For modern Western societies with a regime of monogamy, it has recently been demonstrated that the socioeconomic status of men is positively associated with being or having been married. This study aims to compare marriage patterns (if a person has been married at least once) for cultures with a tradition of monogamy and polygyny. As no worldwide data on polygyny exist, religion was used as a proxy for monogamy (Christians) vs polygyny (Muslims). The analyses were based on 2000–2011 census data from 39 countries worldwide for 52,339,594 men and women, controlling for sex, sex ratio, age, education, migration within the last 5 years and employment. Overall, a higher proportion of Muslims were married compared with Christians, but the difference in the fraction of married men compared with married women at a certain age (the ‘marriage gap’) was much more pronounced in Muslims than in Christians, i.e. compared with Christians, a substantially higher proportion of Muslim women than men were married up to the age of approximately 31 years. As expected for a tradition of polygyny, the results indicate that the socioeconomic threshold for entering marriage is higher for Muslim than Christian men, and Muslim women in particular face a negative effect of socioeconomic status on the probability of ever being married. The large ‘marriage gap’ at a certain age in Muslim societies leads to high numbers of married women and unmarried young men, and may put such polygenic societies under pressure.

This study aimed to assess knowledge, attitude and practice related to consanguinity among multiethnic health care providers in the Kingdom of Saudi Arabia. Using a cross-sectional study design, a validated, self-administered close-ended questionnaire was randomly distributed to health care providers in different health institutions in the country between 1st August 2012 and 31st July 2013. A total of 1235 health care providers completed the study questionnaire. Of the 892 married participants (72.23% of total), 11.43% were married to a first cousin, and were predominantly Arabs, younger than 40 years and male. Only 17.80% of the patients seen by the health care providers requested consanguinity related counselling. A knowledge barrier was expressed by 27.49% of the participants, and 85.67% indicated their willingness to have more training in basic genetic counselling. A language barrier was expressed as a limiting factor to counselling for consanguinity among non-Arabs. The health care providers had a major dearth of knowledge that was reflected in their attitude and practice towards consanguinity counselling. This finding indicates the need for more undergraduate and postgraduate medical and nursing education and training in the counselling of consanguineous couples. It is recommended that consanguinity counselling is included in the current premarital screening and counselling programmes in the Kingdom.

This paper examines the proposition that sexual and contraceptive behaviours mediate the relationship between the pregnancy desires of young, unmarried women and their having an unplanned pregnancy. The sample consisted of 854 18- to 19-year-old women living in Michigan, USA. First, the positive and negative pregnancy desires of these women were measured, as were the women’s perceptions of the positive and negative desires of their sexual partners. Then the extent to which these four types of desires, as well as several types of interactions between them, prospectively predicted the occurrence of subsequent pregnancies were tested with logistic regression analyses, initially alone and then after the addition of several types of sexual and contraceptive mediator variables. The results demonstrated that four of the ten significant motivational predictors became non-significant following the introduction of the contraceptive mediator variables and that the predictive strength of the other six significant motivational predictors was substantially reduced by their introduction. A number of factors that may account for only a partial mediational effect in some models are discussed.

There is an abundant literature on the relationship between women’s education and maternal and child outcomes, including antenatal and postnatal care, onset of antenatal care and skilled birth attendance. However, few studies have adopted the ‘equity’ lens, despite increasing evidence that inequities between rich and poor are increasing although maternal and child mortality is declining. This study examined the differential effects of women’s education within different socioeconomic strata in Africa. The most recent Demographic and Health Surveys (DHS) conducted in the Democratic Republic of the Congo, Egypt, Ghana, Nigeria and Zimbabwe were used. In each country, the original sample was stratified into three socioeconomic groups: poor, middle and rich. For each maternal health service utilization variable, the gross and net effects of women’s education, controlling for age, parity, religion, marital status, health insurance, access to health facilities, partner’s education and current place of residence, were estimated using logistic regression, taking into account the complex sampling design of the DHS. The findings revealed country-specific variations in maternal health service utilization, and for most indicators there was a clear gradient among socioeconomic strata: women living in better-off households exhibited greater access to, and utilization of, maternal health services. Multivariate analyses revealed that women’s education had a positive association with type of antenatal care provider, timing and frequency of antenatal care visits, place of delivery and presence of a skilled birth attendant at delivery. Many other factors were found to be significantly associated with maternal health service utilization. For instance, parity had a negative and significant association with timing of first antenatal care visit. Likewise, partner’s education was positively and statistically associated with timing of first antenatal care visit. It is argued that an over-generalization of the association between women’s education and maternal health service utilization can be misleading. Efforts to improve maternal health service utilization in Africa must adopt an ‘equity’ approach, taking into account the specific needs of sub-populations.

