Worldwide, many women who experience domestic violence keep their experience secret. Few report to official bodies. In a national survey of abuse against women in Pakistan, we examined factors related to disclosure: women who had experienced physical violence telling someone about it. In focus groups, we explored why women do not report domestic violence. Nearly one third of the 23,430 women interviewed had experienced physical violence. Only 35% of them had told anyone about it, almost always someone within their own family. Several personal and family factors were associated with disclosure. Having discussed the issue and feeling empowered to discuss violence were consistent associations. Of the 7,895 women who had suffered physical violence, only 14 had reported the matter to the police. Female focus groups said women who report violence risk their reputation and bring dishonor to the family; women fear reporting violence because it may exacerbate the problem and may lead to separation or divorce and loss of their children. Focus groups of men and women were skeptical about community leaders, councilors, and religious leaders supporting reporting of violence. They suggested setting up local groups where abused women could seek help and advice. There are strong disincentives to reporting violence in Pakistan, which are well known to women. Until better systems for reporting and dealing with reported cases are in place, domestic violence will continue to be a hidden scourge here and elsewhere.

BackgroundChildhood vaccination rates are low in Lasbela, one of the poorest districts in Pakistan's Balochistan province. This randomised cluster controlled trial tested the effect on uptake of informed discussion of vaccination costs and benefits, without relying on improved health services.MethodsFollowing a baseline survey of randomly selected representative census enumeration areas, a computer generated random number sequence assigned 18 intervention and 14 control clusters. The intervention comprised three structured discussions separately with male and female groups in each cluster. The first discussion shared findings about vaccine uptake from the baseline study; the second focussed on the costs and benefits of childhood vaccination; the third focussed on local action plans. Field teams encouraged the group participants to spread the dialogue to households in their communities. Both intervention and control clusters received a district-wide health promotion programme emphasizing household hygiene. Interviewers in the household surveys were blind of intervention status of different clusters. A follow-up survey after one year measured impact of the intervention on uptake of measles and full DPT vaccinations of children aged 12-23 months, as reported by the mother or caregiver.ResultsIn the follow-up survey, measles and DPT vaccination uptake among children aged 12-23 months (536 in intervention clusters, 422 in control clusters) was significantly higher in intervention than in control clusters, where uptake fell over the intervention period. Adjusting for baseline differences between intervention and control clusters with generalized estimating equations, the intervention doubled the odds of measles vaccination in the intervention communities (OR 2.20, 95% CI 1.24-3.88). It trebled the odds of full DPT vaccination (OR 3.36, 95% CI 2.03-5.56).ConclusionThe relatively low cost knowledge translation intervention significantly increased vaccine uptake, without relying on improved services, in a poor district with limited access to services. This could have wide relevance in increasing coverage in developing countries.Trial registrationISRCTN12421731.

Background: There is ample evidence of associations between short birth interval and adverse maternal and child health outcomes, including infant and maternal mortality. Short birth interval is more common among women in low-and middle-income countries. Identifying actionable aspects of short birth interval is necessary to address the problem. To our knowledge, this is the first systematic review to systematize evidence on risk factors for short birth interval in low-and middle-income countries. Methods: A systematic mixed studies review searched PubMed, Embase, LILACS, and Popline databases for empirical studies on the topic. We included documents in English, Spanish, French, Italian, and Portuguese, without date restriction. Two independent reviewers screened the articles and extracted the data. We used the Mixed Methods Appraisal Tool to conduct a quality appraisal of the included studies. To accommodate variable definition of factors and outcomes, we present only a narrative synthesis of the findings. Results: Forty-three of an initial 2802 documents met inclusion criteria, 30 of them observational studies and 14 published after 2010. Twenty-one studies came from Africa, 18 from Asia, and four from Latin America. Thirty-two reported quantitative studies (16 studies reported odds ratio or relative risk, 16 studies reported hazard ratio), 10 qualitative studies, and one a mixed-methods study. Studies most commonly explored education and age of the mother, previous pregnancy outcome, breastfeeding, contraception, socioeconomic level, parity, and sex of the preceding child. For most factors, studies reported both positive and negative associations with short birth interval. Shorter breastfeeding and female sex of the previous child were the only factors consistently associated with short birth interval. The quantitative and qualitative studies reported largely non-overlapping results.

