Franciele Hellwig
@equidade.org
Postdoctoral researcher, Federal Univertity of Pelotas
International Center for Equity in Health
RESEARCH, TEACHING, or OTHER INTERESTS
Epidemiology
Scopus Publications
Scholar Citations
Scholar h-index
Scholar i10-index
Scopus Publications
Laísa Rodrigues Moreira, Cauane Blumenberg, Beatriz Elena Caicedo Velasquez, Fernanda Ewerling, Alejandra Balandrán, Luis Paulo Vidaletti, Andrea Ramirez Varela, Franciele Hellwig, Rodolfo Gomez Ponce de Leon, Aluisio J.D. Barros,et al.
Elsevier BV
Franciele Hellwig and Aluísio J. D. Barros
Frontiers Media SA
BackgroundDespite the efforts to promote universal coverage for family planning, inequalities are still high in several countries. Our aim was to identify which sources of contraceptives women mostly rely on in low- and middle-income countries (LMICs). We also explored the different sources according to age and marital status.MethodsWe used data from national health surveys carried out in 59 LMICs since 2010. Among all sexually active women at reproductive age, we explored inequalities in demand for family planning satisfied by modern methods (mDFPS) and in the source of modern contraceptives according to women's age, classified as: 15–19, 20–34, or 35–49 years of age. Among adolescents, mDFPS and source of method were explored by marital status, classified as married or in union and not married nor in a union.ResultsmDFPS was lower among adolescents than among adult women in 28 of the 59 countries. The lowest levels of mDFPS among adolescents were identified in Albania (6.1%) and Chad (8.2%). According to adolescents' marital status, the pattern of inequalities in mDFPS varied widely between regions, with married and unmarried adolescents showing similar levels of coverage in Latin America and the Caribbean, higher coverage among unmarried adolescents in Africa, and lower coverage among unmarried adolescents in Asia. Public and private health services were the main sources, with a lower share of the public sector among adolescents in almost all countries. The proportion of adolescents who obtained their contraceptives in the public sector was lower among unmarried girls than married ones in 31 of the 38 countries with data. Friends or relatives were a more significant source of contraceptives among unmarried compared to married adolescents in all regions.ConclusionsOur findings indicate lower levels of mDFPS and lower use of the public sector by adolescents, especially unmarried girls. More attention is needed to provide high-quality and affordable family planning services for adolescents, especially for those who are not married.
Janaína Calu Costa, Ghada E. Saad, Franciele Hellwig, Maria Fatima S. Maia, and Aluísio J. D. Barros
Frontiers Media SA
BackgroundQuantifying women's empowerment has become the focus of attention of many international organizations and scholars. We aimed to describe quantitative indicators of women's empowerment that are based on individual-level data.MethodsIn this scoping review, we searched PubMed, Scopus, Web of Science, Science Direct, Google, and Google Scholar for publications describing the operationalization of measures of women's empowerment.ResultsWe identified 36 studies published since 2004, half of them since 2019, and most from low- and middle-income countries. Twelve studies were based on data from the Demographic and Health Surveys and used 56 different variables from the questionnaires (ranging from one to 25 per study) to measure the overall empowerment of women 15–49 years. One study focused on rural women, two included married and unmarried women, and one analyzed the couple's responses. Factor analysis and principal component analysis were the most common approaches used. Among the 24 studies based on other surveys, ten analyzed overall empowerment, while the others addressed sexual and reproductive health (4 studies), agriculture (3) and livestock (1), water and sanitation (2), nutrition (2), agency (1), and psychological empowerment (1). These measures were mainly based on data from single countries and factor analysis was the most frequently analytical method used. We observed a diversity of indicator definitions and domains and a lack of consensus in terms of what the proposed indicators measure.ConclusionThe proposed women's empowerment indicators represent an advance in the field of gender and development monitoring. However, the empowerment definitions used vary widely in concept and in the domains/dimensions considered, which, in turn influence or are influenced by the adopted methodologies. It remains a challenge to find a balance between the need for a measure suitable for comparisons across populations and over time and the incorporation of country-specific elements.
