaths among children and adolescents are a growing concern in Brazil, and firearms are the current leading cause of child and adolescent death.

Cross-National Associations between Age at Marriage and Intimate Partner Violence among Young Women: An Analysis of Demographic and Health Surveys from 48 Countries.

We estimated the associations between age at first marriage and recent intimate partner violence (IPV) among women young women aged 20-24 years using data from demographic and health surveys (DHS) conducted at 48 low- and middle-income countries (LMICs). We fitted a multilevel logistic regression model controlling for sociodemographic covariates. Our pooled analyses revealed that age at marriage is strongly associated with past year IPV in a non-linear way, with steep reductions in violence when young women marry after age 15 and a continued decline in IPV for every year marriage is delayed up to age 24. The risk of physical IPV was 3.3 times higher among women married at age 15 (24.4%, 95% CI 19.7; 29.2%) compared to young women married at age 24 (7.5%, 95% CI 5.8; 9.2%). For sexual IPV, girls married at 15 had 2.2 times higher risk compared to those married at 24 (7.5%, 95% CI 5.6; 9.5% vs. 3.4%, 95% CI 2.7; 4.2%, respectively). For psychological IPV, the relative risk was 3.4 for the same comparison (married at 15: 20.1%, 95% CI 14.6; married at 24: 25.5% vs. 6.0%, 95% CI 3.4; 8.6%). Country specific analyses showed that, age at marriage was negatively associated with physical and psychological IPV in nearly half of the countries (n/48) and with sexual IPV in ten countries. Our findings underscore the importance of integrating violence prevention and response interventions into efforts to prevent child marriage, as well as the health, educations and social services young women access.

The role of female permanent contraception in meeting the demand for family planning in low- and middle-income countries.

OBJECTIVE: Our aim was to describe the reliance on female permanent contraception among women with demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries (LMICs) and to describe socio-economic and demographic patterns of permanent contraception in countries with high use. STUDY DESIGN: Using data from the latest national health survey carried out in LMICs, we estimated mDFPS and the share of each contraceptive method used. Countries with a share of more than 25% of female permanent contraception were further explored for differences by wealth, number of living children, woman's age, and by the intersection of woman's age and number of living children. RESULTS: In the 20 countries studied, between 6% and 94% of the contracepting population used modern methods. Female permanent contraception accounted for more than half of women using modern contraceptives in India, Dominican Republic, El Salvador, Mexico, and Colombia. In India and Tonga, more than 20% of women using contraceptives with fewer than 2 living children were using female permanent contraception. Among women with 2 living children, countries with the highest reliance on permanent contraception were India (79%), El Salvador (61%), Cuba (55%), Colombia (52%), and Thailand (51%). Dominican Republic, El Salvador, India, and Mexico presented high levels of permanent contraception among younger women, with reliance higher than 30% among women aged 25 to 29 and 50% or more among women aged 30 to 34. CONCLUSIONS: Reliance on permanent contraception was high in several countries and among women aged less than 35 years. IMPLICATIONS: Our results may help policymakers and health managers improve family planning services in low- and middle-income settings. We identified high use of female permanent contraception among modern contraceptive users in several countries, even among young women with fewer children.

Sexual violence as a predictor of unintended pregnancy among married women of India: evidence from the fourth round of the National Family Health Survey (2015-16).

BACKGROUND: Sexual Intimate Partner Violence (IPV) is a public health problem globally, with about one in three women experiencing sexual IPV ever in their lifetime. Unintended pregnancy is one of the consequences of sexual IPV and has its repercussions that can span generations. The present study was conducted to estimate the prevalence of sexual intimate partner violence (IPV) and assess the association between sexual IPV and unintended childbirth in India among married women aged 15-49 years. METHODS: The National Family Health Survey-India (NFHS-4) fourth-round dataset was used for the present study. Pregnancies intention was the primary outcome variable, and the main predictor variable was self-reported sexual IPV in the past 12 months. Women's current age, age at marriage, education and occupation, place of residence, wealth quintile, parity, religion, caste, region, mass media exposure, and husband's education were other control variables. Weighted analysis depicted the prevalence of unintended pregnancies and their association with different socio-demographic variables. Binary logistic regression was done in two steps respecting a hierarchical approach for potential confounders. RESULTS: Approximately 6.4% of study participants had ever experienced sexual IPV in India. Prevalence of sexual IPV was significantly higher when the age of marriage was < 19 years, among uneducated, in the lowest wealth index quintile, belonging to scheduled caste, having multiparity, and not having mass media exposure. About 12.1% of pregnancies were considered unintended by the respondents, and 22.9% of women who ever had a history of sexual IPV considered the last pregnancy to be unintentional. Women who experienced sexual IPV were in younger age groups, having parity ≥1, and bigger families had significantly higher odds of having an unintended pregnancy compared to their reference groups. CONCLUSIONS: We observed that sexual IPV has a significant role in unintended pregnancies. Effective counseling means should be rolled out for victims of sexual IPV as it is a taboo subject. The significant factors that can predict unintended pregnancies highlighted in our study should be acknowledged while counseling.

