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Research calls for the sexual and reproductive rights field to prioritize gender norms to ensure that women can act on their reproductive rights. However, there is a gap in accepted measures. We addressed this by including important theoretical components of gender norms: differentiating between descriptive and injunctive norms and adding a referent group. Our team originally developed and validated the G-NORM, a gender norms scale, in India. In this paper, we describe how we subsequently adapted and validated it in Nepal. We administered items to women of reproductive age, conducted exploratory and confirmatory factor analysis, and examined associations between the subscales and reproductive health outcomes. Like the original G-NORM, our factor analyses showed that descriptive norms and injunctive norms comprise two distinct scales which fit the data well and had Cronbach alphas of 0.92 and 0.89. More equitable descriptive gender norms were associated with higher decision-making scores, increased odds of intending to use family planning, disagreeing that it is wrong to use family planning, and older ideal age at marriage. Injunctive gender norms were only associated with disagreeing that it is wrong to use family planning. Findings offer an improved measure of gender norms in Nepal and provide evidence that gender norms are critical for agency and reproductive health outcomes.

Access to safe abortion is a reproductive rights and justice issue, and it is imperative that safe abortion access during and after the COVID-19 pandemic is a reality for all. India imposed a lockdown in March 2020 to contain the spread of the pandemic. Limited mobility, lack of clarity about abortion as an essential service and abortion as a service permitted through telemedicine, shut down of services providing long-acting and permanent methods of contraception, and changes to decision-making about birthing and parenting during a pandemic are factors that may impact the demand for abortion during and after the lockdown. Shortage of raw materials and limited inter- and intra- state transport of drugs may result in breakages in the supply of medication abortion. Given that 73 percent of abortions in India in 2015 occurred outside of health facilities, the pandemic may have several implications on the need for evidence-based information and quality abortion services, as well as if and how medication abortion is accessed in India, and what self-managed abortion looks like in the COVID-19 era. We discuss factors contributing to reduced access to abortion, changes in abortion need, and suggest strategies to respond to an increased demand for abortion in India.

Despite recognition that person-centered care is a critical component to providing high quality family planning services, there lacks consensus on how to operationalize and measure it. This paper describes the development and validation of a person-centered family planning (PCFP) scale in India and Kenya. Cross-sectional data were collected from 522 women in Kenya and 225 women in India who visited a health facility providing family planning services. Psychometric analyses, including exploratory factor analysis, were employed to assess the validity and reliability of the PCFP scale. Separate scales were developed for India and Kenya due to context-specific items. We assessed criterion validity by examining the association between PCFP and global measures of quality and satisfaction with family planning care. The analysis resulted in a multidimensional PCFP scale, including 20 items in Kenya and 22 items in India. Through iterative factor analysis, two subscales were identified for both countries: \"autonomy, respectful care, and communication\" and \"health facility environment.\" This scale may be used to evaluate quality improvement interventions and experiences of women globally to support women in achieving their reproductive health goals.

Women's nutritional status remains poor in South Asia, impacting maternal and infant health outcomes. Women's household status is also low, as evidenced by eating behaviours. We started with triadic qualitative interviews with newly married women, husbands and mothers‐in‐law to explore the link between women's status and eating patterns, followed by longitudinal data from a cohort of 200 newly married women in rural Nepal to measure associations over time. Quantitative data were collected every 6 months for 18 months (four rounds of data) between 2018 and 2020. Interviews suggested that household relationships, women's status, and how much and what types of food she was given were intricately linked. Using mixed effects logistic regression models, we explore the association between markers of changing women's status (becoming pregnant, giving birth and working outside the home) on two outcomes (eating last always/usually and achieving minimum dietary diversity). We also explore for interaction between women's status and household food insecurity. Pregnancy increases women's dietary diversity, but this is not sustained post‐partum. Women who work outside the home are less likely to eat last in the household. Food insecurity is associated with both the order of household eating and dietary diversity. Interactions between food insecurity and giving birth suggested that women who give birth in food insecure households are more likely to eat last in the household. Changes in women's household status are associated with some improvements in dietary diversity and order of household eating, but the associations are not long‐lasting and depend on food security status. Women's status measured by pregnancy or work outside the home may be associated with access to food and nutrition. We find that changes in women's household status are associated with some improvements in dietary diversity and order of household eating, but the associations are not long‐lasting and depend on food security status. Key messages Newly married women in rural Nepal face low dietary diversity, often eat last, and this does not improve over the first few years of marriage. Although pregnancy does improve dietary diversity, this does not remain post‐partum. Working outside the home does appear to lead women to not eat last as frequently. Food insecurity is the most important factor contributing to dietary diversity and order of household eating.