Franciele Hellwig, Ghada E Saad, Andrea Wendt, and Aluísio JD Barros
International Society of Global Health
Background As more households are being led by women, who are often seen as disadvantaged, more attention is being given to the potential association of female household headship with health. We aimed to assess how demand for family planning satisfied by modern methods (mDFPS) is associated with residence in female or male headed households and how this intersects with marital status and sexual activity. Methods We used data from national health surveys carried out in 59 low- and middle-income countries between 2010 and 2020. We included all women aged 15 to 49 years in our analysis, regardless of their relationship with the household head. We explored mDFPS according to household headship and its intersectionality with the women’s marital status. We identified households as male-headed households (MHH) or female-headed households (FHH), and classified marital status as not married/in a union, married with the partner living in the household, and married with the partner living elsewhere. Other descriptive variables were time since the last sexual intercourse and reason for not using contraceptives. Results We found statistically significant differences in mDFPS by household headship among reproductive age women in 32 of the 59 countries, with higher mDFPS among women living in MHH in 27 of these 32 countries. We also found large gaps in Bangladesh (FHH = 38%, MHH = 75%), Afghanistan (FHH = 14%, MHH = 40%) and Egypt (FHH = 56%, MHH = 80%). mDFPS was lower among married women with the partner living elsewhere, a common situation in FHH. The proportions of women with no sexual activity in the last six months and who did not use contraception due to infrequent sex were higher in FHH. Conclusions Our findings indicate that a relationship exists between household headship, marital status, sexual activity, and mDFPS. The lower mDFPS we observed among women from FHH seems to be primarily associated with their lower risk of pregnancy; although women from FHH are married, their partners frequently do not live with them, and they are less sexually active than women in MHH.
Franciele Hellwig and Aluisio JD Barros
F1000 Research Ltd
Background Universal access to family planning services is a well-recognized human right and several countries and organizations are committed to this goal. Our objective was to identify countries who improved family planning coverage in the last 40 years and investigate which contexts enabled those advances. Methods Analyses were based on data from publicly available national health surveys carried out since 1986 in Egypt, Ethiopia, Rwanda, Afghanistan, Brazil, and Ecuador, selected based on previous evidence. We estimated demand for family planning satisfied with modern methods (mDFPS) for each country and explored inequalities in terms of wealth, women’s education, and women’s age. We also explored contextual differences in terms of women’s empowerment, percentage of population living in extreme poverty, and share of each type of contraceptive. To better understand political and sociocultural contexts, country case studies were included, based on literature review. Results Patterns of mDFPS increase were distinct in the selected countries. Current level of mDFPS coverage ranged between 94% in Brazil and 38% in Afghanistan. All countries experienced an important reduction in both gender inequality and extreme poverty. According to the share of each type of contraceptive, most countries presented higher use of short-acting reversible methods. Exceptions were Ecuador, where the most used method is sterilization, and Egypt, which presented higher use of long-acting reversible methods. In the first years analyzed, all countries presented huge gaps in coverage according to wealth, women’s education and women’s age. All countries managed to increase coverage over recent years, especially among women from the more disadvantaged groups. Conclusions Family planning coverage increased along with reductions in poverty and gender inequality, with substantial increases in coverage among the most disadvantaged in recent years. Policies involving primary health care services, provision of various methods, and high quality training of health providers are crucial to increase coverage.