Maternal adverse childhood experiences (ACEs) and their associations with intimate partner violence and child maltreatment: Results from a Brazilian birth cohort.

Adverse childhood experiences (ACEs) have been found to predict many negative life outcomes. However, very little evidence exists on Intimate Partner Violence (IPV) and Child Maltreatment (CM). We investigated the impact of maternal ACEs on IPV and CM in three different: cumulative risk, individual adversities and particular groupings of ACEs. The 2015 Pelotas Birth Cohort, Southern Brazil, has followed a population-based sample mothers and children repeatedly until children were aged 4 years, when mothers provided data on ACEs, and current IPV and CM. ACEs were examined in three different ways: (i) as a cumulative risk score; (ii) individual adversities; and (iii) patterns of ACEs (Latent Class Analysis: LCA). One quarter (25.4%) of mothers reported having 5+ ACEs in childhood. Compared to mothers with no ACEs, those who reported 5+ ACEs, had 4.9 (95%CI 3.5; 6.7) times the risk of experiencing IPV and 3.8 (95%CI 2.5; 5.6) times the risk of reporting child maltreatment. LCA results also highlighted the major influence of multiple ACEs on later IPV and CM. However, individual ACEs related to violence (exposure to abuse or domestic violence) showed some specificity for both later IPV and CM, over and above the influence of cumulative childhood adversity. This is the first large study to demonstrate a strong link between maternal ACEs and both IPV and CM. Cumulative ACE exposure and some specificity in effects of childhood violence are important for later IPV and CM. Integrated prevention is essential for reducing the intergenerational transmission of adversity and violence.

Assessing Wealth-Related Inequalities in Demand for Family Planning Satisfied in 43 African Countries.

Background: Around 80% of the African population lives in urban areas, and a rapid urbanization is observed in almost all countries. Urban poverty has been linked to several sexual and reproductive health risks, including high levels of unintended pregnancies. We aim to investigate wealth inequalities in demand for family planning satisfied with modern methods (mDFPS) among women living in urban areas from African countries. Methods: We used data from 43 national health surveys carried out since 2010 to assess wealth inequalities in mDFPS. mDFPS and the share of modern contraceptive use were stratified by groups of household wealth. We also assessed the ecological relationship between the proportion of urban population living in informal settlements and both mDFPS and inequalities in coverage. Results: mDFPS among urban women ranged from 27% (95% CI: 23-31%) in Chad to 87% (95% CI: 84-89%) in Eswatini. We found significant inequalities in mDFPS with lower coverage among the poorest women in most countries. In North Africa, inequalities in mDFPS were identified only in Sudan, where coverage ranged between 7% (95% CI: 3-15%) among the poorest and 52% (95% CI: 49-56%) among the wealthiest. The largest gap in the Eastern and Southern African was found in Angola; 6% (95% CI: 3-11%) among the poorest and 46% (95% CI: 41-51%) among the wealthiest. In West and Central Africa, large gaps were found for almost all countries, especially in Central African Republic, where mDFPS was 11% (95% CI: 7-18%) among the poorest and 47% (95% CI: 41-53%) among the wealthiest. Inequalities by type of method were also observed for urban poor, with an overall pattern of lower use of long-acting and permanent methods. Our ecological analyses showed that the higher the proportion of the population living in informal settlements, the lower the mDFPS and the higher the inequalities. Conclusion: Our results rise the need for more focus on the urban-poorer women by public policies and programs. Future interventions developed by national governments and international organizations should consider the interconnection between urbanization, poverty, and reproductive health.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa.

BACKGROUND: The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys. METHODS: We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status. RESULTS: Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = - 1.7%, p < 0.001) and unmarried (AARC = - 4.7%, p < 0.001) AGYW from poorest households in Mozambique. CONCLUSION: Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. RESULTS: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). CONCLUSION: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

Intimate partner violence against women and child maltreatment in a Brazilian birth cohort study: co-occurrence and shared risk factors.

