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Women’s Empowerment and Child Nutrition (and Growth): Spotlight on Africa

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By Victoria Adebiyi

Child malnutrition or undernutrition has both short and long-term consequences such as limited cognitive development, poor school performance, poor economic productivity in adulthood, increased risk of chronic diseases later in life and child and infant mortality 1. The burden of child undernutrition is particularly high in Sub-Saharan Africa where approximately 60 million children are stunted, and 14 million wasted, of whom 4 million children are severely wasted 2. During my training as a Registered Dietitian in Nigeria, I had a first-hand experience of this burden while working in a tertiary hospital in South-Western Nigeria, which was quite alarming. I supported the management of both moderately and severely undernourished children, some of which could not survive.

Women’s empowerment is important for improved child nutrition, and both underpin the achievement of several Sustainable Development Goals (SDGs); specifically, SDG 5 – to achieve gender equality and empower all women, and SDG 2 – to end hunger and all forms of malnutrition 3. Women’s empowerment serves as a foundational path to improving child nutrition because when women are empowered, there is a significant impact on both the long- and short-term nutritional status of their children 3,4. This is consistent across South Asia, Sub-Saharan Africa and Latin America and the Caribbean regions 4.

Different pathways have been explored to understand the relationship between women’s empowerment and child nutrition and growth. Women with higher social status- defined as decision-making power relative to men within the household tend to have better nutritional status themselves, are better cared for, provide higher quality food and care including better health-promoting practices to their children; while women with low social status tend to have weaker control over household resources, tighter time constraints, less access to information and health services, poorer mental health, and lower self-esteem 4-6. Empowered women also have better agency and autonomy in decision-making especially regarding food and care provision for their children 3,5. Also, an empowered mother has increased access to and more decision‐making opportunities around the use of financial resources, enabling the purchasing of soap for handwashing, supplies to ensure toilet cleanliness, and safe drinking water; which reduce the risk of infection and improve the nutrition and growth of children 7.

A cash transfer program I supported during my work with an international non-governmental organization in Northern Nigeria made me realize the importance of women’s empowerment for improved child nutrition. Cash transfers to women (economic empowerment) coupled to nutrition and health education helped to significantly reduce child malnutrition in target communities. This points to how crucial it is to empower women as part of efforts to address child malnutrition especially in Sub-Saharan African countries. In particular, women’s empowerment (especially women’s decision-making in the household) has been found to have significant impact on the nutritional status of children in Sub-Saharan Africa 4,5Empowered women are also more likely to have better nutrition, which in turn improves the nutrition of their children 3,8.

To explore the African context, a study in Ghana, West Africa found that the mean height-for-age z-scores (anthropometric index)) of children born to women with high autonomy, defined as maternal decision-making power was significantly higher than height-for-age z-scores of children born to women with low autonomy.  This implies that the rates stunting among children born to women with high autonomy were significantly lower, compared to children born to women with low autonomy 9. Another study in East Africa found that each unit increase in the agency of women for household decision-making was associated with an increase in the anthropometric status (height and weight) of children and a reduction in child stunting and wasting.

Another study in Ghana found that women who participate in final decision-making are almost two times more likely to achieve higher dietary diversity compared to those who do not participate in household decision-making. This may indicate autonomy to buy nutritious foods, suggesting that improving women’s decision-making autonomy could have a positive impact on women’s dietary intake, which indirectly improves the nutrition of their children 8. Also, children born to women with high autonomy were more likely to meet the minimum acceptable diet (composite indicator of minimum dietary diversity and minimum meal frequency), compared to children born to women with low autonomy 9.  

Therefore, making a decision at the policy level to improve women’s status produces significant benefits. Not only does a woman’s own nutritional status improve, but so too does the nutritional status of her young children 4. Knowing how crucial women’s empowerment is for adequate nutrition and growth of children especially in Sub-Saharan Africa where there is a high burden of child undernutrition,

  • Policies and programs should prioritize women’s empowerment as a key investment to improve both women and children’s well‐being 5,7.
  • Policy-makers should prioritize economic empowerment for women and improving women’s access to health care and health information. This should be coupled with interventions to shift gender norms and improve women’s participation in decision-making both within the household and in the community.
  • It is also important to increase access to education and life skills to empower girls and young women especially in countries where child marriage is prevalent, considering the high rates of child malnutrition in those countries.

Nutrition interventions implemented in Sub-Saharan African countries should be intentional about empowering women to influence their nutrition as well as the nutrition and health of their children.

References

  1. Victora, C. G., Adair, L., Fall, C., Hallal, P. C., Martorell, R., Richter, L., Sachdev, H. S., & Maternal and Child Undernutrition Study Group (2008). Maternal and child undernutrition: consequences for adult health and human capital. Lancet (London, England), 371(9609), 340–357. https://doi.org/10.1016/S0140-6736(07)61692-4
  2. World Health Organization (2019). Accessed on June 2, 2021 via: https://www.afro.who.int/news/strategic-plan-reduce-malnutrition-africa-adopted-who-member-states#:~:text=The%20number%20of%20undernourished%20people,million%20due%20to%20population%20growth.
  3. Jones, R., Haardörfer, R., Ramakrishnan, U., Yount, K. M., Miedema, S., & Girard, A. W. (2019). Women’s empowerment and child nutrition: The role of intrinsic agency. SSM – Population Health, 9, 100475. doi:10.1016/j.ssmph.2019.100475
  4. Smith, L. C., Haddad, L. J., Martorell, R., Ramakrishnan, U., & Ndiaye, A. (2003). The importance of women’s status for child nutrition in developing countries. Retrieved from http://econpapers.repec.org/paper/fprresrep/131.htm
  5. Yaya, S., Odusina, E. K., Uthman, O. A., & Bishwajit, G. (2020). What does women’s empowerment have to do with malnutrition in sub-saharan Africa? Evidence from demographic and health surveys from 30 countries. Springer Science and Business Media LLC. doi:10.1186/s41256-019-0129-8
  6. Santoso, M. V., Kerr, R. B., Hoddinott, J., Garigipati, P., Olmos, S., & Young, S. L. (2019). Role of women’s empowerment in child nutrition outcomes: A systematic review. Advances in Nutrition (Bethesda, Md.), 10(6), 1138-1151. doi:10.1093/advances/nmz056
  7. Cunningham, K., Ferguson, E., Ruel, M., Uauy, R., Kadiyala, S., Menon, P. P., & Ploubidis, G. (2018). Water, sanitation, and hygiene practices mediate the association between women’s empowerment and child length‐for‐age z ‐scores in Nepal. doi:10.1111/mcn.12638
  8. Amugsi, D. A., Lartey, A., Kimani, E., & Mberu, B. U. (2016). Women’s participation in household decision-making and higher dietary diversity: Findings from nationally representative data from Ghana. Journal of Health, Population and Nutrition, 35(1), 16. doi:10.1186/s41043-016-0053-1
  9. Saaka, M. (2020). Women’s decision-making autonomy and its relationship with child feeding practices and postnatal growth. Journal of Nutritional Science, 9, e38. doi:10.1017/jns.2020.30

 

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Anemia and Gender Norms: When Women Eat Last

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By Erica Sedlander

My co-authors and I recently published a qualitative paper in the Journal of Nutrition showing how “gender norms” affect the prevalence of anemia among women in rural India.  I thought back fondly to my time preparing for data collection in Odisha, India – colorful saris, spicy chai on the side of the road, and the women who graciously gave their time to be interviewed. I also reflected on the women who recounted the vastly different expectations of women compared to men. They spent their days dedicated solely to taking care of the family (cooking chapati, sweeping floors, bathing their children, and making sure their mother-in-law had everything she needed). Their own nutrition and well-being were an afterthought. Men always came first. In sum, women’s livelihood and well-being were much less valued.

Our charge on this trip to Odisha was to understand the barriers and facilitators for intake of iron-folic-acid supplements and eating iron rich food to reduce anemia as part of the Reduction in Anemia through Normative Innovations (RANI) project. An emphasis on gender norms was not in our proposal, nor our research questions. But we quickly found that they were a potent upstream barrier that would make this seemingly simple behavior (taking a weekly iron supplement) difficult to enact. After interviewing men, women, and key informants, we found that fatigue, the primary symptom of anemia, is considered a woman’s plight. Therefore, anemia is more likely to go undetected and unremarked upon. Women have less autonomy to leave the house to seek preventive treatment — such as iron- folic- acid supplements or testing for anemia. Women focus on others in the family – often eating “last,” or consuming “leftover” food after other family members have eaten – which often means less iron-rich food. One woman stated, “After they’ve finished their meals, I have my meal from the leftovers; I have to adjust.” Men are also the primary decision makers for household spending and may overlook the need for iron-rich food for the family. Women also reported that men spent most of their earnings on alcohol – leaving less money for food.

Our findings highlight the need to examine the entire social context of a person’s life when trying to change behavior. While these norms are entrenched in social systems of unequal power and gender hierarchies, it is critical to understand them — and even better to try to challenge them. Of course, social and gender norms differ across sub-groups and contexts; formative research and local stakeholder input is essential to relevant intervention design.