Andrea Wendt, Franciele Hellwig, Ghada E Saad, Cheikh Faye, Ties Boerma, Aluisio J D Barros, and Cesar G Victora
Springer Science and Business Media LLC
Abstract Background Within-country inequalities in birth registration coverage (BRC) have been documented according to wealth, place of residence and other household characteristics. We investigated whether sex of the head of household was associated with BRC. Methods Using data from nationally-representative surveys (Demographic and Health Survey or Multiple Indicator Cluster Survey) from 93 low and middle-income countries (LMICs) carried out in 2010 or later, we developed a typology including three main types of households: male-headed (MHH) and female-led with or without an adult male resident. Using Poisson regression, we compared BRC for children aged less than 12 months living the three types of households within each country, and then pooled results for all countries. Analyses were also adjusted for household wealth quintiles, maternal education and urban-rural residence. Results BRC ranged from 2.2% Ethiopia to 100% in Thailand (median 79%) while the proportion of MHH ranged from 52.1% in Ukraine to 98.3% in Afghanistan (median 72.9%). In most countries the proportion of poor families was highest in FHH (no male) and lowest in FHH (any male), with MHH occupying an intermediate position. Of the 93 countries, in the adjusted analyses, FHH (no male) had significantly higher BRC than MHH in 13 countries, while in eight countries the opposite trend was observed. The pooled analyses showed t BRC ratios of 1.01 (95% CI: 1.00; 1.01) for FHH (any male) relative to MHH, and also 1.01 (95% CI: 1.00; 1.01) for FHH (no male) relative to MHH. These analyses also showed a high degree of heterogeneity among countries. Conclusion Sex of the head of household was not consistently associated with BRC in the pooled analyses but noteworthy differences in different directions were found in specific countries. Formal and informal benefits to FHH (no male), as well as women’s ability to allocate household resources to their children in FHH, may explain why this vulnerable group has managed to offset a potential disadvantage to their children.
Carolina V. N. Coll, Thiago M. Santos, Andrea Wendt, Franciele Hellwig, Fernanda Ewerling, and Aluisio J. D. Barros
Frontiers Media SA
Background: Women’s empowerment may play a role in shaping attitudes towards female genital mutilation/cutting (FGM/C) practices. We aimed to investigate how empowerment may affect women’s intention to perpetuate FGM/C and the practice of FGM/C on their daughters in African countries.Materials and methods: We used data from Demographic and Health Surveys carried out from 2010 to 2018. The countries included in our study were Benin, Burkina Faso, Chad, Côte d´Ivoire, Ethiopia, Guinea, Kenya, Mali, Nigeria, Senegal, Tanzania, and Togo. This study included 77,191 women aged 15–49 years with at least one daughter between zero and 14 years of age. The proportion of women who reported having at least one daughter who had undergone FGM/C as well as the mother’s opinion towards FGM/C continuation were stratified by empowerment levels in three different domains (decision-making, attitude to violence, and social independence) for each country. We also performed double stratification to investigate how the interaction between both indicators would affect daughter’s FGM/C.Results: The prevalence of women who had at least one daughter who had undergone FGM/C was consistently higher among low empowered women. Tanzania, Benin, and Togo were exceptions for which no differences in having at least one daughter subjected to FGM/C was found for any of the three domains of women’s empowerment. In most countries, the double stratification pointed to a lower proportion of daughters’ FGM/C among women who reported being opposed to the continuation of FGM/C and had a high empowerment level while a higher proportion was observed among women who reported being in favor of the continuation of FGM/C and had a low empowerment level. This pattern was particularly evident for the social independence domain of empowerment. In a few countries, however, a higher empowerment level coupled to a favorable opinion towards FGM/C was related to a higher proportion of daughters’ FGM/C.Conclusion: Women’s empowerment and opinion towards FGM/C seems to be important factors related to the practice of FGM/C in daughters. Strategies to improve women’s empowerment combined with shifts in the wider norms that support FGM/C may be important for achieving significant reductions in the practice.
Rodolfo Gómez Ponce de Leon, Maria Valeria Bahamondes, Franciele Hellwig, Aluísio Barros, Luis Bahamondes, Federico Tobar, Mariangela Freitas da Silveira, Moazzam Ali, Pio Iván Gómez-Sánchez, Jason Bremner,et al.
Pan American Health Organization
Objectives. To estimate inequalities in demand for family planning satisfied with modern methods among women in Latin America and the Caribbean, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to long-acting contraceptives (LARC) after the COVID-19 pandemic. Methods. National health surveys from 2006 to 2018 were used to estimate the demand for family planning satisfied with modern methods and how it was affected by the COVID-19 pandemic. The scenario included three variables: coverage, health outcomes, and costs. Considering coverage, United Nations Population Fund data were used to estimate the impact of COVID-19 on access to contraception in Latin America and the Caribbean. Health outcomes were assessed with the Impact 2 tool. Direct investment was used to evaluate cost-effectiveness. Results. Substantial inequalities were found in the use of modern contraceptive methods before the pandemic. We showed the potential cost-effectiveness of avoiding maternal deaths by introducing LARCs. Conclusions. In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted disability-adjusted life years are modest. Governments in Latin America and the Caribbean should consider promoting LARCs as a highly efficient and cost-effective intervention.