BACKGROUND: Intimate partner violence (IPV) against women and child maltreatment (CM) are major public health problems and human rights issues and may have shared causes. However, their overlap is understudied. We investigated the prevalence of IPV and CM, their co-occurrence in households and possible shared risk factors, in the general population of a Brazilian urban setting. METHODS: Prospective population-based birth cohort, including over 3500 mother-child dyads with maternal reports on both IPV and CM when children were 4 years old. Eleven neighbourhood, family and parental risk factors were measured between birth and age 4 years. Bivariate and multivariate Poisson regression models with robust variance were used to test which potential risk factors were associated with IPV, CM and their co-occurrence. RESULTS: The prevalence of any IPV and CM were 22.8% and 10.9%, respectively; the co-occurrence of both types of violence was 5%. Multivariate analyses showed that the overlap of IPV and CM was strongly associated with neighbourhood violence, absence of the child's biological father, paternal antisocial behaviour in general and a mother-partner relationship characterised by high levels of criticism, maternal depression and younger maternal age. A concentration of many risk factors among 10% of the population was associated with a sixfold increase in risk for overlapping IPV and CM compared with households with no risk factors. CONCLUSION: IPV and CM share important risk factors in the family and neighbourhood environments and are particularly common in households with multiple social disadvantages and family difficulties. Integrated preventive interventions are needed.

Identifying the women most vulnerable to intimate partner violence: A decision tree analysis from 48 low and middle-income countries.

BACKGROUND: Primary prevention strategies are needed to reduce high rates of intimate partner violence (IPV) in low- and middle-income countries (LMICs). The effectiveness of population-based approaches may be improved by adding initiatives targeted at the most vulnerable groups and tailored to context-specificities. METHODS: We applied a decision-tree approach to identify subgroups of women at higher risk of IPV in 48 LMICs and in all countries combined. Data from the most recent Demographic and Health Survey carried out between 2010 and 2019 with available information on IPV and sociodemographic indicators was used. To create the trees, we selected 15 recognized risk factors for IPV in the literature which had a potential for targeting interventions. Exposure to IPV was defined as having experienced physical and/or sexual IPV in the past 12 months. FINDINGS: In the pooled decision tree, witnessing IPV during childhood, a low or medium empowerment level and alcohol use by the partner were the strongest markers of IPV vulnerability. IPV prevalence amongst the most vulnerable women was 43% compared to 21% in the overall sample. This high-risk group included women who witnessed IPV during childhood and had lower empowerment levels. These were 12% of the population and 1 in 4 women who experienced IPV in the selected LMICs. Across the individual national trees, subnational regions emerged as the most frequent markers of IPV occurrence. INTERPRETATION: Starting with well-known predictors of IPV, the decision-tree approach provides important insights about subpopulations of women where IPV prevalence is high. This information can help designing targeted interventions. For a large proportion of women who experienced IPV, however, no particular risk factors were identified, emphasizing the need for population wide approaches conducted in parallel, including changing social norms, strengthening laws and policies supporting gender equality and women´s rights as well as guaranteeing women´s access to justice systems and comprehensive health services. FUNDING: Bill and Melinda Gates Foundation (Grant INV-010051/OPP1199234), Wellcome Trust (Grant Number: 101815/Z/13/Z) and Associação Brasileira de Saúde Coletiva (ABRASCO).

Women's Empowerment as It Relates to Attitudes Towards and Practice of Female Genital Mutilation/Cutting of Daughters: An Ecological Analysis of Demographic and Health Surveys From 12 African Countries.

Background: Women's empowerment may play a role in shaping attitudes towards female genital mutilation/cutting (FGM/C) practices. We aimed to investigate how empowerment may affect women's intention to perpetuate FGM/C and the practice of FGM/C on their daughters in African countries. Materials and methods: We used data from Demographic and Health Surveys carried out from 2010 to 2018. The countries included in our study were Benin, Burkina Faso, Chad, Côte d´Ivoire, Ethiopia, Guinea, Kenya, Mali, Nigeria, Senegal, Tanzania, and Togo. This study included 77,191 women aged 15-49 years with at least one daughter between zero and 14 years of age. The proportion of women who reported having at least one daughter who had undergone FGM/C as well as the mother's opinion towards FGM/C continuation were stratified by empowerment levels in three different domains (decision-making, attitude to violence, and social independence) for each country. We also performed double stratification to investigate how the interaction between both indicators would affect daughter's FGM/C. Results: The prevalence of women who had at least one daughter who had undergone FGM/C was consistently higher among low empowered women. Tanzania, Benin, and Togo were exceptions for which no differences in having at least one daughter subjected to FGM/C was found for any of the three domains of women's empowerment. In most countries, the double stratification pointed to a lower proportion of daughters' FGM/C among women who reported being opposed to the continuation of FGM/C and had a high empowerment level while a higher proportion was observed among women who reported being in favor of the continuation of FGM/C and had a low empowerment level. This pattern was particularly evident for the social independence domain of empowerment. In a few countries, however, a higher empowerment level coupled to a favorable opinion towards FGM/C was related to a higher proportion of daughters' FGM/C. Conclusion: Women's empowerment and opinion towards FGM/C seems to be important factors related to the practice of FGM/C in daughters. Strategies to improve women's empowerment combined with shifts in the wider norms that support FGM/C may be important for achieving significant reductions in the practice.