Qualitative findings from this study also informed items for a new gender norms scale, the G-NORM, (currently under review). Based on our research, in combination with the theory of gender and power, and social norms theory, we identified scale sub domains. This scale is unique in that it captures both descriptive norms (perceptions about what others are doing) and injunctive norms (perceptions about what behavior is expected). With additional qualitative research and cognitive interviewing, it is currently being adapted for Nepal and could also be validated in other South Asian countries and emerging economies. Quantitatively measuring the complex phenomenon of gender norms is not an easy task but it is critical to properly adapt the measure across multiple contexts. For example, while we identified eating order as an important item in this scale, this might not be as relevant in Sub-Saharan Africa. On the other hand, this scale elucidates some aspects of gender norms in South Asia that often go unmeasured such as women eating last within the family and thereby not getting enough to eat. Given that more than one third of women worldwide suffer from anemia, understanding how gender norms contribute to anemia could change the narrative from a biomedical issue to one of social justice.

Dr. Erica Sedlander is the Director of Research and Dissemination in the Family and Community Medicine Department at the University of California, San Francisco (UCSF).

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Half of American Women Feel Unsafe Because They Are Women

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By Jeni Klugman and Elena Ortiz

March 31, 2021

The US ranks 19th out of 167 countries in the world in terms of women’s status and opportunities, according to the Georgetown Institute of Women, Peace and Security. Countries like Norway and Canada score best while Afghanistan and Yemen are at the bottom.

But country averages can conceal large disparities within national borders. Indeed, when Georgetown undertook investigations of all 50 states and Washington DC, we found Massachusetts at the top scored four times higher in terms of women’s status and opportunities than Louisiana at the bottom (figure 1), with large racial disparities in every state. Black women in New Jersey, for example, experience maternal mortality at rates nearly quadruple those for white women.

There is much to do to advance the status of women in the US and the Biden administration—and its new White House Gender Policy Council tasked with advancing gender equality and combatting systemic discrimination— is well positioned to embark on the reforms needed.

Note: Possible index scores range from a low of 0 to a high of 1

Source: GIWPS & PRIO 2019. [/vc_column_text][vc_column_text disable_pattern=”false” el_class=”blog-p”]There is widespread support for this agenda: four in five adults believe it is important for elected officials to advance gender equality, according to a Georgetown survey in partnership with YouGov and Perry Undem.

Where do we start? We argue that the Biden administration should focus on women’s legal protections, affordable childcare, and sexual and reproductive health.

First, universal legal protections for women are key, including ensuring abusers do not have access to firearms. Only 13 states currently enforce the relinquishment of firearms by domestic violence perpetrators subject to protective orders. Shortfalls in national legislation mean that women are at higher risk of violence: when an abuser has access to a gun, victims are five times more likely to be killed.

Across the country, nearly half of women surveyed said they “feel unsafe because they are a woman” frequently or sometimes in their daily life. Strengthening legal protections for women, including the Violence Against Women Act (VAWA), is a critical entry point for increasing security and justice.

The updated VAWA, passed in the House and pending Senate approval, would be a major step forward. For the first time, it would prevent perpetrators of stalking from accessing firearms, grant tribal courts authority to prosecute non-Indigenous perpetrators of violence against Indigenous women, and close the “boyfriend loophole”, a current shortfall in federal law that allows abusers who have not formerly cohabitated with victims to access firearms.

Women also need basic economic rights – including decent pay. President Biden has pledged to increase the federal hourly minimum wage to $15, which would benefit 23 million working women, including 43 percent of single working women and more than one in three women of color. Women are better positioned to leave abusive relationships and fight workplace harassment when they earn a living wage.

Second, access to affordable childcare is critical to ensuring equal opportunities in the workplace – a need that has been amplified by the COVID-19 crisis. Women are leaving the workforce during the pandemic at four times the rate of men, and Black, Latinx, and women of color—disproportionately represented among low-wage workers—have left the workforce at even higher rates due to childcare needs. Even before the pandemic, American mothers were 40 percent more likely than fathers to report that lack of childcare harmed their careers. This has short term repercussions on financial security and child wellbeing and long-term costs for women’s career prospects and retirement earnings.

Countries as varied as Australia and South Korea have shown how government policies can alleviate the burdens of caregiving on women.  President Biden has pledged to support states in subsidizing childcare in order to ensure that it is universally affordable, and to provide access to free, high-quality pre-kindergarten for children ages 3-4 years.

The COVID-19 Relief Bill allocates $39 billion to support affordable childcare through subsidies to childcare centers and low-income parents. While this legislation offers much-needed immediate relief, the administration should work to expand and sustain federal support for childcare in the post-pandemic period in order to facilitate paid work for women and strengthen the long-term prospects for children, especially low-income children of color.

Third, there is a critical need to safeguard access to reproductive healthcare and a woman’s right to choose. Our index reveals huge gaps across states in access to reproductive health services. In Wyoming, fewer than 1 in 20 women live in a county with an abortion provider, compared with 19 in 20 women in states like California.  All state Medicaid programs cover abortion costs in extreme cases— rape, incest, and when the mother’s life is in jeopardy (although South Dakota only covers the last case). While states have the option to cover a broader range of abortions with their own funds, only 16 states currently cover abortions for low-income women insured by Medicaid.

Ensuring access begins with several key reforms in the Democratic Party platform, namely reversing roll-backs to the Affordable Care Act’s coverage of contraception and reversing the changes to patient non-discrimination protections and religious exemptions that the Trump administration introduced.  Targeted grants could be used by the Biden administration to incentivize states to expand funding dedicated to ensuring universal access, especially for low-income women.

Women’s safety, economic opportunities, and access to healthcare interact in important ways, especially for women who are disadvantaged on other fronts.  Because gender inequality in the US is compounded by racial and class-based discrimination, intersectional approaches to reform are needed. The Biden Administration, with the important new Gender Policy Council in place, should undertake the further reforms needed to demonstrate that advancing the status and opportunities for all women and girls in the United States is indeed a top priority.

Dr. Jeni Klugman is Managing Director of the Georgetown Institute for Women, Peace and Security. Elena Ortiz is a senior at Georgetown’s School of Foreign Service and a research assistant at the Georgetown Institute for Women, Peace and Security.

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Women’s Local Political Leadership Key to Managing COVID-19 Impacts

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March 6, 2021

Devaki Singh1, Madhu Joshi1, Shiney Chakraborty2, Anamika Priyadarshini1

1 Centre for Catalyzing Change, India

2 Economist based in New Delhi, India

The COVID-19 pandemic is an extraordinary public health and economic emergency. Bihar, the third most populous state of India, is uniquely challenged, as it also faced the influx of returning migrants, straining an overburdened administrative machinery. Even so, the pandemic highlighted the myriad ways in which grassroots women leaders have engaged in relief and rebuilding activities, supporting their community’s needs. Globally, women’s grassroots leadership is increasingly being recognized as a critical indicator of gendered governance, moving beyond the previous focus on their numerical representation in national legislatures alone. However, local women leaders’ actual and potential contributions, particularly in crisis response and their central role in community resilience, remain untapped assets in risk reduction and recovery strategies.

Learning from the voices of Elected Women Representatives

Centre for Catalyzing Change’s (C3) Sakshamaa Initiative embarked on a cross-sectional mixed-methods research to identify the role and impact of local women political leaders in rural Bihar, India. Bihar has 50% quotas for women in rural government. C3 implements a mentoring and capacity building program with these Elected Women Representatives (EWR) across 10 districts of the state. We interviewed 1338 EWRs to explore how their participation and leadership in local governance has evolved through this crisis, using qualitative and quantitative research tools.

The majority (87%) of the EWRs were first time representatives (87%). Almost all were married (96%), with 34% married before the age of 18. More than one-third (37%) had only completed primary school, and 23% had received no formal education.  finished undergraduate studies. Most were Hindu (90%), and of Other Backward Castes (63%) and Scheduled Castes (24%). Most EWRs (79%) are not engaged in paid work outside of their responsibilities as Elected Representatives.

How has the role and recognition of Elected Women Representatives changed under the pandemic?

  1. Increased Workload to Meet Community Needs

Half (46%) of EWRs said that their workload increased significantly since the start of the pandemic and lockdown – signaling the key role EWRs played as first responders. These efforts included:

  • Identifying returning migrants and providing supports for them and their families.
  • Spreading awareness about the COVID-19 disease and associated precautions.
  • Arranging rations, isolation areas, or hospital beds for the COVID-19 patients
  • Providing urgent medical support for pregnant women.

The pandemic also changed the kind of work EWRs were involved in, signaling a shift in their priorities aligning with emerging community needs. Prior to the pandemic, social services (arranging pension, ration cards etc.), roads and other infrastructure, access to drinking water, sanitation, and childcare services (Anganwadi) were indicated as the top priorities for EWRs. During the pandemic, their efforts related to migrants/migration and ensuring food security gained prominence – reflecting their community demands and needs related to rapid and mismanaged return migration, rising hunger in the face of income loss, and supply chain restrictions. EWRs expect increased need in the areas of local education, health and nutrition services as part of rebuilding post-pandemic.