Ghada E Saad, Hala Ghattas, Andrea Wendt, Franciele Hellwig, Jocelyn DeJong, Ties Boerma, Cesar Victora, and Aluisio JD Barros
International Global Health Society
Background Female-headed households (FHHs) are regarded as disadvantaged. There are multiple social trajectories that can lead to women heading households. It is important to distinguish between these trajectories, as well as societal norms and contextual factors, to understand how and when are FHHs represented as a dimension of gender inequity. Our analysis defines and describes a typology of 16 FHH types (FHH16) based on demographic characteristics. Methods This cross-sectional study used national Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) in 103 low- and middle-income countries (LMICs) to identify a typology of FHHs based on the family composition and additional household members. We performed descriptive analyses at the household level to generate median proportions of the FHH16 types and selected household characteristics. We conducted cluster analyses to explore FHH16 patterns across naturally grouped clusters of countries and described selected social and economic indicators at the ecological level. Results The most common FHH16 types were those where the women household heads lived with children only, were alone, or lived with men, women, and children, but without a husband. In Africa and South Asia, the most common FHH was one where women heads resided with children only. In East Asia and the Pacific, the highest proportion of FHHs were those with men, women, and children. In MENA and Eastern Europe & Central Asia, households with women heads living alone were the most prevalent. Latin America had more FHHs with husbands, comparatively, and the most common FHHs were those with heads living alone or with children. Our exploratory cluster analysis generated five clusters with unique FHH16 patterns. The clusters had distinct geographic, contextual and economic characteristics. Conclusions Our typology showed that FHHs are heterogeneous within and between countries. The ecological analysis emphasized further variation created by different societal and cultural factors. Research around their vulnerabilities and strengths needs to consider these factors and their influence on socioeconomic status and health-related outcomes within households headed by women.
Franciele Hellwig, Fernanda Ewerling, Carolina V.N. Coll, and Aluísio J.D. Barros
Elsevier BV
Andrea Wendt, Franciele Hellwig, Ghada E. Saad, Cheikh Faye, Zitha Mokomane, Ties Boerma, Aluisio J.D. Barros, and Cesar Victora
Elsevier BV
Franciele Hellwig, Carolina V. N. Coll, Cauane Blumenberg, Fernanda Ewerling, Caroline W. Kabiru, and Aluisio J. D. Barros
Frontiers Media SA
Background: Around 80% of the African population lives in urban areas, and a rapid urbanization is observed in almost all countries. Urban poverty has been linked to several sexual and reproductive health risks, including high levels of unintended pregnancies. We aim to investigate wealth inequalities in demand for family planning satisfied with modern methods (mDFPS) among women living in urban areas from African countries.Methods: We used data from 43 national health surveys carried out since 2010 to assess wealth inequalities in mDFPS. mDFPS and the share of modern contraceptive use were stratified by groups of household wealth. We also assessed the ecological relationship between the proportion of urban population living in informal settlements and both mDFPS and inequalities in coverage.Results: mDFPS among urban women ranged from 27% (95% CI: 23–31%) in Chad to 87% (95% CI: 84–89%) in Eswatini. We found significant inequalities in mDFPS with lower coverage among the poorest women in most countries. In North Africa, inequalities in mDFPS were identified only in Sudan, where coverage ranged between 7% (95% CI: 3–15%) among the poorest and 52% (95% CI: 49–56%) among the wealthiest. The largest gap in the Eastern and Southern African was found in Angola; 6% (95% CI: 3–11%) among the poorest and 46% (95% CI: 41–51%) among the wealthiest. In West and Central Africa, large gaps were found for almost all countries, especially in Central African Republic, where mDFPS was 11% (95% CI: 7–18%) among the poorest and 47% (95% CI: 41–53%) among the wealthiest. Inequalities by type of method were also observed for urban poor, with an overall pattern of lower use of long-acting and permanent methods. Our ecological analyses showed that the higher the proportion of the population living in informal settlements, the lower the mDFPS and the higher the inequalities.Conclusion: Our results rise the need for more focus on the urban-poorer women by public policies and programs. Future interventions developed by national governments and international organizations should consider the interconnection between urbanization, poverty, and reproductive health.