Intimate partner violence in 46 low-income and middle-income countries: an appraisal of the most vulnerable groups of women using national health surveys.

Introduction: Intimate partner violence (IPV) against women is a critical public health issue that transcends social and economic boundaries and considered to be a major obstacle to the progress towards the 2030 women, children and adolescents' health goals in low-income and middle-income countries (LMICs). Standardised IPV measures have been increasingly incorporated into Demographic and Health Surveys carried out in LMICs. Routine reporting and disaggregated analyses at country level are essential to identify populational subgroups that are particularly vulnerable to IPV exposure. Methods: We examined data from 46 countries with surveys carried out between 2010 and 2017 to assess the prevalence and inequalities in recent psychological, physical and sexual IPV among ever-partnered women aged 15-49 years. Inequalities were assessed by disaggregating the data according to household wealth, women's age, women's empowerment level, polygyny status of the relationship and area of residence. Results: National levels of reported IPV varied widely across countries-from less than 5% in Armenia and Comoros to more than 40% in Afghanistan. Huge inequalities within countries were also observed. Generally, richer and more empowered women reported less IPV, as well as those whose partners had no cowives. Different patterns across countries were observed according to women's age and area of residence but in most cases younger women and those living in rural areas tend to be more exposed to IPV. Conclusion: The present study advances the current knowledge by providing a global panorama of the prevalence of different forms of IPV across LMICs, helping the identification of the most vulnerable groups of women and for future monitoring of leaving no one behind towards achieving the elimination of all forms of violence among women and girls.

Female infants are more susceptible to the effects of maternal antenatal depression; findings from the Pelotas (Brazil) Birth Cohort Study.

BACKGROUND: We utilised data from the 2015 Pelotas Birth Cohort, a large prospective cohort in southern Brazil, to examine the association of moderate and severe antenatal depression with child birth outcomes and explore interactions with sociodemographic characteristics. METHODS: Data was available for n = 3046 participants and their infants. We measured antenatal depression using the Edinburgh Postnatal Depression Scale (EPDS, ≥13 for moderate and ≥17 for severe depression). Outcome measures included gestational age, birth weight, length and head circumference, using the Intergrowth-21st standards. We controlled for known confounders including obstetric risk. RESULTS: We did not find differences in childbirth outcomes by maternal depression status for participants with at least moderate depression, although there was an increased risk for female offspring to be small for gestational age (SGA, OR 2.33[1.37,3.97]). For severe depression (EPDS≥17) we found an increased risk for lower APGAR scores (OR 1.63[1.02,2.60]) and being SGA (OR 1.77[1.06,2.97], with an increased risk for female offspring in particular to be in lower weight centiles (-10.71 [-16.83,-4.60]), to be SGA (OR 3.74[1.89, 7.44]) and in the lower 10th centile for length (OR 2.19[1.25,3.84]). LIMITATIONS: include the use of a maternal report questionnaire to ascertain depressive symptoms. CONCLUSIONS: In this recent large longitudinal cohort in Brazil we did not find independent effects of depression on adverse birth outcomes or interactions with sociodemographic characteristics. We found an increased risk of being SGA for female offspring of women with moderate and severe depression, in line with other research suggesting females may be more susceptible to antenatal disturbances. FUNDING: This work was supported by the Wellcome Trust, United Kingdom (095582), the Brazilian National Research Council (CNPq) and the Coordination for the Improvement of Higher Education Personnel (CAPES). EN was supported by the UK Economic and Social Research Council GCRF Postdoctoral Fellowship (ES/P009794/1).

The association between disrespect and abuse of women during childbirth and postpartum depression: Findings from the 2015 Pelotas birth cohort study.

