Early marriage (EM) and early childbearing (ECB) have far-reaching consequences. This study describes the prevalence, trends, inequalities, and drivers of EM and ECB in South Asia using eight rounds of Demographic and Health Survey data across 13 years. We report the percentage of ever-married women aged 20-24 years (n = 105,150) married before 18 years (EM) and with a live birth before 20 years (ECB). Relative trends were examined using average annual rate of reduction (AARR). Inequalities were examined by geography, marital household wealth, residence, and education. Sociodemographic drivers of changes for EM were assessed using regression decomposition analyses. We find that EM/ECB are still common in Bangladesh (69%/69%), Nepal (52%/51%), India (41%/39%), and Pakistan (37%/38%), with large subnational variation in most countries. EM has declined fastest in India (AARR of-3.8%/year), Pakistan (-2.8%/year), and Bangladesh (-1.5%/year), but EM elimination by 2030 will not occur at these rates. Equity analyses show that poor, uneducated women in rural areas are disproportionately burdened. Regression decomposition analysis shows that improvements in wealth and education explained 44% (India) to 96% (Nepal) of the actual EM reduction. Investments across multiple sectors are required to understand and address EM and ECB, which are pervasive social determinants of maternal and child wellbeing.
IntroductionImproving the impact of nutrition interventions requires adequate measurement of both reach and quality of interventions, but limited evidence exists on advancing coverage measurement. We adjusted contact-based coverage estimates, taking into consideration the inputs required to deliver quality nutrition services, to calculate input-adjusted coverage of nutrition interventions across the continuum of care from pregnancy through early childhood in Bangladesh.MethodsWe used data from the 2014 Bangladesh Demographic and Health Surveys to assess use of maternal and child health services and the 2014 Service Provision Assessment to determine facility readiness to deliver nutrition interventions. Service readiness captured availability of nutrition-specific inputs (including human resources and training, equipment, diagnostics and medicines). Contact coverage was combined with service readiness to create a measure of input-adjusted coverage at the national and regional levels, across place of residence, and by maternal education and household socioeconomic quintiles.ResultsContact coverage varied from 28% for attending at least four ANC visits to 38% for institutional delivery, 35% for child growth monitoring and 81% for sick child care. Facilities demonstrated incomplete readiness for nutrition interventions, ranging from 48% to 51% across services. Nutrition input-adjusted coverage was suboptimal (18% for ANC, 23% for institutional delivery, 20% for child growth monitoring and 52% for sick child care) and varied between regions within the country. Inequalities in input-adjusted coverage were large during ANC and institutional delivery (14–17 percentage points (pp) between urban and rural areas, 15 pp between low and high education, and 28-34 pp between highest and lowest wealth quintiles) and less variable for sick child care (<2 pp).ConclusionNutrition input-adjusted coverage was suboptimal and varied subnationally and across the continuum of care in Bangladesh. Special efforts are needed to improve the reach as well as the quality of health and nutrition services to achieve the Sustainable Development Goals.
Adolescent birth is a major global concern owing to its adverse effects on maternal and child health. We assessed trends in adolescent birth and examined its associations with child undernutrition in Bangladesh using data from seven rounds of Demographic and Health Surveys (1996-2017, n = 12,006 primiparous women with living children <5 years old). Adolescent birth (10-19 years old) declined slowly, from 84% in 1996 to 71% in 2017. Compared with adult mothers (≥20 years old), young adolescent mothers (10-15 years old) were more likely to be underweight (+11 pp), have lower education (−24 pp), have less decision-making power (−10 pp), live in poorer households (−0.9 SD) with poorer sanitation (−15 pp), and have poorer feeding practices (10 pp), and were less likely to access health and nutrition services (−3 to −24 pp). In multivariable regressions controlled for known determinants of child undernutrition, children born to adolescents had lower height-for-age Z-scores (−0.29 SD for young and −0.10 SD for old adolescents (16-19 years old)), weight-for-age Z-score (−0.18 and −0.06 SD, respectively) as well as higher stunting (5.9 pp) and underweight (6.0 pp) than those born to adults. In conclusion, birth during adolescence, a common occurrence in Bangladesh, is associated with child undernutrition. Policies and programs to address poverty and improve women's education can help delay marriage, reduce early childbearing, and improve child growth.
Objectives Adolescent pregnancy is a major global concern due to its adverse effects on maternal and child health and wellbeing. Bangladesh has one of the highest rates of adolescent pregnancy globally. We sought to examine trends in adolescent pregnancy and associated factors in Bangladesh in the last two decades, and to understand why children of adolescent mothers are at high risk of poor growth. Methods Data were from 6 rounds of Bangladesh Demographic and Health Survey (1996–2014). Women aged 15–49 years who gave birth in the 5 years preceding each survey (n = 30,331) were classified based on age at first birth: ≤19 years (adolescence), 20–24 years (young adulthood), and ≥25 years (adulthood). Trend analysis was used to assess the progress over time. Multivariable regression and structural equation models were used to understand how adolescent pregnancy is linked to child undernutrition through maternal nutritional status, education and bargaining power, health service use, child feeding and living conditions. Results Adolescent pregnancy has declined slowly, from 84% in 1996 to 73% in 2014. Children born to adolescent mothers had lower z-scores for height-for-age (mean difference: −0·64 SD), weight-for-age (−0·45 SD), and higher prevalence of stunting (18 percentage points [pp]) and underweight (12pp) than children born to adult mothers. Compared to adult mothers, adolescent mothers were shorter (−0·8 cm), lighter (−6.9 kg), more likely to be underweight (+14pp), had lower education (−4·3 years), less decision-making power (−9pp), and lived in poorer households (−0·79 SD) with poorer sanitation (−23pp) (all P < 0.05). Adolescent mothers were less likely to access ANC (−20pp), institutional delivery (−42pp), postnatal care services (−24pp) and had poorer complementary feeding practices (−15pp). In path analyses, these intermediate factors explained 66% of the association between adolescent pregnancy and child anthropometry, with the strongest links being through women's weight, education, socioeconomic status and complementary feeding practices. Conclusions Adolescent pregnancy is still the norm in Bangladesh. Policies and programs to address poverty and improve women's education can help to improve women's health, reduce early childbearing and break the intergenerational cycle of poverty and undernutrition. Funding Sources A4NH at IFPRI.
Objectives Bangladesh's National Nutrition Services aims to deliver nutrition services to pregnant women and children through the primary health care system. Previous research highlighted gaps in coverage of preventive nutrition intervention delivery through this system but little is known about feasibility of reshaping service delivery to close the gaps. Prior to designing new approaches, we used a novel scenario-based feasibility testing approach to assess potential to strengthen service delivery. Methods We interviewed 32 service providers and 16 policymakers and conducted 4 focus group discussions with potential beneficiaries, asking respondents about the feasibility of four hypothetical scenarios for preventive service delivery: community-based events (CBE) for pregnant women; well-child services integrated into immunization contacts; CBE for well-children and well-child visits at facilities. Transcribed interviews were systematically coded, synthesized and interpreted using a pre-defined framework. Results Opinions on the need for new platforms for preventive services were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women were perceived as feasible, but workforce shortages emerged as a key challenge. Challenges such as equipment portability, upset children, and a fast-moving service environment suggested low feasibility of integrating nutrition into immunization contacts. In contrast, CBE and facility-based well-child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation. Conclusions A scenario-based approach is an efficient method to assess potential feasibility options for nutrition service delivery. Introducing preventive nutrition services requires addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services. Funding Sources Bill & Melinda Gates Foundation, through A&T, managed by FHI 360.
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