Adriana Kramer Fiala Machado, Débora Dalmas Gräf, Fabiane Höfs, Franciele Hellwig, Karoline Sampaio Barros, Laísa Rodrigues Moreira, Pedro Augusto Crespo, and Mariângela Freitas Silveira
FapUNIFESP (SciELO)
Monitoring trends of contraceptive use and identifying the groups with less coverage are needed to guide public policies and make them more efficient. But, in Brazil, recent data about these aspects are limited. This study aimed to investigate the prevalence of contraceptive use and its inequalities during adolescence and early adulthood. Data from the 1993 Pelotas birth cohort, Rio Grande do Sul State, Brazil, were used. At 15, 18 and 22 years, respectively, 335, 1,458 and 1,711 women reported having started their sexual lives and were included in analysis. Prevalence and 95% confidence intervals were obtained to describe the most used contraceptive methods. Inequalities in modern contraceptive use were evaluated according to wealth index, scholastic backwardness and ethnicity. In all follow-ups, more than 80% of women used at least one modern method. The use of barrier methods decreased with age; at 22 this prevalence was 36.3%. Such use concomitant with other modern methods was lower than 50% in all follow-ups. We observed inequalities in the use of modern contraceptive methods, mainly in barrier methods used with other modern methods. These findings may contribute and improve the public policies in family planning.
Fernanda Ewerling, Anita Raj, Cesar G Victora, Franciele Hellwig, Carolina VN Coll, and Aluisio JD Barros
International Global Health Society
Introduction In 2017, a survey-based women's empowerment index (SWPER) was proposed for African countries, including three domains: social independence, decision making and attitude to violence. External validity and predictive value of the SWPER has been demonstrated in terms of coverage of maternal and child interventions and use of modern contraception. To determine its value for global monitoring, we explored the applicability of the SWPER in national health surveys from low- and middle- income countries (LMICs) in other world regions. Methods We used data from the latest Demographic and Health Survey for 62 LMICs since 2000. 14 pre-selected questions (items) were considered during the validation process. Content adaptations included the exclusion of women's working status and recategorization of the decision-making related items. We compared the loading patterns obtained from principal components analysis performed for each country separately with those obtained in a pooled dataset with all countries combined. Country rankings based on the score of each SWPER domain were correlated with their rankings in the Gender Development Index (GDI) and the Gender Inequality Index (GII) for external validation. Results Consistency regarding item loadings for the three SWPER empowerment domains was observed for most countries. Correlations between the scores generated for each country and global score obtained from the combined data were 0.89 or higher for all countries. Correlations between the country rankings according to SWPER and GDI were, respectively, 0.74, 0.72 and 0.67 for social independence, decision-making, and attitude to violence domains. The correlations were equal to 0.81, 0.67, and 0.44, respectively, with GII. Conclusion The indicator we propose, named SWPER Global, is a suitable common measure of women's empowerment for LMICs, addressing the need for a single consistent survey-based indicator of women's empowerment that allows for tracking of progress over time and across countries at the individual and country levels.