BACKGROUND: This study examined the association between disrespect and abuse of women during facility-based childbirth and postpartum depression (PD) occurrence. METHODS: We used data from the 2015 Pelotas (Brazil) Birth Cohort, a population-based cohort of all live births in the city. We assessed 3065 mothers at pregnancy and 3-months after birth. Self-reported disrespect and abuse experiences included physical abuse, verbal abuse, denial of care, and undesired procedures. We estimate the occurrence of each disrespect and abuse type, one or more types and disrespect and abuse score. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess PD. EPDS scores ≥13 and ≥15 indicated at least moderate PD and marked/severe. Odds ratios (OR) were calculated by logistic regression. RESULTS: The prevalence of at least moderate PD and marked/severe PD was 9.4% and 5.7%, respectively. 18% of the women experienced at least one type of disrespect and abuse. Verbal abuse increased the odds of having at least moderate PD (OR = 1.58; 95%CI 1.06-2.33) and marked/severe PD (OR = 1.69; 95%CI 1.06-2.70) and the effect among women who did not experience antenatal depressive symptoms was greater in comparison to those who did (OR = 2.51; 95%CI 1.26-5.04 and OR = 4.27; 95%CI 1.80-10.12). Physical abuse increased the odds of having marked/severe PD (OR = 2.28; 95%CI 1.26-4.12). Having experienced three or more mistreatment types increased the odds of at least moderate PD (OR = 2.90; 95%CI 1.30 - 35.74) and marked/severe PD (OR=3.86; 95%CI 1.58-9.42). LIMITATIONS: Disrespect and abuse experiences during childbirth were self-reported. CONCLUSIONS: Disrespect and abuse during childbirth increased the odds of PD three months after birth. Strategies to promote high quality and respectful maternal health care are needed to prevent mother-child adverse outcomes.

Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: prevalence and inequalities in 23 countries.

BACKGROUND: The rise in contraceptive use has largely been driven by short-acting methods of contraception, despite the high effectiveness of long-acting reversible contraceptives. Several countries in Latin America and the Caribbean have made important progress increasing the use of modern contraceptives, but important inequalities remain. We assessed the prevalence and demand for modern contraceptive use in Latin America and the Caribbean with data from national health surveys. METHODS: Our data sources included demographic and health surveys, multiple indicator cluster surveys, and reproductive health surveys carried out since 2004 in 23 countries of Latin America and the Caribbean. Analyses were based on sexually active women aged 15-49 years irrespective of marital status, except in Argentina and Brazil, where analyses were restricted to women who were married or in a union. We calculated contraceptive prevalence and demand for family planning satisfied. Contraceptive prevalence was defined as the percentage of sexually active women aged 15-49 years who (or whose partners) were using a contraceptive method at the time of the survey. Demand for family planning satisfied was defined as the proportion of women in need of contraception who were using a contraceptive method at the time of the survey. We separated survey data for modern contraceptive use by type of contraception used (long-acting, short-acting, or permanent). We also stratified survey data by wealth, area of residence, education, ethnicity, age, and a combination of wealth and area of residence. Wealth-related absolute and relative inequalities were estimated both for contraceptive prevalence and demand for family planning satisfied. FINDINGS: We report on surveys from 23 countries in Latin America and the Caribbean, analysing a sample of 212 573 women. The lowest modern contraceptive prevalence was observed in Haiti (31·3%) and Bolivia (34·6%); inequalities were wide in Bolivia, but almost non-existent in Haiti. Brazil, Colombia, Costa Rica, Cuba, and Paraguay had over 70% of modern contraceptive prevalence with low absolute inequalities. Use of long-acting reversible contraceptives was below 10% in 17 of the 23 countries. Only Cuba, Colombia, Mexico, Ecuador, Paraguay, and Trinidad and Tobago had more than 10% of women adopting long-acting contraceptive methods. Mexico was the only country in which long-acting contraceptive methods were more frequently used than short-acting methods. Young women aged 15-17 years, indigenous women, those in lower wealth quintiles, those living in rural areas, and those without education showed particularly low use of long-acting reversible contraceptives. INTERPRETATION: Long-acting reversible contraceptives are seldom used in Latin America and the Caribbean. Because of their high effectiveness, convenience, and ease of continuation, availability of long-acting reversible contraceptives should be expanded and their use promoted, including among young and nulliparous women. In addition to suitable family planning services, information and counselling should be provided to women on a personal basis. FUNDING: Wellcome Trust, Pan American Health Organization.