  1. Increased community respect and self-confidence as leaders

EWRs’ active involvement in COVID containment and relief measures revealed the complex nature of Bihar’s prevalent gender norms, especially in relation to EWRs’ leadership positioning. All EWR’s agreed that people’s attitude towards them has changed for the better post COVID-19 and they were now perceived as “a people’s leader” who could be approached to address concerns. Statistical testing found that older relative to younger EWRs were more likely to report that under they pandemic they have greater potential as a leaders or in a better leadership role and are more valued as a leader by the community. As 23% of EWRs are aged 18-34 years, this is a concern, and it may be related to more split family and domestic responsibilities and expectations for these younger EWRs.

Many EWRs also mentioned their confidence and eagerness to compete in elections again. However, few felt that they had any actual power to affect change easily- only 23% believed that they could easily change things in their constituencies. This represents an interesting dichotomy, where women leaders are feeling more valued by their constituents, and more self-confident, but at the same time finding it difficult to navigate existing local governance systems.

  1. Increased decision-making and impact

EWRs have played a pivotal role in the COVID-19 response in Bihar from the start- spreading awareness about the COVID-19 disease and the precautions to prevent it, helping people to get subsidized ration, arranging health care for COVID-19 and other health issues, including vital maternal and reproductive health care. Their efforts not only offer valuable evidence of the centrality of local government in crisis situations, they demonstrate the important role EWRs play in times of community health and economic crises. While some have referred to these women political leaders as “Proxy Representatives,” negating the leadership and contributions of EWRs, their impacts during this pandemic, from social to survival supports, have been too visible to be denied.

Greater support for EWRs is needed

While EWRs have been vitally important across a number of areas for rural communities contending with the COVID-19 pandemic and lockdown periods, inadequate resources impede their capacities and impact. They are expected to supervise, monitor, and ensure effective implementation of various development initiatives through smartphones, but smartphones are not always available to them. Only 63% EWR participants owned a phone and among them, only 24% had a smartphone. EWRs often relied on other family members, especially sons and husbands, for smartphone access, document/file maintenance, financial processes, and transport. Two in five EWRs (42%) said they receive such support in all work matters. Our EWRs need resources, tools and access to information to continue their important work. Prioritizing their education, financial literacy, and digital access are crucial to sustain their confidence and capacities. Gender equality and empowerment for communities cannot occur if we do not invest in the development of our women leaders, and in their absence, neither pandemic management nor post-pandemic rebuilding will be possible.

The Principal Investigators for this study are Shiney Chakraborty, PhD (Economist based in New Delhi) and Anamika Priyadarshini, PhD (Lead Research – Sakshamaa, Centre for Catalyzing Change). 

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Understanding patterns of unplanned pregnancies and abortions in India during the COVID-19 pandemic using Google Trends data

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February  4, 2021

Arnab Dey1, Nabamallika Dehingia1, Anita Raj1
1 Center on Gender Equity and Health, University of California San Diego, USA

Background
The COVID-19 pandemic has affected almost every aspect of our lives in profound ways. In addition to the catastrophic loss of life and livelihoods 1,2, the pandemic has severely impacted the physical and mental health of people around the world. 3,4 In forcing us to change the ways we eat, sleep, work and socialize, the pandemic has altered our health behaviors significantly. One of its major effects on our health and wellbeing has been on our Sexual and Reproductive Health (SRH) behaviors. A recent study conducted in Turkey found that female sexual desires and frequency of sexual intercourse increased during the pandemic, while contraceptive use and continuation declined during the period.5 Another study conducted in Italy indicated that unplanned pregnancies and pregnancy terminations might have increased during the pandemic. 6 These problems are further accentuated in countries like India that already have low rates of contraceptive use,7 and high rates of unintended pregnancies and abortions. 8,9

While studies indicate that unplanned pregnancies and abortions might have increased during the pandemic, lack of robust data in India, which is understandable during the pandemic, limits our ability to study and understand these phenomena. The limitations of availability of primary data can be somewhat addressed by using publicly available data sources such Google Trends to analyze patterns in health behaviors based on Google searches in a particular geography, over a specific period. Given the popularity and hegemony of Google as the primary search engine in India 10 and its rapidly increasing share of internet users in both rural and urban areas,11 Google searches can be used to gain a reasonable understanding of these patterns.

In this brief, we analyze trends of searches related to unplanned pregnancies and abortions in India between January 01, 2019 and December 31, 2020. We study the patterns in these search terms and try to assess if there was a meaningful increase in search terms related to unplanned pregnancies and abortions in India during the COVID-19 pandemic. Findings from this analysis can help us understand how the COVID-19 pandemic affected reproductive health behaviors in India and can inform programs and policy on the need to strengthen Sexual and Reproductive Health  services during the ongoing COVID-19 crisis.

Our Approach
Selecting search terms: The first step in identifying search terms for the analysis involved creating a list of ‘base terms’ related to unplanned pregnancies and abortions in India. 12 Two researchers, with contextual understanding of SRH in India, brainstormed related search terms that might be used to search for unplanned pregnancies and abortions. The researchers initially identified 17 search terms and narrowed it down to 13 base terms by removing terms that were not specifically associated unplanned pregnancies or abortions. The 13 base terms identified are as follows:

  • abortion
  • abortion medicine
  • abortion pill
  • abortion tablet
  • emergency contraceptive pills
  • i-pill
  • medical termination of pregnancy
  • morning after pill
  • pregnancy termination
  • unintended pregnancy
  • unplanned pregnancy
  • unwanted pregnancy
  • unwanted 72

Subsequently, the researchers used Google’s autocomplete feature to identify nuanced search terms used by people related to these base-terms.12 In order to identify search terms specific to India, the researchers changed the ‘Region Setting’ in Google to India. 13 The researchers then switched to incognito mode to avoid their personal search patterns from affecting the autocomplete results.12,14 For each of the base-terms, the researchers first identified the search terms suggested by the autocomplete feature after the ‘base-term’ (Figure 1) and then also identified search terms suggested by the autocomplete feature before the ‘base-term by adding a * in front of the base-term as shown in Figure 2.[/vc_column_text][vc_single_image image=”21311″ img_size=”full” alignment=”center” onclick=”link_image”][vc_column_text]This process led to the identification of a total of 243 search terms, including the base-terms. Two researchers then independently identified search terms that were not related to the thematic areas of unplanned pregnancy or abortion e.g. one of the search terms suggested by the autocomplete feature for the base-term ‘unplanned pregnancies’ was ‘unplanned pregnancy romance novels’. The researchers identified 63 such search terms and excluded them from analysis. The next step involved identifying and removing duplicate search terms or terms that were very similar to each other. A total of 21 such terms were identified, and the remaining 159 terms were used for subsequent analysis. The next step involved identifying search terms that did not have enough data to produce results on Google Trends (https://trends.google.com/trends/?geo=IN) for our study period of January 01, 2019 to December 31, 2020 with the region specified as India. An example of such a term excluded from the analysis is shown in Figure 3.[/vc_column_text][vc_single_image image=”21312″ img_size=”full” alignment=”center” onclick=”link_image”][vc_column_text]Removal of search terms that yielded no results on Google Trends excluded 88 terms and 71 search terms remained for further analysis. The researchers then categorized these terms into the following four thematic categories: 12

  • Theme-1: Emergency Contraceptive Pills (27 terms)
  • Theme-2: Unplanned Pregnancy (7 terms)
  • Theme-3: Abortion Procedure (16 terms)
  • Theme-4: Abortion pills (21 terms)

The researchers then created a single ‘search-string’ for each of the categories by combining the search terms in a way that captured the thematic category sufficiently and succinctly, while ensuring that the combined search string the terms yielded results on Google Trends for the study period and geography. The following search-strings were finally used for the analysis for each of the thematic categories:

  • Theme-1: Emergency Contraceptive Pills – “emergency contraceptive pills” + “morning after pill” + “unwanted 72” + “i pill”
  • Theme-2: Unplanned Pregnancy – “unwanted pregnancy” + “unintended pregnancy” + “unplanned pregnancy”
  • Theme-4: Abortion Pills – “abortion tablet” + “abortion pill price” + “abortion pill” + “abortion pill side effects”
  • Theme-3: Abortion Procedure – “abortion” + “types of abortion” + “abortion process” + “surgical abortion”

Data Analysis: We used the search-strings described above to download ‘Interest over time’ data from Google Trends, for our study period and geography for each of the five thematic categories. Google Trends generated one data point on interest over time for each week in our study period. To identify periods where there was higher or lower interest in our thematic categories, we used changepoint analysis. 12 Changepoint analysis is a statistical tool that helps in detecting meaningful changes in time-series data by identifying periods that are qualitatively different from their neighboring points. 12,15 We used the ‘changepoint’ package 16 in R (version 4.0.3) and used the pruned exact linear time (PELT) algorithm as the method for detecting changepoints. This allowed us to break our study period into discrete regions where the interest over time for a specific thematic category was statistically different from their neighboring periods. Finally, we plotted graphs for each of the thematic categories with the changepoint periods laid atop the trend for interest over time data obtained from Google Trends.