Cauane Blumenberg, Franciele Hellwig, Fernanda Ewerling, and Aluísio J. D. Barros
Springer Science and Business Media LLC
Abstract Background Contraception is a key component of sustainable development, empowering women, reducing the risk of maternal and child mortality and promoting economic growth. It is part of the Sustainable Development Goals agenda, where the aim is to achieve universal access to sexual and reproductive health. Our objective was to evaluate trends and inequalities in modern contraceptive prevalence, and according to the type of modern contraceptive, in 11 low- and middle-income countries that are partners of the Family Planning 2020 initiative. Methods Analyses were performed using 62 Performance Monitoring and Accountability 2020 (PMA2020) surveys from 11 countries. Forty surveys were nationally representative, while 22 had regional coverage. Regional surveys were analyzed separately, totalizing 15 geographies from 11 countries. We described trends on modern contraceptive prevalence, and its subtypes (short- and long-acting reversible contraceptives, and permanent methods), by calculating absolute average annual changes. Absolute inequalities on the prevalence of modern contraceptives were assessed for the most recent survey of each geography using the slope index of inequality, and according to wealth, education and age. Results The overall prevalence of modern contraception increased in most geographies analyzed, reaching a 7.2 percentage points increase per year in Lagos, Nigeria. This increase was mostly influenced by the long-acting reversible contraceptives, which increased in 73% of the geographies. Although the largest share of modern contraception is represented by short-acting reversible contraceptives, these are reducing and giving space for the long-acting methods. The exception was Rajasthan, India, where the permanent methods accounted for 70% of the modern contraception share, and their prevalence was almost 40%. Inequalities were identified in favor of richer, older and better educated women. Conclusions Out of the 15 geographies analyzed, 11 demonstrated an increase in overall modern contraceptive use – mainly driven by the uptake of long-acting reversible contraception. However, even in the groups with the highest prevalence, modern contraceptive use was at most 60% in most geographies. So, we are far from reaching the desired universal coverage proposed by the Sustainable Development Goals.
Inacio Crochemore M. da Silva, Fernanda Everling, Franciele Hellwig, Carine Ronsmans, Lenka Benova, Jennifer Requejo, Anita Raj, Aluisio J. D. Barros, and Cesar G. Victora
Springer Science and Business Media LLC
Abstract Background The Sustainable Development Goals (SDGs) include specific targets for family planning (SDG 3.7) and birth attendance (SDG 3.1.2), and require analyses disaggregated by age and other dimensions of inequality (SDG 17.18). We aimed to describe coverage with demand for family planning satisfied with modern methods (DFPSm) and institutional delivery in low- and middle-income countries across the reproductive age spectrum. We attempted to identify a typology of patterns of coverage by age and compare their distribution according to geographic regions, World Bank income groups and intervention coverage levels. Methods We used Demographic and Health Survey and Multiple Indicator Cluster Surveys. For DFPSm, we considered the woman’s age at the time of the survey, whereas for institutional delivery we considered the woman’s age at birth of the child. Both age variables were categorized into seven groups of 5 year-intervals, 15–19 up to 45–49. Five distinct patterns were identified: (a) increasing coverage with age; (b) similar coverage in all age groups; (c) U-shaped; (d) inverse U-shaped; and (e) declining coverage with age. The frequency of the five patterns was examined according to UNICEF regions, World Bank income groups, and coverage at national level of the given indicator. Results We analyzed 91 countries. For DFPSm, the most frequent age patterns were inverse U-shaped (53%, 47 countries) and increasing coverage with age (41%, 36 countries). Inverse-U shaped patterns for DFPSm was the commonest pattern among lower-middle income countries, while low- and upper middle-income countries showed a more balanced distribution between increasing with age and U-shaped patterns. In the first and second tertiles of national coverage of DFPSm, inverse U-shaped was observed in more than half of countries. For institutional delivery, declining coverage with age was the prevailing pattern (44%, 39 countries), followed by similar coverage across age groups (39%, 35 countries). Most (79%) upper-middle income countries showed no variation by age group while most low-income countries showed declining coverage with age (71%). Conclusion Large inequalities in DFPSm and institutional delivery were identified by age, varying from one intervention to the other. Policy and programmatic approaches must be tailored to national patterns, and in most cases older women and adolescents will require special attention due to lower coverage and because they are at higher risk for maternal mortality and other poor obstetrical outcomes.