Reproduction in India is mainly confined to within marriage. The fertility preferences of spouses will not necessarily be the same, but discussion between couples creates scope for understanding between spouses after marriage. Knowing each other’s opinions facilitates decision-making on sensitive matters such as contraception use and desired family size. This study used data from the India Human Development Survey-II (2011–12), and was based on a sample of 31,276 currently married women. The aim was to understand the role of pre-marital communication, studied through the choosing of husbands, mutual communication before marriage and duration of time spouses knew each other before marriage on the fertility preferences of couples post-marriage. These preferences included contraception use, who has most say on the number of children and the gap between desired and actual number of offspring. The results showed that wives who knew their husbands or who had any kind of communication with them before marriage had a greater chance of being involved in fertility decisions. However, most fertility decisions were found to be male-driven. Wives who knew their husbands for more than a month before marriage took more decisions on number of children (27%) than those who only knew their husbands from the day of their wedding (20%). Wives were less likely to have more children/sons/daughters than desired if they had some communication with their husbands before marriage. A better understanding of fertility preferences between spouses might help to curb unwanted births through delaying or limiting births by contraception use. Families in India could encourage couples to interact before marriage so they can make collective decisions on contraception use and/or the number of children they have.

This study assessed whether agricultural and household incomes were the same across different agro-ecological environments in Bangladesh. An in-depth analysis of the effect of unfavourable ecologies on maternal and child malnutrition was carried out. Data were from a longitudinal data set comprising a nationally representative data sample collected in 2014 and the Food Security Nutrition Surveillance Project (FSNSP) conducted in 2011 and 2012. Anthropometric indices were used to assess the nutritional status of mothers and under-five children. The key variables of interest were food seasonality and geographical location. Data were analysed using the General Linear Model and multinomial and binary logistic regression analysis. Panel data analysis showed that household income was not equal across agro-ecological zones, indicating that the fragility of the environment affects a household’s ability to access food, and thus the nutritional status of mothers and children. Coastal areas of Bangladesh were found to be less dependent on agriculture, particularly cultivation, which had diminished during last few decades. Per capita income has been increasing in coastal areas of Bangladesh, led by remittance (money sent home by migrant workers) growing at 8% per year against 6% in other areas. Regression analysis showed that a household in a coastal zone earned 19% less than one in more favourable zones. Although the income from farm practices was found to be lower in unfavourable areas, the deficiency was compensated by increased non-farm incomes. The results from the FSNSP data showed that overall the rates of stunting and wasting among under-five children were 37% and 11.7%, respectively, and nearly 28% of mothers suffered from undernutrition. A highly significant regional heterogeneity in undernutrition was found, with alarmingly high levels in the Haor Basin and coastal belt areas. There were significantly higher rates of underweight and wasting in the monsoon season compared with the two harvest seasons among children under the age of five. The findings stress the importance of bringing geographical location and seasonality thinking into debates on hunger and nutrition in Bangladesh.

This study analysed the association between menopause, menarche and number of live births using cross-sectional primary data for 75 post-menopausal rural women from Shimla in the Indian state of Himachal Pradesh. The mean/median ages at menarche of the 75 women were 14.23/14 years, and those at menopause 45.35/45 years. There were no significant differences in these values between women in the age groups 40–55 and 56–65 years. Age at menopause was found to be significantly associated with age at menarche and maternal age at birth of the first and last child, but not with menopausal symptom severity score. The majority of the 75 post-menopausal women (70.7%) had very mild or no menopausal symptoms. Three principal components were identified that explained 72.43% of the underlying variation in menopausal symptoms.

Several studies have indicated that consanguineous marriages (unions between biologically related persons) are associated with increased risk of autosomal recessive diseases and several multifactorial traits. Mandaeans are a closed ethno-religious community living in areas of southern Iraq and Iran (Khuzestan Province). There are currently no data on the prevalence of consanguineous marriages among Mandaeans. The present study was carried out in 2016 to determine the prevalence of consanguinity among Iranian Mandaeans living in Khuzestan Province, south-west Iran. A total of 137 couples (urban areas: 79 couples; rural areas: 58 couples) were included in the study. Information on the consanguineous marriages of the subjects was collected through direct interviews. Marriages were classified by the degree of relationship between couples as double first cousins, first cousins, first cousin once removed, second cousins and unrelated marriages. The coefficient of inbreeding (F) was calculated for each couple and the mean coefficient of inbreeding (α) estimated for the population, stratified by rural and urban areas. The overall frequency of consanguinity was found to be 50.7% in urban and 86.2% in rural areas. There was a significant difference between rural and urban areas in types of marriages (χ2=24.8, df=4, p<0.001) and first cousin marriages (51.8%) were the most common type. The overall α-value was estimated to be 0.0363 for the Iranian Mandaean population.