Results: Our analysis reveals clear patterns of increased interest over time around all four thematic categories during the onset of the COVID-19 pandemic. Search trends for terms related to Emergency Contraceptive pills indicate an increased volume of searches around emergency contraceptive pills between December 2019 and March 2020 (Figure 5). The search volume then decreased till June 2020 and then seem to be increasing gradually again since that time. Search patterns related to unplanned pregnancies also show a similar trend, but they peaked a little late, relative to the emergency contraceptive pills, between March and April 2020 (Figure 6).[/vc_column_text][vc_single_image image=”21313″ img_size=”full” alignment=”center” onclick=”link_image”][vc_column_text disable_pattern=”false”]Search terms related to abortion pills and abortion procedure had peak periods between February to May 2020 and January to May 2020 (Figures 6 and 7) respectively. The peak periods for these searches were wider as compared to those for emergency contraceptive pills and unplanned pregnancies.[/vc_column_text][vc_single_image image=”21314″ img_size=”full” alignment=”center” onclick=”link_image”][vc_column_text disable_pattern=”false”]Interestingly, the search volume for emergency contraceptive pills, unplanned pregnancy, and abortion pill (figures 4, 5 and 6) decreased after their peak periods for a few months and seem to be increasing in terms of interest over time towards the end of 2020. The trend for searches around abortion procedure, however, does not follow this pattern and seems to be stable towards the end of the year.

Implications
The sharp increase in search terms around these topics can be considered as a reflection of the SRH needs of women in India during the COVID-19 pandemic. These needs were at their peak during the onset of the pandemic in 2020 and seemed to decline from May 2020 onwards.  However, recent trends around search terms related to emergency contraceptive pills, unplanned pregnancies, and abortion pills seem to suggest that these needs might be on an incline again. While our analyses of these search terms are some reflection of SRH needs, they do not tell us  about how these needs were addressed by the health system, especially during the country wide lock-downs that were in effect during the same months where we see a peak in these trends. 17 This calls for further research into the access and utilization of SRH services in India during the COVID-19 pandemic, especially given the premonition of an increase in interest around these topics as indicated in this analysis. Having a deeper understanding of the SRH needs of women and the challenges in ensuring access and utilization of SRH services can help the system to be better prepared to provide timely and effective services and can contribute significantly in improving the health outcomes of women in the country.

This work was supported by a grant to UC San Diego from the Bill and Melinda Gates Foundation (INV-018007; PI: Raj)[/vc_column_text][mk_divider style=”thin_solid” divider_width=”one_half” align=”left” thin_single_color=”#e8e8e8″][vc_column_text disable_pattern=”false”]References

  1. WHO. Impact of COVID-19 on people’s livelihoods, their health and our food systems. 2020. https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people’s-livelihoods-their-health-and-our-food-systems.
  2. UNDP. Socio-economic impact of COVID-19. 2020. https://www.undp.org/content/undp/en/home/coronavirus/socio-economic-impact-of-covid-19.html.
  3. Cullen W, Gulati G, Kelly B. Mental health in the Covid-19 pandemic. QJM: An International Journal of Medicine 2020; 113(5): 311-2.
  4. Woods J, Hutchinson NT, Powers SK, et al. The COVID-19 pandemic and physical activity. Elsevier; 2020.
  5. Yuksel B, Ozgor F, Obstetrics. Effect of the COVID‐19 pandemic on female sexual behavior. International Journal of Gynecology 2020.
  6. Caruso S, Rapisarda AMC, Minona P, Care RH. Sexual activity and contraceptive use during social distancing and self-isolation in the COVID-19 pandemic. The European Journal of Contraception 2020; 25(6): 445-8.
  7. International Institute for Population Sciences (IIPS) and MoHFW. National Family Health Survey (NFHS-4), 2015-16.
  8. Dixit P, Ram F, Dwivedi LK, childbirth. Determinants of unwanted pregnancies in India using matched case-control designs. BMC pregnancy 2012; 12(1): 84.
  9. Sebastian MP, Khan M, Sebastian D. Unintended pregnancy and abortion in India: country profile report. 2014.
  10. Statista. Share of desktop search traffic originating from Google in selected countries as of October 2020. 2020. https://www.statista.com/statistics/220534/googles-share-of-search-market-in-selected-countries/.
  11. Mishra D, Chanchani M. For the first time, India has more rural net users than urban 2020. https://timesofindia.indiatimes.com/business/india-business/for-the-first-time-india-has-more-rural-net-users-than-urban/articleshow/75566025.cms.
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  17. Wikipedia. COVID-19 lockdown in India. 2020. https://en.wikipedia.org/wiki/COVID-19_lockdown_in_India.

 

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Measuring Women’s Mobility in Low Resource Settings

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By Devaki Singh, Madhu Joshi, Sonal Shah
October  5, 2020

Even before COVID-19 transformed our public lives, women’s access to education and employment opportunities was constrained in low-resource settings like the state of Bihar in India. A historically poor state, Bihar is characterized by rigid gender norms, which translate to low levels of secondary school completion—just 12% women ages 15-49 have 12 or more years of schooling—and the lowest female labour force participation rate in India at 4.4%. While several supply- and demand-level interventions to facilitate women’s economic engagement and empowerment have been initiated in the state, women’s access to opportunities remains limited. ‘Access’ itself is a gendered issue, referring to the ability to reach and use diverse resources such as information, skills, rights, political participation, and voice. Constrained daily mobility, or the ability to physically access different facilities, has a profound impact on women’s economic participation and their empowerment. The inability to safely and easily reach educational institutions or places of work limits women’s economic engagement and participation. The daily mobility of women is guided by complex factors including established social norms, transport infrastructure, urban planning, governance, and access to information and communication technology. 

With this background, mapping women’s experiences with transport and their mobility patterns in urban Bihar is an important first step to devise urban planning and policy solutions that can improve their public experiences and participation in the economy. Further, accelerating conventionally ‘gender-neutral’ interventions, like electricity, lighting, pavements, roads, that can have a positive impact on women’s public lives, is vital in rigid patriarchal contexts like Bihar – where gender norm change may take generations to materialize.

As part of Centre for Catalyzing Change’s (C3) Sakshamaa – Initiative for What Works Bihar, an urban mobility mapping exercise was undertaken between January and March 2020. The sample survey of 1947 respondents across three cities of Bihar – Patna, Gaya and Muzaffarpur – collected their demographic information and recorded their monthly travel diaries. The sample focused on the prime working age group – people between 18 and 49 years of age – and was split equally across gender, with 49.9% (women) and 50.1% (men). Focus group discussion (FGDs) were conducted with women on their professional aspirations and the challenges and barriers they faced while traveling to access economic and other opportunities. FGDs were also completed with transport providers to understand their perceptions of safety and harassment, awareness of their role, and openness to change.

Travel Diaries: Travel diaries are a widely used measure to assess the mobility patterns of individuals or groups, and draw inferences for transport and city planning. For this survey, a traditional travel diary based on memory recall was used. Respondents’ typical weekday travel schedules were recorded, covering their travel time, trip purpose, destination, main travel mode, and cost.[/vc_column_text][mk_divider style=”thin_solid” divider_width=”one_half” align=”left” thin_single_color=”#e8e8e8″][mk_fancy_title size=”12″ font_family=”none”]1 International Institute for Population Sciences (IIPS) and ICF. 2017. National Family Health Survey (NFHS-4), India, 2015-16: Bihar. Mumbai: IIPS.

2 Labour force participation rate (LFPR) (in percent) according to usual status (ps+ss) for women aged 15- 59. Ministry of Statistics and Programme Implementation (2017-18) Annual Report, Periodic Labour Force Survey. Government of India. New Delhi.  [/mk_fancy_title][vc_column_text]What did we find?
Even though the sample belongs to the prime working age group, there is a gender employment gap of 50 percentage points between men and women. 

  • 62% of women respondents are homemakers.  
  • Women who work do so as tailors, domestic workers, vegetable vendors, teachers, home-based workers making mosquito nets, in beauty parlours, or in grocery stores.
  • Women who work in urban Bihar earn 25-50 percent less than working men. 

The household and care work burden falls squarely on women. 

  • Women who work spend 4 hours per day on household and care work, compared to 1 hour by working men. 
  • The gender disparity is also observed amongst students, as female students spend twice the time (median = 2 hours) on household work, as compared to male students (median = 1 hours).

Women travel less than men, but make more trips by walking and shared intermediate public transport (i.e. autos/tuk-tuks/e-rickshaws). Contrary to global travel trends, where women travel more frequently than men, women in urban Bihar make 37% fewer trips per day than men. 