Carolina V N Coll, Fernanda Ewerling, Claudia García-Moreno, Franciele Hellwig, and Aluisio J D Barros
BMJ
IntroductionIntimate partner violence (IPV) against women is a critical public health issue that transcends social and economic boundaries and considered to be a major obstacle to the progress towards the 2030 women, children and adolescents’ health goals in low-income and middle-income countries (LMICs). Standardised IPV measures have been increasingly incorporated into Demographic and Health Surveys carried out in LMICs. Routine reporting and disaggregated analyses at country level are essential to identify populational subgroups that are particularly vulnerable to IPV exposure.MethodsWe examined data from 46 countries with surveys carried out between 2010 and 2017 to assess the prevalence and inequalities in recent psychological, physical and sexual IPV among ever-partnered women aged 15–49 years. Inequalities were assessed by disaggregating the data according to household wealth, women’s age, women’s empowerment level, polygyny status of the relationship and area of residence.ResultsNational levels of reported IPV varied widely across countries—from less than 5% in Armenia and Comoros to more than 40% in Afghanistan. Huge inequalities within countries were also observed. Generally, richer and more empowered women reported less IPV, as well as those whose partners had no cowives. Different patterns across countries were observed according to women’s age and area of residence but in most cases younger women and those living in rural areas tend to be more exposed to IPV.ConclusionThe present study advances the current knowledge by providing a global panorama of the prevalence of different forms of IPV across LMICs, helping the identification of the most vulnerable groups of women and for future monitoring of leaving no one behind towards achieving the elimination of all forms of violence among women and girls.
Carolina de Vargas Nunes Coll, Fernanda Ewerling, Franciele Hellwig, and Aluísio Jardim Dornellas de Barros
Springer Science and Business Media LLC
Rodolfo Gomez Ponce de Leon, Fernanda Ewerling, Suzanne Jacob Serruya, Mariangela F Silveira, Antonio Sanhueza, Ali Moazzam, Francisco Becerra-Posada, Carolina V N Coll, Franciele Hellwig, Cesar G Victora,et al.
Elsevier BV
Franciele Hellwig, Carolina VN Coll, Fernanda Ewerling, and Aluisio JD Barros
International Global Health Society
Background Universal access to family planning is key to extend its health and economic benefits worldwide. Our aim was to track progress in demand for family planning satisfied with modern methods (mDFPS) and its inequalities in low- and middle-income countries (LMICs). Methods Analyses were based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys carried out between 1993 and 2017 in 73 LMICs, using data for married women aged 15-49 years. We estimated trends in mDFPS coverage by country and world region and evaluated trends in wealth-based inequalities. The analyses pooling all countries together were stratified by wealth quintiles, area of residence and woman’s age. mDFPS coverage in 2030 for each country was predicted using a linear model. Results Overall, mDFPS increased and poor-rich gaps narrowed. Eastern & Southern Africa showed an average increase of 1.5 percentage points (p.p.) a year, being the region with the fastest progress. West & Central Africa had an increase in mDFPS of 1 p.p. a year but current coverage is still below 40%. Generally, inequalities were reduced, except for West & Central Africa and Europe & Central Asia where almost no change was observed. The country with the fastest progress in mDFPS was Rwanda, with an increase of 5 p.p./y, while Timor Leste had the fastest reduction in absolute inequality, less 3.8 p.p./y. Inequalities by area of residence were reduced, but large gaps remain. A similar trend was observed for different age groups. If the current trend is not accelerated, 44 countries will not achieve universal coverage in mDFPS by 2030. Conclusions Generally, mDFPS is increasing and inequalities are decreasing. However, progress is slow in some regions, especially West & Central Africa, where low coverage is combined with high levels of inequalities. Efforts to increase family planning coverage must be prioritized in countries where progress is slow or inexistent.