BackgroundAchieving equity means increased uptake of health services for those who need it most. But the poorest families continue to have the poorest service. In Pakistan, large numbers of children do not access vaccination against measles despite the national government's effort to achieve universal coverage.MethodsA cross-sectional study of a random sample of 23 rural and 9 urban communities in the Lasbela district of south Pakistan, explored knowledge, attitudes and discussion around measles vaccination. Several socioeconomic variables allowed examination of the role of inequities in vaccination uptake; 2479 mothers provided information about 4007 children aged 10 to 59 months. A Mantel-Haenszel stratification analysis, with and without adjustment for clustering, clarified determinants of measles vaccination in urban and rural areas.ResultsA high proportion of mothers had appropriate knowledge of and positive attitudes to vaccination; many discussed vaccination, but only one half of children aged 10-59 months accessed vaccination. In urban areas, having an educated mother, discussing vaccinations, having correct knowledge about vaccinations, living in a community with a government vaccination facility within 5 km, and living in houses with better roofs were associated with vaccination uptake after adjusting for the effect of each of these variables and for clustering; maternal education was an equity factor even among those with good access. In rural areas, the combination of roof quality and access (vaccination post within 5 km) along with discussion about vaccines and knowledge about vaccines had an effect on uptake.ConclusionStagnating rates of vaccination coverage may be related to increasing inequities. A hopeful finding is that discussion about vaccines and knowledge about vaccines had a positive effect that was independent of the negative effect of inequity - in both urban and rural areas. At least as a short term strategy, there seems to be reason to expect an intervention increasing knowledge and discussion about vaccination in this district might increase uptake.

ObjectivesTo study prevalence at two time points and risk factors for experience of forced or coerced sex among school-going youth in 10 southern African countries.DesignCross-sectional surveys, by facilitated self-administered questionnaire, of in-school youth in 2003 and 2007.SettingSchools serving representative communities in eight countries (Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia and Zimbabwe) in 2003 and with Tanzania and South Africa added in 2007.ParticipantsStudents aged 11–16 years present in the school classes.Main outcome measuresExperience of forced or coerced sex, perpetration of forced sex.ResultsIn 2007, 19.6% (4432/25 840) of female students and 21.1% (4080/21 613) of male students aged 11–16 years reported they had experienced forced or coerced sex. Rates among 16-year-olds were 28.8% in females and 25.4% in males. Comparing the same schools in eight countries, in an analysis age standardised on the 2007 Botswana male sample, there was no significant decrease between 2003 and 2007 among females in any country and inconsistent changes among males. In multilevel analysis using generalised linear mixed model, individual-level risk factors for forced sex among female students were age over 13 years and insufficient food in the household; school-level factors were a lower proportion of students knowing about child rights and higher proportions experiencing or perpetrating forced sex; and community-level factors were a higher proportion of adults in favour of transactional sex and a higher rate of intimate partner violence. Male risk factors were similar. Some 4.7% of female students and 11.7% of male students reported they had perpetrated forced sex. Experience of forced sex was strongly associated with perpetration and other risk factors for perpetration were similar to those for victimisation.ConclusionsForced or coerced sex remained common among female and male youth in 2007. Experience of sexual abuse in childhood is recognised to increase the risk of HIV infection. The association the authors found between forced sex and school-level factors suggests preventive interventions in schools could help to tackle the HIV epidemic in southern Africa.

BackgroundRates of childhood vaccination in Pakistan remain low.There is continuing debate about the role of consumer and service factors in determining levels of vaccination in developing countries. MethodsIn a stratified random cluster sample of census enumeration areas across four districts in Pakistan, household interviews about vaccination of children and potentially related factors with 10,423 mothers of 14,542 children preceded discussion of findings in separate male and female focus groups. Logistic regression analyses helped to clarify local determinants of measles vaccination.ResultsAcross the four districts, from 17% to 61% of mothers had formal education and 50% to 86% of children aged 12-23 months had received measles vaccination. Children were more likely to receive measles vaccination if the household was less vulnerable, if their mother had any formal education, if she knew at least one vaccine preventable disease, and if she had not heard of any bad effects of vaccination. Discussing vaccinations in the family was strongly associated with vaccination. In rural areas, living within 5 km of a vaccination facility or in a community visited by a vaccination team were associated with vaccination, as was the mother receiving information about vaccinations from a visiting lady health worker. Focus groups confirmed personal and service delivery obstacles to vaccination, in particular cost and poor access to vaccination services. Despite common factors, the pattern of variables related to measles vaccination differed between and within districts.ConclusionsVaccination coverage varies from district to district in Pakistan and between urban and rural areas in any district. Common factors are associated with vaccination, but their relative importance varies between locations. Good local information about vaccination rates and associated variables is important to allow effective and equitable planning of services.