  • 82% of women’s trips are for non-work purposes. In fact, a third of women’s trips are for household shopping and other related household work. 
  • 57% of women’s trips are by walking and 30% are by shared intermediate public transport. Women make 60 percent (1.6 times) more walking trips than men do and 50 percent (1.5 times) more trips by shared intermediate public transport. 
  • Twice the number of men and thrice the number of women rated the streets as very poor in the night, as compared to in the day. Poor lighting, broken footpaths and waterlogging were cited as reasons for the poor ratings.
  • Close to one-fourth of the female respondents have faced harassment while commuting. 

In a novel finding, men are more dissatisfied with the mobility situation than women, including foregoing economic opportunities. Women have perhaps normalized the existing situation, implying the need for a concerted effort on awareness campaigns. 

What next?
This research is one of very few that has estimated women’s care-related travel – a key policy input. Conventional mobility services planning, based only on work and education trips, will exclude around 40% of all trips in urban Bihar, and most (62%) of the trips made by women – creating gender-blind plans and erasing women’s care-related and other travel needs. One of the ‘low-hanging fruit’ solutions for women’s mobility is to improve the urban walking environment, particularly by addressing lighting, footpaths, and bus stops. In terms of larger policy interventions, some actions that should be explored include awareness and behaviour change campaigns on safe mobility and public harassment, increasing the supply of buses, and increased regulation of intermediate public transport services.

This research is led by Sonal Shah (The Urban Catalysts), under C3’s Sakshamaa – Initiative for What Works Bihar.[/vc_column_text][vc_column_text]What did we find?
Even though the sample belongs to the prime working age group, there is a gender employment gap of 50 percentage points between men and women. 

  • 62% of women respondents are homemakers.  
  • Women who work do so as tailors, domestic workers, vegetable vendors, teachers, home-based workers making mosquito nets, in beauty parlours, or in grocery stores.
  • Women who work in urban Bihar earn 25-50 percent less than working men. 

The household and care work burden falls squarely on women. 

  • Women who work spend 4 hours per day on household and care work, compared to 1 hour by working men. 
  • The gender disparity is also observed amongst students, as female students spend twice the time (median = 2 hours) on household work, as compared to male students (median = 1 hours).

Women travel less than men, but make more trips by walking and shared intermediate public transport (i.e. autos/tuk-tuks/e-rickshaws). Contrary to global travel trends, where women travel more frequently than men, women in urban Bihar make 37% fewer trips per day than men. 

  • 82% of women’s trips are for non-work purposes. In fact, a third of women’s trips are for household shopping and other related household work. 
  • 57% of women’s trips are by walking and 30% are by shared intermediate public transport. Women make 60 percent (1.6 times) more walking trips than men do and 50 percent (1.5 times) more trips by shared intermediate public transport. 
  • Twice the number of men and thrice the number of women rated the streets as very poor in the night, as compared to in the day. Poor lighting, broken footpaths and waterlogging were cited as reasons for the poor ratings.
  • Close to one-fourth of the female respondents have faced harassment while commuting. 

In a novel finding, men are more dissatisfied with the mobility situation than women, including foregoing economic opportunities. Women have perhaps normalized the existing situation, implying the need for a concerted effort on awareness campaigns. 

What next?
This research is one of very few that has estimated women’s care-related travel – a key policy input. Conventional mobility services planning, based only on work and education trips, will exclude around 40% of all trips in urban Bihar, and most (62%) of the trips made by women – creating gender-blind plans and erasing women’s care-related and other travel needs. One of the ‘low-hanging fruit’ solutions for women’s mobility is to improve the urban walking environment, particularly by addressing lighting, footpaths, and bus stops. In terms of larger policy interventions, some actions that should be explored include awareness and behaviour change campaigns on safe mobility and public harassment, increasing the supply of buses, and increased regulation of intermediate public transport services.

This research is led by Sonal Shah (The Urban Catalysts), under C3’s Sakshamaa – Initiative for What Works Bihar.

ACCOMPANYING PHOTOS ( © The Urban Catalysts and Centre for Catalyzing Change)

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Gendered Impact of COVID-19 on the Decision-Making Power of Adolescents in Northern Nigeria

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By Dr. Modupe Taiwo, Rahinatu Adamu Hussaini, Miftahu Yahaya, Nasiru Muhammad, Akeem Adesina, Save the Children Nigeria

August 12, 2020

The COVID-19 pandemic has severely disrupted normal life around the world and has widened gaps in gender relations and gender equality. Indeed, disasters like this pandemic often exacerbate pre-existing gender inequities and power hierarchies, and violence in the home may worsen as prolonged quarantine and economic stressors increases tension in the household. Women and girls are isolated from people and resources that can help them, and they have few opportunities to distance themselves from their abusers.

More importantly, women and girls may lose the rights and opportunities for decision making in homes and social interaction and may have a more limited control over their reproductive rights. Our research shows this has occurred for many girls in Northern Nigeria.

Nigeria reported its first case of coronavirus in February 2020 and following the global trend to do so, restrictive measures including a lockdown were introduced by the government for more than four months. This significantly negatively impacted the economy, education and health services and social relations. It also resulted in a substantial rise in cases of gender-based violence in Nigeria. Prior to the virus and lockdown, 30% of women and girls reported experiencing physical violence by age 15 either through early or forced marriages, physical, mental or sexual assault.[1] UN women found that under lockdown, there was a monthly increase of gender-based violence by 149% in 23 out of 36 states of Nigeria where data are available.[2]

Methodology

In June 2020, Reaching and Empowering Adolescent to make Informed Choices for their Health (REACH), a three year (2018-2021) sexual and reproductive health project funded by Global Affairs Canada (GAC) in Northern Nigeria conducted a rapid assessment to understand the effect of COVID-19 pandemic on girls and women’s agency in the project communities in Gombe, Katsina and Zamfara. The study aimed to examine the gendered effect of COVID-19 pandemic, especially in access and utilisation of adolescent sexual and reproductive health (ASRH) services, household chores and decision-making power on project beneficiaries.

The telephone interviews with 566 respondents (305 female and 261 male) were conducted with adolescents aged 10-19 years, of whom 26% were married and 74% were unmarried. Most were in school (67%), while 19% were out of school having completed school, 13% discontinued schooling and 1% refused to give their educational status.

Summary of Five Key Findings on the Decision-Making Power of Adolescents

The ability of adolescents, especially girls, to make their own decisions was assessed with carefully selected relevant items.

How much control do you have over your decision on leaving the house to go into the community when you have to?
General acceptable practice in Northern Nigeria is to restrict women’s and girls’ ability to leave their home. The COVID situation exacerbated this restriction and further disempowered girls and women in making their own decisions. Forty-one per cent of the female respondents reported that they have very little control over their decision to leave the house and 40% have no control at all.  As for married adolescents’ girls, 62% reported that their husbands have full control over the decision to leave the house. In addition, 51% of married girls reported they would be stopped and 15% would be punished if their husbands disagree with their decision. However, during COVID-19 pandemic and restriction of movement, 79% of the adolescent girls experienced further loss of control over their own decisions.

How much control do you have over your decision on who you will associate with outside of your household?
During lockdown, 40% of girls reported having very little control over their decision on who to associate with outside their households while 18% have full control. In the same vein, 48% noted that either their husbands or another household member has full control over their decision on social association in the community. Fifty-three per cent would be stopped and 15% would be punished if there is disapproval of their social association.

Access and utilisation of health services including SRH
Decision on where to seek healthcare during lockdown is dependent on the willingness of the husbands to grant permission to the wife, especially in a non-emergency situation, as confirmed by 60% of married girls. Husbands or household members have full control over their decision on where and when to seek healthcare and if the husband or family member do not agree with her decision, she will be punished. In addition, 67% of married girls reported that their husbands would stop them and punish them if they failed to seek prior permission.

Are you or your partner currently using any method to delay or avoid getting pregnant?
The majority (66%) of the married boys and girls are not using any contraceptive method during the lockdown while 34% reported currently using their preferred modern contraceptive methods. A few married adolescents have been denied access to SRH services and faced pressure to become pregnant. Husbands sometimes keep away the contraceptives or sometimes resort to physical abuse such as beating to get the cooperation of the wives.

With reference to quality of health service received, 20% of the respondents have had to see a health provider due to an injury or illness since the start of the pandemic. The majority (76%) visited government health centers while 24% patronized Private Patent Medicine Vendor (PPMV). The majority, 66%, could not associate the COVID-19 pandemic with lower quality of health care but indicated that the pandemic limited their access due to: fear of being infected, compliance to government movement restriction, inability to secure permission to go out and longer waiting time to see the available health workers.

Experiences of domestic violence and marital conflicts
Domestic violence was one of the greatest human rights violations documented with higher scale of occurrence in the COVID-19 pandemic. Some married girls have experienced different levels of domestic violence during the lock down ranging from being pressured by husbands or partners to get pregnant (39%), prevented from visiting the clinic or pharmacy to get family planning commodities (23%) and/or being physically abused for not getting pregnant (20%). Examples of marital conflict experienced include being slapped, hit, kicked, having things thrown at them, being forced to have sex without consent and getting bruised in the process.