Aluísio J. D. Barros, Fernanda Ewerling, and Franciele Hellwig
American Medical Association (AMA)
In the context of the United Nations’ Sustainable Development Goals, it is not enough to make progress overall at the country level. Equity is central to these goals; thus, it is essential to guarantee that progress is achieved among every subgroup in the population so that no one is left behind. The article by Keats and colleagues1 presents a comprehensive analysis of inequalities for a set of reproductive, maternal, newborn, child, and adolescent health (RMNCAH) indicators that involve the whole continuum of care. The article used data from national health surveys to present an overview of the progress in coverage of health interventions in Kenya and evaluates the inequalities related to these indicators. Along with several other health indicators, the authors presented the composite coverage index (CCI), a summary measure that can be considered a proxy for universal health coverage with RMNCAH interventions. The CCI is a weighted average of 8 essential health interventions and covers the spectrum of the continuum of care, including indicators of reproductive health, maternal and child interventions, vaccination coverage, and the management of sick children. Absolute and relative inequalities are evaluated with the slope index of inequality and the concentration index, both of which take into account the coverage in all wealth quintiles, not only in the extremes. Absolute and relative inequality measures are considered complementary, and equity analyses should always present both.2 The authors also present geographical analyses that are extremely useful for policy makers. The north eastern region presented CCI coverage of less than 30% in all provinces, while in the central provinces coverage was greater than 70%. Finer geographical stratification would be desirable but is not usually available in these national health surveys. We urge the agencies that plan national health surveys to conduct the studies to be representative at smaller subnational levels than those currently used. Kenya presented substantial improvement in RMNCAH intervention coverage overall. But examining the equiplot presented in Keats et al1 in Figure 2, we can see that absolute inequalities remained largely unchanged. Unfortunately, this scenario is quite common in lowand middleincome settings—people living in rural areas and the poorest groups generally fare the worst in terms of health intervention coverage. In many settings, we can add to these groups illiterate or poorly educated people and marginalized minorities, including ethnic and religious groups.2,3 When coverage increases and equity is not built into the programs and policies, the first groups to be reached are usually the least vulnerable, further increasing the inequalities and leaving the most marginalized groups lagging.2 This is an inequality pattern called bottom inequality, which can be clearly seen for full immunization coverage in Kenya in 2014.1 The wealth-related inequalities observed for skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits are striking. Kenya has one of the highest levels of inequality in eastern and southern Africa, especially for rates of skilled birth attendance.3 These inequalities are further revealed by the analysis of intersectionality between wealth and residence. The results show that the poorest individuals living in rural areas lag the most in access to family planning, antenatal care, skilled birth attendants, and vaccines. The CCI summarizes this disadvantage well, showing that the rural poorest are roughly 20 percentage points behind the urban poorest. The global health monitoring community is increasingly interested in quality of care and not only in access to health services. Keats et al1 highlight that almost all women in Kenya had at least 1 + Related article
Fernanda Ewerling, Cesar G. Victora, Anita Raj, Carolina V. N. Coll, Franciele Hellwig, and Aluisio J. D. Barros
Springer Science and Business Media LLC
Inácio Crochemore Mohnsam da Silva, Maria Clara Restarepo-Mendez, Janaína Calu Costa, Fernanda Ewerling, Franciele Hellwig, Leonardo Zanini Ferreira, Luis Paulo Vidaletti Ruas, Gary Joseph, and Aluísio J. D. Barros
FapUNIFESP (SciELO)
This study aims to describe methodological approaches to measure and monitor health inequalities and to illustrate their applicability. The measures most frequently used in the literature were reviewed. Data on coverage and quality of antenatal care in Brazil, from the Demographic and Maternal and Child Health Survey (PNDS-2006) and from the National Health Survey (PNS2013), were used to illustrate their applicability. Absolute and relative measures of inequalities were presented, highlighting their complementary character. Despite the progress achieved at national level in antenatal care, important inequalities were still identified between population subgroups, with no change in the magnitude of the differences throughout the studied period. Brazil has important social inequalities, which consequently lead to health inequalities. Their description and monitoring are highly relevant to support polices focused on those vulnerable population groups who have been left behind.
Cesar Augusto Oviedo Tejada, Lívia Madeira Triaca, Flávia Katrein da Costa, and Franciele Hellwig
Public Library of Science (PLoS)
High fertility rates among disadvantaged subgroups are a public health problem because fertility levels significantly affect socioeconomic conditions and a population’s welfare. This paper aims to analyze the sociodemographic, behavioral, and reproductive factors associated with fertility rates among Brazilian women aged between 15–49 years. A Poisson regression was used to analyze data from the 2006 PNDS (Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher), which evaluates socioeconomic, demographic, geographic, reproductive, behavioral, and chronic disease variables. The results show that the following characteristics are positively associated with an increase in the number of children born: being aged 20–24, residing in the North, being nonwhite, not being in paid employment, having lower education levels, having lower socioeconomic status, being in a stable union, having the first sexual intercourse before the age of 16 and having the first child before the age of 20. Thus, it is important to implement efficient family planning policies targeting these subgroups in order to improve life conditions, reduce inequalities and avoid the adverse outcomes of high fertility.