The gap in access to maternal health care services is a challenge of an unequal world. In 2015, each day about 830 women died due to complications of pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented. This study quantified the contributions of the socioeconomic determinants of inequality to the utilization of maternal health care services in four countries in diverse geographical and cultural settings: Bangladesh, Ethiopia, Nepal and Zimbabwe. Data from the 2010–11 Demographic and Health Surveys of the four countries were used, and methods developed by Wagstaff and colleagues for decomposing socioeconomic inequalities in health were applied. The results showed that although the Concentration Index (CI) was negative for the selected indicators, meaning maternal health care was poorer among lower socioeconomic status groups, the level of CI varied across the different countries for the same outcome indicator: CI of −0.1147, −0.1146, −0.2859 and −0.0638 for <3 antenatal care visits; CI of −0.1338, −0.0925, −0.1960 and −0.2531 for non-institutional delivery; and CI of −0.1153, −0.0370, −0.1817 and −0.0577 for no postnatal care within 2 days of delivery for Bangladesh, Ethiopia, Nepal and Zimbabwe, respectively. The marginal effects suggested that the strength of the association between the outcome and explanatory factors varied across the different countries. Decomposition estimates revealed that the key contributing factors for socioeconomic inequalities in maternal health care varied across the selected countries. The findings are significant for a global understanding of the various determinants of maternal health care use in high-maternal-mortality settings in different geographical and socio-cultural contexts.

Using data from India’s National Family Health Survey, 2005–06 (NFHS-3), this article examines the patterns of relationship between birth order and infant mortality. The analysis controls for a number of variables, including mother’s characteristics such as age at the time of survey, current place of residence (urban/rural), years of schooling, religion, caste, and child’s sex and birth weight. A modest J-shaped relationship between birth order of children and their risk of dying in the neonatal period is found, suggesting that although both first- and last-born children are at a significantly greater risk of dying compared with those in the middle, last-borns (i.e. fourth and higher order births) are at the worst risk. However, in the post-neonatal period first-borns are not as vulnerable, but the risk increases steadily with the addition of successive births and last-borns are at much greater risk, even worse than those in the neonatal period. Although the strength of relationship between birth order and mortality is attenuated after the potential confounders are taken into account, the relationship between the two variables remains curvilinear in the neonatal period and direct in the post-neonatal period. There are marked differences in these patterns by the child’s sex. While female children are less prone to the risk of dying in the neonatal period in comparison with male children, the converse is true in the post-neonatal period. Female children not only run higher risks of dying in the post-neonatal period, but also become progressively more vulnerable with an increase in birth order.

This study aimed to contribute to the evidence on the timing of sexual debut in young people in sub-Saharan African countries. Data were extracted from 34 nationally representative surveys conducted in the region between 2006 and 2014. The study sample comprised unmarried women (n=167,932) and men (n=76,900) aged 15–24 years. Descriptive techniques and Cox proportional regression models were used to estimate the timing of sexual debut, and Kaplan–Meier hazard curves were used to describe the patterns of sexual debut in each country by sex. For the countries studied, sexual debut for both women and men occurred between the ages of 15 and 18 years, with median ages of 16 for women and 17 for men. Overall, education and household wealth provided significant protection against early sexual debut among women, but the reverse was found among men for wealth. Women in rural areas, in female-headed households and in Central, South and West Africa reported higher hazards of early commencement of sexual activity than their counterparts in urban, male-headed households and East Africa. However, the impact of these variables on male sexual debut did not follow a consistent pattern. Varied timing, as well as country-specific risk factors associated with sexual debut for young women and men across sub-Saharan Africa, were identified. Sexual health programmes and interventions for young people may require different approaches for young women and men.