Conclusion

Our research supports UN data showing that the COVID pandemic and the safety options adopted by the government have contributed to increasing gender equality gaps. This is not only tragic for the persons facing violence and restrictions, but it is reversing the gains of SDG 5 (achieve gender equality) with only one decade left to accomplish it. This must be addressed.

For our part, the REACH project is taking forward our findings to adapt current intervention approach for well-targeted gender responsive strategies to close the gender equality gaps in project states.

[1] Nigeria Demographic Health Survey report (NDHS) 2018

[2] UNWOMEN SGBV during COVID pandemic in Nigeria, 2020.

———–

About the authors:

Lead author: Dr. Modupe Taiwo is a public health professional with 20 years’ experience in design and management of development and humanitarian projects across Health, Nutrition, Gender and protection and Education themes in different international development agencies. She is currently the project director at Save the Children International, for an adolescent sexual and reproductive health project in Northern Nigeria. She is passionate about adolescent health and wellbeing. She is leads on gender and social norms research for the organization.

Co-author: Rahinatu Adamu Hussaini is a Gender Equality and inclusion expert.  In the last 15 years she has worked with different international development agencies and NGOs including ActionAid, British council, Voluntary services Overseas, Medicines Sans Frontières, IntraHealth International and currently with Save the children International Nigeria as a Gender Equality Adviser. She is passionate about girls and women’s rights and believes in gender and social justice. She is an advocate of working with empathy and development from “within”.

Co-author: Miftahu Yahaya, Monitoring, Evaluation, Accountability and Learning Officer at Save the Children International is a graduate of Mechanical Engineering. He has over 4 years’ experience in supporting monitoring and evaluation of development projects. His expertise includes database management, researches, accountability systems for community feedback and project monitoring.

Co-author: Nasiru Muhammad is currently the Monitoring, Evaluation, Accountability and Learning (MEAL) Officer for Save the Children’s REACH Project based in Katsina. He is experienced in M&E with a focus on Malaria, MNCH, Nutrition, ASRH and Food Security and Livelihood for development and humanitarian projects.

Co-author: Akeem Adesina is a Monitoring, Evaluation, Accountability and Learning (MEAL) Advisor with Save the Children International in Nigeria. His expertise includes M&E Systems Development, Information Systems Management, Research Design, Implementation and Quality Monitoring. He currently provides technical leadership on adolescent sexual and reproductive health project in Northern Nigeria.

 

Anita Raj, PhD is a Tata Chancellor Professor of Society and Health and the Director of the Center on Gender Equity and Health (GEH) at the University of California San Diego. Her research, including both epidemiologic and intervention studies, focuses on sexual and reproductive health, maternal and child health, and gender data and measurement. She is also Principal Investigator on the EMERGE study referenced in this blog. She has served as an advisor to UNICEF, WHO, and the Bill and Melinda Gates Foundation. She recently contributed to the Lancet series on Gender Equality and Health as an author and steering committee member; she co-led analyses of gender inequalities in health systems and the role of gender norms on health.

 

Jay Silverman, PhD is a Professor of Medicine and Global Public Health, and Director of Research for the Center on Gender Equity and Health at the University of California, San Diego. Over the past 20 years, he has led multiple research programs on the nature and effects of gender-based violence and other gender inequities on health, including development and testing of community and health service-based interventions to reduce GBV and improve reproductive health and autonomy. He has published over 200 peer-reviewed studies on these topics, and co-authored the award-winning practitioner guidebook, The Batterer as Parent (Sage, 2002; 2009).

 

Rebecka Lundgren, MPH, PhD is a professor at the Center on Gender Equity and Health (GEH) at the University of California San Diego, leads the global secretariat of the Social Norms Learning Collaborative and supports its regional communities in Nigeria and East Africa. Her work seeks to advance social norms theory, measurement and practice, with a focus on developing practical guidance for implementing and scaling norms-shifting interventions to promote gender equity and prevent gender-based violence.

 

Nandita Bhan, MSc, MA, PhD is a Research Scientist–India at the Center on Gender Equity and Health at UC San Diego, based in Delhi. She is a social epidemiologist with degrees from Harvard University, University College London, and Delhi University. She works on developing rigorous measurement science on gender equality and empowerment for research, capacity building, and field-based program monitoring and evaluation. Her research also includes the role of gender, social context, and urbanization as determinants of agency and equity among adolescents, and in understanding the enablers and barriers to adolescent programming in India.

Meredith Pierce, MPH is a Research Project Manager supporting the research portfolios of Dr. Anita Raj and Dr. Rebecka Lundgren at University of California San Diego’s Center of Gender Equity and Health (GEH). Meredith’s most recent areas of work include focus on family planning, youth, research utilization, and HIV/AIDS. Prior to GEH, Meredith worked at Population Reference Bureau in International Programs and at USAID in the Office of HIV/AIDS and the Office of Population and Reproductive Health. Meredith holds a Master of Public Health from George Washington University.

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Monitoring COVID-19’s Effects on Family Planning: What Should We Measure?

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By Anita Raj, Jay Silverman, Rebecka Lundgren, Nandita Bhan, and Meredith Pierce

This blog originally appeared on Knowledge Success

The rapid growth of the COVID-19 pandemic has raised global awareness of inadequacies in our public health systems across high-, middle-, and low-income nations. As health care systems are stretched to capacity dealing with the pandemic, many of us are worried that delivery of essential health services—including family planning—is being severely compromised. Earlier this month, Marie Stopes International reported that up to 9.5 million women and girls may not get vital family planning services this year because of COVID-19, due to issues both in supply and demand, resulting in tens of thousands of maternal deaths. On the supply side, there are worries that reduced manufacturing and delivery may affect contraceptive access, and inadequate health care availability due to COVID-19 burdens on health systems may impede access to more effective contraceptives such as IUD and tubal ligation. Still, on the supply side, we may be able to monitor availability of family counselors and contraceptives to meet needs. But what of the demand side? How can we monitor shifts in women’s family planning needs and preferences in light of the social and economic shocks they are facing due to the pandemic?

Why Measure Demand for Family Planning During the COVID-19 Pandemic?

First, we must clarify why we need ongoing measurement to better understand demand for family planning. Obviously, the issue is important, as there is extensive research, including our own study released this month, documenting the negative health consequences of unintended pregnancy, including risk for maternal and neonatal death. This study among women who had given birth in the past year in Uttar Pradesh, India found that those with an unintended pregnancy were twice as likely to experience pre-eclampsia in pregnancy and post-partum and almost 50% more likely to have experienced post-partum hemorrhage, relative to those reporting a planned pregnancy. While the importance of family planning is widely recognized, we do not understand how the pandemic will exacerbate inequalities in demand and how health and economic fears may affect pregnancy desire and contraceptive preferences. Additionally, not only do the contexts of lockdowns affect women’s ability to obtain and use contraception due to the supply issues noted above, but family influence and control over them may also be greater at this time.

Globally, we are seeing an increase in reports of domestic violence since the establishing of national lockdowns. As social, health, and financial stresses increase as a consequence of the pandemic and lockdowns, we can expect elevation in both the frequency and severity of these abuses. Domestic violence has been associated with greater reproductive control and coercion of women and impeding access to and use of contraceptives. Importantly, there is also increasing evidence that women experiencing violence or reproductive coercion  are more likely to use women-controlled reversible contraceptives (e.g., IUDs), with some findings from ongoing analyses indicating that this is often occurring as covert use. Thus, access to methods such as IUDs, which require little ongoing contact with a provider (apart from addressing potential unwanted side effects), may be particularly useful and preferred by women during the pandemic.

As we consider how best to monitor and track women’s family planning needs, considerations of violence, reproductive autonomy, and female control of contraceptive methods will be important, emphasizing the need to focus on women’s agency in our measurement. Our conceptualization of women’s agency in health focuses on the Can-Act-Resist constructs of agency, beginning with an emphasis on women’s choice and goals for family planning. In this time of pandemic, where people are feeling less control over their lives, measuring family planning agency is even more important to include in our efforts to monitor demand. Hence, measurement of family planning demand among women should include:

  • What family planning methods do they want to use, and feel that they can use in their current situation? [Choice and Can]
  • What actions have they taken to meet their family planning needs (e.g., using covertly)? [Act]
  • Who if anyone has impeded or influenced their access to or use of contraceptives, and how have they overcome these impediments? [Resist]

To assess these questions quantitatively, a growing body of evidence-based measures of gender equity and health speaks to a broad range of needs, constructs, and cultural contexts. GEH’s EMERGE platform is an open-access, one-stop shop where researchers and survey implementers can find and draw from over 300+ gender measures in the areas of health, politics, economics, and other social spheres, including family planning and household/family dynamics. In the coming months, we plan to launch a special webpage that focuses on gender measures in family planning. In the interim, we have selected a few measures of agency in family planning from our website that demonstrate strong measurement science and ease of use:

The EMERGE site includes additional details on the context and science of the measures, as well as their citations.