BackgroundMalnutrition remains an important cause of childhood morbidity and mortality; the levels of childhood malnutrition in Nigeria are among the highest in the world. The literature supports many direct and indirect causes of malnutrition, but few studies have examined the link between maternal care during pregnancy and childbirth and childhood malnutrition. This study examines this potential link in Bauchi and Cross River states in Nigeria.Design and methodsIn 2011, a household survey collected information about children under four years old and their mothers’ last pregnancy. Trained fieldworkers measured mid-upper arm circumference (MUAC) of children aged 6-47 months. We examined associations with childhood malnutrition in bivariate and multivariate analysis.ResultsSome 4.4% of 3643 children in Cross River, and 14.7% of 2706 in Bauchi were malnourished (MUAC z-score). In both states, a child whose mother had fewer than four government antenatal care visits was more likely to be malnourished (Cross River: OR 1.85, 95%CIca 1.33-2.55; Bauchi: OR 1.29, 95%CIca 1.02-1.63). In Bauchi, a child whose mother who rarely or never discussed pregnancy and childbirth with her husband (OR 1.34, 95%CIca 1.07-1.68), and who did not have her last delivery attended by a skilled health worker was more likely to be malnourished (OR 1.50, 95%CIca 1.09-2.07).ConclusionsThese findings, if confirmed in other studies, suggest that poor care of women in pregnancy and childbirth could pose a longer term risk to the health of the child, as well as increasing immediate risks for both mother and child.Significance for public healthChildhood malnutrition is a public health priority, accounting for almost 1/5 of global disease burden among children under five years old. Many studies have examined risk factors for childhood malnutrition, but few have examined the link between maternal care during pregnancy and childbirth and childhood malnutrition. This study, albeit a cross-sectional design, provides evidence of a link between poor care during pregnancy and childbirth and childhood malnutrition in two states of Nigeria. This is important for public health because it suggests another benefit of caring for women during pregnancy and childbirth. This could not only reduce maternal and child perinatal mortality, but also have benefits for the longer-term health and development of children. This finding could be useful for paternal advocacy; it may motivate men to support their wives during pregnancy and childbirth since through this support, fathers can also protect the future development of their children.

BackgroundNigeria continues to have high rates of maternal morbidity and mortality. This is partly associated with lack of adequate obstetric care, partly with high risks in pregnancy, including heavy work. We examined actionable risk factors and underlying determinants at community level in Bauchi and Cross River States of Nigeria, including several related to male responsibility in pregnancy.MethodIn 2009, field teams visited a stratified (urban/rural) last stage random sample of 180 enumeration areas drawn from the most recent censuses in each of Bauchi and Cross River states. A structured questionnaire administered in face-to-face interviews with women aged 15-49 years documented education, income, recent birth history, knowledge and attitudes related to safe birth, and deliveries in the last three years. Closed questions covered female genital mutilation, intimate partner violence (IPV) in the last year, IPV during the last pregnancy, work during the last pregnancy, and support during pregnancy. The outcome was complications in pregnancy and delivery (eclampsia, sepsis, bleeding) among survivors of childbirth in the last three years. We adjusted bivariate and multivariate analysis for clustering.FindingsThe most consistent and prominent of 28 candidate risk factors and underlying determinants for non-fatal maternal morbidity was intimate partner violence (IPV) during pregnancy (ORa 2.15, 95%CIca 1.43-3.24 in Bauchi and ORa 1.5, 95%CI 1.20-2.03 in Cross River). Other spouse-related factors in the multivariate model included not discussing pregnancy with the spouse and, independently, IPV in the last year. Shortage of food in the last week was a factor in both Bauchi (ORa 1.66, 95%CIca 1.22-2.26) and Cross River (ORa 1.32, 95%CIca 1.15-1.53). Female genital mutilation was a factor among less well to do Bauchi women (ORa 2.1, 95%CIca 1.39-3.17) and all Cross River women (ORa 1.23, 95%CIca 1.1-1.5).InterpretationEnhancing clinical protocols and skills can only benefit women in Nigeria and elsewhere. But the violence women experience throughout their lives – genital mutilation, domestic violence, and steep power gradients – is accentuated through pregnancy and childbirth, when women are most vulnerable. IPV especially in pregnancy, women's fear of husbands or partners and not discussing pregnancy are all within men's capacity to change.