Despite years of health and medical advancement, children still suffer from infectious diseases that are vaccine preventable. India reacted in 1978 by launching the Expanded Programme on Immunization in an attempt to reduce the incidence of vaccine-preventable diseases (VPDs). Although the nation has made remarkable progress over the years, there is significant variation in immunization coverage across different socioeconomic strata. This study attempted to identify the determinants of wealth-based inequality in child immunization using a new, modified method. The present study was based on 11,001 eligible ever-married women aged 15–49 and their children aged 12–23 months. Data were from the third District Level Household and Facility Survey (DLHS-3) of India, 2007–08. Using an approximation of Erreyger’s decomposition technique, the study identified unequal access to antenatal care as the main factor associated with inequality in immunization coverage in India.

This study aimed to assess whether shocks experienced by children in the mother’s womb can have an adverse effect on their future health, and whether these effects can be ameliorated by government welfare schemes. Data were taken from three phases of the Young Lives Survey carried out in the Indian state of Andhra Pradesh in 2002, 2007 and 2009–2010. Different types of in utero shock were distinguished from the data. Using ordinary least squares (OLS) estimation, it was observed that multiple in utero shocks reduced children’s weight-for-age and height-for-age z-scores by 0.07–0.08 and 0.08–0.15 units respectively. The roles of two Indian government welfare schemes – the Midday Meal Scheme (MDMS) and the National Rural Employment Guarantee Scheme (NREGS) – in mitigating the adverse effects of in utero shocks were examined. While the effect of the MDMS was statistically insignificant, that of the NREGS was significant. Although not designed to protect child health, the NREGS has been playing a more effective role than the MDMS in acting as a buffer against the damaging effects of in utero shocks on child health. The study points to the need for greater co-ordination between the two welfare schemes.

The enduring sub-replacement level of fertility in Iran is the result of changing timing of births. Using data from the 2015 Hamedan Survey of Fertility, conducted in a representative sample of 3000 married women aged 15–49, this study examined variations in median lengths of birth intervals employing cumulative survival functions, and investigated the determinants of birth interval lengths using regression hazard models. The results showed that the median first, second and third birth intervals, estimated at 28, 74 and 136 months respectively, doubled between 1995 and 2015. The multivariate analysis results indicated the strong impact of contraceptive use and higher education on lengthening birth intervals, with greater effects on the timing of second and third births. The relative risks of second and third births were higher among rural migrants, unemployed women and those with shorter periods of breast-feeding and the death of a preceding birth. Only timing of the third birth was influenced by son preference. The implications of the results for low fertility and maternal and child health in Iran are discussed.

Substantial numbers of married women use contraceptives without their partner’s knowledge in sub-Saharan Africa, but studies of female covert use across time are rare. This study investigates the levels, trends and correlates of covert use in nine countries and determines which contraceptive methods are more frequently used covertly by women. Data from monogamous couples in Demographic and Health Surveys were used from nine sub-Saharan African countries that had experienced an increase of 10 percentage points in current modern contraceptive use between an earlier (1991–2004) and later (2007–2011) survey. Covert use was indirectly estimated as the percentage of women who reported a female modern method whose husband did not report a modern method. The percentage of women using covertly increased in eight of the countries studied (significantly in three of them), yet when comparing across countries cross-sectionally, covert use was lower where contraceptive prevalence was higher. In general, women with more years of schooling and those with larger spousal schooling gaps had lower odds of covert use. There was no significant difference between covert and open injectable use, though more than half of both groups used this method in the later surveys. Encouraging couple communication about contraception, where the woman feels it is safe to do so, could be an important strategy to minimize covert use. Further research is needed to better identify the contraceptive prevalence and social context in which covert use declines within a country.

Child marriage has significant negative impacts, not only for girls, but also for a range of development outcomes. This study aimed to assess, in a more detailed way than done so far, the magnitude of the relationship between child marriage and total fertility in multiple countries representing diverse settings. Data from the most recent Demographic and Health Surveys in the fifteen countries of interest were used. Analysis was restricted to a subsample of women aged 35–49 years in order to capture completed fertility. Poisson regression was conducted to estimate the impact of each additional year of early marriage on the total number of births women have, controlling for selected sociodemographic characteristics. Counterfactual analyses were carried out to estimate the reduction in the number of children that women would have over their lifetime in the absence of child marriage. Controlling for socioeconomic and other characteristics, girls who marry as children have more children over their lifetime than women marrying after the age of 18. Nationally, across fifteen countries, the reduction in total fertility from ending child marriage ranges from 0.24 to 1.06 children per woman. The simulated change in total fertility that would result from ending child marriage tends to be higher in countries that have a higher incidence of child marriage.