While there is much advancement on the science and validation of promising measures, we continue to face many gaps, requiring further research to improve our measures. For example, we often ask questions about contraceptives used, but not about contraception preferred or not preferred and reasons for this (Choice and Can). We assess family planning communication and decision-making but not negotiation, where women navigate compromise to achieve their family planning goals (Act and Resist). We assess barriers to family planning use, including reproductive coercion, but not the ways women are able to ensure they can have their needs met despite these barriers, such as via covert use (Resist). Certainly, beyond these issues, we need to ensure that the measures we have can be adapted and tested for use in more diverse contexts. To that end, more research is needed in the area of measurement science. For those interested in this line of inquiry, please review our guidance on measurement development.

Where Do We Go from Here?

While we promote and offer guidance to get measures into the field to ensure we understand changes in family planning demand and unmet need as the COVID-19 pandemic continues to grow, it is with an understanding that most surveys in the field have ceased at this time. Once we are able to return to the field and assessment opportunities arise to identify health needs beyond COVID-19, it is likely we’ll find that women’s reproductive health needs and agency have been substantially affected by this pandemic. Now is the time to prepare our surveys, including those that are rapid and those that are deep, as both will be needed. Rapid assessments will likely roll out first, with early health assessments to capture health needs, particularly in our lowest resourced and most marginalized groups. Deeper assessments are likely to follow, as we not only assess immediate needs but help understand the health damage and losses that occur as a consequence of the pandemic. We must be forward thinking in our approach, and include family planning considerations with a lens of women’s agency as we move forward.

———–

Anita Raj, PhD is a Tata Chancellor Professor of Society and Health and the Director of the Center on Gender Equity and Health (GEH) at the University of California San Diego. Her research, including both epidemiologic and intervention studies, focuses on sexual and reproductive health, maternal and child health, and gender data and measurement. She is also Principal Investigator on the EMERGE study referenced in this blog. She has served as an advisor to UNICEF, WHO, and the Bill and Melinda Gates Foundation. She recently contributed to the Lancet series on Gender Equality and Health as an author and steering committee member; she co-led analyses of gender inequalities in health systems and the role of gender norms on health.

Jay Silverman, PhD is a Professor of Medicine and Global Public Health, and Director of Research for the Center on Gender Equity and Health at the University of California, San Diego. Over the past 20 years, he has led multiple research programs on the nature and effects of gender-based violence and other gender inequities on health, including development and testing of community and health service-based interventions to reduce GBV and improve reproductive health and autonomy. He has published over 200 peer-reviewed studies on these topics, and co-authored the award-winning practitioner guidebook, The Batterer as Parent (Sage, 2002; 2009).

Rebecka Lundgren, MPH, PhD is a professor at the Center on Gender Equity and Health (GEH) at the University of California San Diego, leads the global secretariat of the Social Norms Learning Collaborative and supports its regional communities in Nigeria and East Africa. Her work seeks to advance social norms theory, measurement and practice, with a focus on developing practical guidance for implementing and scaling norms-shifting interventions to promote gender equity and prevent gender-based violence.

Nandita Bhan, MSc, MA, PhD is a Research Scientist–India at the Center on Gender Equity and Health at UC San Diego, based in Delhi. She is a social epidemiologist with degrees from Harvard University, University College London, and Delhi University. She works on developing rigorous measurement science on gender equality and empowerment for research, capacity building, and field-based program monitoring and evaluation. Her research also includes the role of gender, social context, and urbanization as determinants of agency and equity among adolescents, and in understanding the enablers and barriers to adolescent programming in India.

Meredith Pierce, MPH is a Research Project Manager supporting the research portfolios of Dr. Anita Raj and Dr. Rebecka Lundgren at University of California San Diego’s Center of Gender Equity and Health (GEH). Meredith’s most recent areas of work include focus on family planning, youth, research utilization, and HIV/AIDS. Prior to GEH, Meredith worked at Population Reference Bureau in International Programs and at USAID in the Office of HIV/AIDS and the Office of Population and Reproductive Health. Meredith holds a Master of Public Health from George Washington University.

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Data On Gender Norms: Can We Find And Use What Is Missing?

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By: Rebecka Lundgren, Meredith Pierce, Anita Raj, Namratha Rao

Published by: ALIGN
Gender norms – the social norms that define and restrict behaviours and opportunities for individuals based on their biological sex – are increasingly recognized as key drivers maintaining gender inequalities across nations. In response, global development programmes and initiatives have increased their focus on gender norms as targets of change. In March 2020, the United Nations Development Programme released, for the first time, the Gender Social Norms Index (GSNI) to highlight these norms at the national level. This index sets a baseline for change in these norms and demonstrates that gender norms are associated with gender inequalities at the national level. The GSNI report documents that half of people globally believe men make better political leaders than women, and 40% believe men make better business executives than women.

The most striking and disturbing finding of this new work is that these restrictive gender norms have, in fact, increased rather than decreased across the globe. (See graphs below, taken from GSNI Report). These findings contrast sharply with continued improvements on key gender equality indicators (e.g. girls’ education, women’s political participation) in this same period. This indicates that, even while we are seeing face-value improvements in women and girls’ access to socio-economic opportunities, restrictive gender norms are pervasive.

Figure taken from UDNP’s 2020 Human Development Perspectives Tackling Social Norms: A game changer for gender inequalities report.Click to view full-size. Figure taken from UDNP’s 2020 Human Development Perspectives Tackling Social Norms: A game changer for gender inequalities report.

How does GSNI measure norms?

This new index focused on gender norms is vitally important to track progress on Sustainable Development Goal 5: Achieving Gender Equality and Empowerment of All Women and Girls. Unfortunately, the index is also limited by relying on component indicators pulled from large-scale surveys that are not norms, but are individual attitudes and beliefs. This is not a flaw of the index per se, but of the indicators we have available as relates to gender norms. Social norms should be measured for a given group as:

  • social expectations from those important to them (i.e., Injunctive norms- “People who matter to me expect me to…”) or
  • social observations of what others around them do (i.e., Descriptive norms- “Others in my community mostly do this…”).

While attitudes, beliefs and norms are all related to gender equity, they are distinct constructs and should be measured as such. Applied to gender norms, this might change the phrasing of a  statement designed to measure attitudes, such as changing “Boys are better at science than girls” (an attitude) into:

  • “People who matter to me think that boys should be scientists, while girls should be teachers.” (an injunctive norm), or
  • “In my school, boys major in science, not girls.” (a descriptive norm).

Norms can also be measured by assessing whether social rewards or punishments are received for engagement in the given behaviour (i.e., social sanctions). For example, girls pursuing engineering in a context where assumptions are that only boys go into engineering may face harassment or discrimination from peers or even professors in that context.

Why are improvements in measurement needed?

Why does this distinction between attitudes and norms matter, conceptually and for measurement? Because growing evidence indicates that social norms, as well as individual attitudes, influence human behaviour. To affect gender inequalities at scale, shifting gender norms (rather than individual attitudes) may have more of a far reaching and sustained effect.  Hence, we must measure these important targets of changes at national levels, and we must have such quantitative measures available for inclusion in global indices like GSNI.

The first step toward having these measures at scale is to have evidence-based social norms measures available for inclusion in our large-scale national surveys. To that end, we find the field sadly lacking. We recently analyzed social norms measures in just one area of gender equality, women’s economic empowerment, using measures from EMERGE, a one stop shop platform for open access (i.e. freely available) survey measures on gender equality and empowerment. (See the EMERGE Website to learn more, find measures for your work, and submit your measures.)

EMERGE has a compilation of 300+ survey measures on gender equality and empowerment for researchers and implementers, with measures crossing the areas of health, education, economics, politics, and other social spheres. Upon examining the available social norms measures (those showing face validity of assessing social norms and those defined by the authors of the measures as social norms), we found 26 measures purported to assess norms with respect to women’s economic empowerment. However, further examination of the measures by social norms experts on our team indicated that even these measures largely relied on attitudes, and that no measures focused on injunctive norms.

Where do we go from here as a field and in partnership?

  1. Increase use of gender norms measures at scale. EMERGE is working to build the science and enhance the usage of evidence-based measures at scale on both norms and agency in economic empowerment. We have had the opportunity to work with the Karolinska Institutet on inclusion of gender norms questions in the next iteration of the World Values Survey. Because their measures serve as the basis for much of the GSNI, their expansion of surveys to include norms measures will offer significant improvements to this index.
  2. Increase development of social norms measures for use at scale. Researchers and implementers must prioritize rigorous development and testing of gender norms measures, with a conceptual foundation consistent with social norms science. Too often, people are creating measures without this conceptual and theoretical grounding, and without rigorous measurement science (e.g. formative research and psychometric). For the latter, we recommend guidance from EMERGE on how to develop and test measures using best evidence measurement science methodologies. This guidance also offers insight into how to adapt measures to new contexts, an important consideration to ensure our measures are able to fit and work within diverse populations.
  3. Collectively advocate for the recognition of social norms as conceptually distinct from attitudes/beliefs and requiring specific measures that capture injunctive and descriptive norms and the social sanctions that reinforce them. Simultaneously, advocate among those of us working in this space and using these measures in the field to a) use rigorous methodologies to increase recognition of the reliability and validity of these measures and b) disseminate the measures with the information about their conceptual underpinnings and documentation of their methodological strength.

Through these efforts, we hope to see expansion of gender norms measures, improved application of measurement science in development of these measures, and greater representation of actual gender norms measures in our national level indicators and global indices. Without strong quantitative measures, it will continue to be difficult to identify the norms that matter to achieving the SDGs and to assess the effectiveness of norms-shifting interventions. We at EMERGE encourage researchers working in this area to join us, and take a more active role in developing and testing social-norms measures for global gender equality.

About the authors

(All co-authors contributed equally and we have listed them out alphabetically)

Rebecka Lundgren, MPH, PhD – is a professor at the Center on Gender Equity and Health (GEH) at the University of California San Diego, leads the global secretariat of the Social Norms Learning Collaborative and supports its regional communities in Nigeria and East Africa.  Her work seeks to advance social norms theory, measurement and practice, with a focus on developing practical guidance for implementing and scaling norms-shifting interventions to promote gender equity and prevent gender-based violence

Meredith Pierce, MPH – is a Research Project Manager supporting the research portfolios of Dr. Anita Raj and Dr. Rebecka Lundgren at University of California San Diego’s Center of Gender Equity and Health (GEH). Meredith’s most recent areas of work include focus on family planning, youth, research utilization, and HIV/AIDS. Prior to GEH, Meredith worked at Population Reference Bureau in International Programs and at USAID in the Office of HIV/AIDS and the Office of Population and Reproductive Health. Meredith holds a Master of Public Health from George Washington University.

Anita Raj, PhD – is a Tata Chancellor Professor of Society and Health and the Director of the Center on Gender Equity and Health (GEH) at the University of California San Diego. Her research, including both epidemiologic and intervention studies, focuses on sexual and reproductive health, maternal and child health, and gender data and measurement. She is also Principal Investigator on the EMERGE study referenced in this blog. She has served as an advisor to UNICEF, WHO, and the Bill and Melinda Gates Foundation. She recently contributed to the Lancet series on Gender Equality and Health as an author and steering committee member; she co-led analyses of gender inequalities in health systems and the role of gender norms on health.

Namratha Rao, MSPH – is a Research Program Manager/Consultant at the University of California San Diego’s Center of Gender Equity and Health, supporting the Center’s research portfolio in India. She has experience working in the HIV/AIDS, family planning, and WASH sectors and is extremely interested in health behavior change approaches to intervention and the intersections of environment, gender and health. Namratha received her Masters of Science in Public Health from Johns Hopkins University, MD.

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Measuring Agency

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By Alison Decker, Aletheia Donald, and Rachael Pierotti [1]

Imagine Fatou, a woman entrepreneur selling beignets in the streets of a bustling Dakar neighborhood. Her beignets sell out daily, and she knows there is potential to earn more money, so she decides to hire a worker who can help her to bake beignets in the morning. Her business grows.

Fatou has exercised agency—defined by Naila Kabeer (1999) as “the ability to define one’s goals and act on them.” She had to set a goal based on her preference to expand her business, perceive that her goal was potentially achievable, and then act—and in the process, she boosted her economic empowerment.

Indeed, agency is the process through which empowerment is achieved. That’s why many types of international development interventions seek to increase women’s agency, either explicitly or implicitly. These can be programs that try to shift existing beliefs or norms about women’s status and capabilities, or programs that increase women’s control over critical resources.

Measuring agency is difficult, however, and existing measures are incomplete. A recent paper by Donald et al (2020), lays out a framework for comprehensive measurement of the three components of agency: goal setting, perceived sense of control and ability, and ability to act on goals and values.

Goal setting

To have agency, an individual must have the ability to define goals that are in line with their personal values. When choices or actions are motivated by fear of judgement or internalized social expectations, these actions are not a manifestation of agency. The Women’s Empowerment in Agriculture Index (WEAI) captures this sense of motivational autonomy. Questions in the index ask, for example, why a woman chooses to keep certain livestock. Is it because she is unaware of any other options? Is it because she fears judgment from her community if she goes against the grain? Or does she act based on the belief that her choices are the best ones?

While these questions capture the concept, there is a tricky complication: distinguishing between choices that are indeed motivated by personal values, and ones motivated by internalized social norms. Internalization of restrictive norms can constrain the horizon of opportunities before someone even makes a choice—and play a role in perpetuating gender inequality. For example, the filtering of men and women into different sectors of the economy based on perceptions of what is “suitable” for men and women exacerbates gender differences in earnings. Of course, discrimination contributes to gender segregation of the labor market, but research from the World Bank’s Africa Gender Innovation Lab shows that it is also the product of gender differences in choices of career paths.

Perceived control

The “perceived control” aspect of agency means that individuals feel they have some control over their lives, and the ability to achieve their goals. This psychological dimension of agency is fundamental because perceiving oneself as able to achieve a goal is necessary to motivate action. Perceived control is most commonly captured with measures of self-efficacy or locus of control. Another avenue worth exploring is how well this dimension of agency can be captured by certain measures of socioemotional skills, such as perseverance, which are correlated with improved outcomes. A study in Malawi (Montalvao et al, 2017), for example, showed that women with higher levels of perseverance are more likely to adopt cash crops. Researchers used a scale developed by psychologists to capture women’s sense of perseverance, measuring it via questions including:

  • I can think of many times when I persisted with work even when others quit.
  • I continue to work on hard projects even when others oppose me.

These questions get at this sense of control—a woman who responds affirmatively indicates that she perseveres in the face of challenges, presumably because she believes her efforts can make a difference in her life. Future research should examine whether measures of perseverance adequately capture the “perceived control” dimension of agency.

Acting on goals

The third dimension regards taking decisions and acting on goals, or having the ability to do so. This component of agency can be directly limited by women’s relationships with other people or her status within her community.

To examine this third component, researchers have commonly used questions that measure a woman’s decision-making power relative to her husband. One drawback to these questions, however, is that the decision-making process is dynamic and nuanced – both things that are hard to capture with questions about who has ‘the final say’. Recent research using responses from both husband and wife about decision-making power finds that using only one person’s assessment of who has final authority can limit our understanding of a woman’s ability to enact her goals.

The study by Donald et al (2019) finds differences across measures of economic, health, and violence outcomes, depending on whether the husband and wife agree that the wife has some decision-making power, whether she claims more power than he attributes to her (or vice versa), or whether she is excluded from decision-making. These differences suggest that additional measures to capture women’s power to act, and when and how that power is contested, will add to our understanding of women’s agency.

Much more experimentation is needed for improving our methods of measuring agency. Developing measurement tools that can accurately determine the extent of women’s agency can help to diagnose the constraints that women face. This is a critical step in designing policy and development programs that are effective at boosting women’s empowerment.[/vc_column_text]

Courtesy of Jonathan Torgovnik/Getty Images/Images of Empowerment. Some rights reserved.

[1] The authors work with the Gender Innovation Lab at The World Bank. The Gender Innovation Lab conducts impact evaluations of development interventions in Sub-Saharan Africa, seeking to generate evidence on how to close the gender gap in earnings, productivity, assets, and agency. The impact objective of GIL is increasing take-up of effective policies by governments, development organizations, and the private sector in order to address the underlying causes of gender inequality in Africa, particularly in terms of women’s economic and social empowerment.

ABOUT THE AUTHORS:

Alison Decker is a research uptake specialist at the World Bank’s Africa Gender Innovation Lab, working to disseminate evidence on women’s economic empowerment related to social norms, property rights, and agriculture. Prior to joining the World Bank, Alison worked in communications with the UN World Food Program in Senegal and the Aspen Institute in Washington, DC. She holds a Master’s degree in International Economics and International Development from Johns Hopkins School of Advanced International Studies.

Aletheia Donald is an Economist at the World Bank’s Africa Gender Innovation Lab. Her research focuses on identifying and addressing gender-based constraints through the analysis of development project impacts and improving the measurement of their outcomes. Aletheia coordinates the Gender Innovation Lab’s work on measuring women’s empowerment. Before joining the World Bank, Aletheia was a Research Fellow at Harvard’s Evidence for Policy Design and Head of Research for the NGO Empower Dalit Women of Nepal. She holds a Master’s degree in Economics from Yale University.

Rachael Pierotti is a Social Development Specialist for the World Bank’s Africa Gender Innovation Lab. She is a sociologist who specializes in the study of the social dynamics that drive gender gaps in labor force participation, occupational choice, entrepreneurial success, wages, and agricultural productivity. She also has a background in the study of demographic behaviors, such as marriage timing, fertility, and reproductive health. Rachael earned a PhD in sociology from the University of Michigan in 2013.[/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row]