The aim of this paper was to establish whether the differences in the risks of union dissolution between cohabitors and non-cohabitors in Uganda have converged over time using event history data. Data were collected in 2013 from 1200 women in central Uganda using retrospective methods. Of these, 839 provided information on three types of first union: women who married directly (without first cohabiting), those who married following cohabitation and those who were still cohabiting. The data were analysed using decrement lifetable analysis. Though the analysis indicated a small difference in the timing of first union dissolution for women who married directly, no evidence was found that the difference in the risk of union dissolution between cohabitors and non-cohabitors had converged over the 9-year period following first union. Women’s union/marriage status, number of living children in a union, parental union status and birth cohort were found to significantly influence the timing of union dissolution. Overall, the rate of union dissolution was fairly high, regardless of type of union.

This study aimed to identify the determinants of nutritional status of children in India with a special focus on dietary diversity at the state level. Household-level consumption data from three rounds of the Consumer Expenditure Survey of the National Sample Survey Organization (1993–2012) were used. Information on the nutritional status of children was taken from the National Family Health Survey (2005–06). Dietary diversity indices were constructed at the state level to examine diversity in quantity of food consumed and food expenditure. Multilevel regression analysis was applied to examine the association of state-level dietary diversity and other socioeconomic factors with the nutritional status of children. It was observed that significant variation in childhood stunting, wasting and underweight could be explained by community- and state-level factors. The results indicate that dietary diversity has increased in India over time, and that dietary diversity at the state level is significantly associated with the nutritional status of children. Moreover, percentage of households with a regular salaried income in a state, percentage of educated mothers and mothers receiving antenatal care in a community are important factors for improving the nutritional status of children. Diversity in complementary child feeding is another significant determinant of nutritional status of children. The study thus concludes that increasing dietary diversity at the state level is an effective measure to reduce childhood malnutrition in India.

In contrast to the extensive knowledge on the association between women’s empowerment and the nutritional status of children under the age of five, relatively little is known about the influence of women’s empowerment on adolescents’ nutritional status. This study aimed to assess the association between women’s empowerment and gender inequalities in adolescent nutritional status. Data were from the Indonesian Family Life Survey (IFLS) covering the period 1997 to 2015, and consisted of 16,683 observations from 13,396 adolescents between the ages of 10 and 19 years born in 6781 families. Three indicators of women’s empowerment were used: mother’s education, mother’s bargaining power and mother’s working status. Multivariate linear regression with robust standard errors was used to examine whether and how these indicators of women’s empowerment influenced adolescent nutritional status. Interaction terms were added to analyse how the association between women’s empowerment and adolescent nutritional status differed by gender. The results showed that mother’s education and mother’s working status were significantly associated with adolescent nutritional status, particularly with height-for-age. Adolescents of well-educated mothers had a higher height-for-age while those who were raised by mothers with a blue-collar job had a lower height-for-age. Although no gender differences were found for height-for-age, gender differences for BMI-for-age were obvious, with boys having a lower BMI-for-age than girls. Interactions between indicators of mother’s empowerment and gender showed that the gender gap in BMI-for-age was smaller for adolescents of more educated mothers. However, further analyses of food consumption patterns showed that boys whose mothers were more educated consumed more fast food and had higher instant noodle consumption than girls, thus suggesting gender bias in new disguise.

The inability to have children affects couples worldwide and causes emotional and psychological distress in both men and women. Turkey is a country that lays particular emphasis on the issue of infertility, especially after experiencing a dramatic fertility decline over the last two decades. This study aimed to understand the changes in the prevalence of infertility in Turkey using three different approaches: the DHS Approach, the Constructed Approach and the Current Duration Approach. Furthermore, the factors contributing to elevated risks of infertility as derived from the Constructed Approach were investigated using four different logistic regression models. The data came from the 1993, 1998, 2003, 2008 and 2013 Demographic and Health Surveys conducted by the Hacettepe University Institute of Population Studies. The findings of the Constructed and Current Duration Approaches suggested that the prevalence of infertility decreased markedly from 1993 to 2013 in Turkey. This decline was the result of improvements in maternal health care services in Turkey, as well as an increase in the use of Assisted Reproductive Technology (ART), from 1.9% in 2008 to 4.1% in 2013. The results of the final logistic regression model suggested that the risk of infertility was significantly higher among women aged between 35 and 49 (p<0.01), uneducated women (p<0.01), women whose age at first marriage was over 30 (p<0.01), women defined as overweight (p<0.05) and women whose age at menarche was less than 12 years (p<0.05). This is the first nationwide study to examine the prevalence of infertility and its socio-demographic risk factors in Turkey, a developing country; previous studies have established these risk factors mainly in developed countries.