Eating last is a gendered cultural norm in which the youngest daughters‐in‐law are expected to eat last after serving others in the household, including men and in‐laws. Using women's eating last as an indicator of women's status, we studied the association between eating last and women's mental health. Using four rounds of prospective cohort data of 18–25‐year‐old newly married women (n = 200) cohabiting with mothers‐in‐law between 2018 and 2020 in the Nawalparasi district of Nepal, we examined the association between women eating last and depressive symptom severity (measured using 15‐item Hopkins Symptom Checklist for Depression; HSCL‐D). Twenty‐five percent of women reported eating last always. The prevalence of probable depression using the established cutoff was 5.5%, consistent with the prevalence of depression in the general population. Using a hierarchical mixed‐effects linear regression model, we found that women who always ate last had an expected depressive symptom severity (0–3 on HSCL‐D) 0.24 points (95% confidence interval [CI]: 0.13–0.36) greater compared to women who did not eat last when adjusted for demographic variables, household food insecurity, and secular trends. Sensitivity analysis using logistic regression also suggested that women who eat last have greater odds of having probable depression (adjusted odds ratio [AOR] = 4.05; 95% CI: 1.32–12.44). We explored if the association between eating last and depressive symptom severity was moderated by household food insecurity and did not observe evidence of moderation, underscoring the significance of eating last as a woman's status indicator. Our study findings highlight that newly young married women in Nepal are a vulnerable group. Key points/highlights Newly married women in rural Nepal face harmful gender norms, such as eating last in the family, which does not improve over the first 2 years of marriage. In patrilocal societies like Nepal, newly married women often occupy the lowest status in the household, and eating last is a reflection of their low status. Women who eat last in the household experience greater depressive symptoms, irrespective of their household food insecurity status. The low status of women and harmful gender norms place them in situations that are detrimental to their mental health and well‐being.

Introduction Social support in pregnancy and postpartum is important for optimizing maternal and infant health. Group prenatal care offers the opportunity for in-person social support yet does not extend into the postpartum period. Mobile social support models may further meet the needs of pregnant individuals and partners during pregnancy and into the postpartum period. However, the use and utility of mobile social support for pregnant people and their partners in the context of group prenatal care and beyond has not been studied. Assessing Centering patients’ utilization of existing social media platforms can inform programmatic development. Methods We conducted a retrospective cross-sectional study among recent participants of UCSF’s Centering Pregnancy ® program and their partners. Study participants were recruited through UCSF’s electronic health record system or direct email and partners were recruited through referral from participants. Online surveys sought to understand participant perspectives on mobile groups, educational and social support needs, and recommendations. Results Participants gave birth between 2018 and 2021 (68%), were college-educated (97.3%), and regularly accessed social media (> 75% across platforms). Most participants engaged in Centering Pregnancy ® online communications outside of formal activities (79% during pregnancy, 74% postpartum) for social support (78.1%) and knowledge sharing (65.2%). Most posted content monthly (54.6%) but read content more frequently (48.0% at least weekly). Communication frequency and topics changed with the COVID-19 pandemic. Respondents wanted more information on infant sleep (42.6%), maternal recovery/health (38.7%), breastfeeding/formula feeding (37.4%), newborn health and care (34.2%), and child development (27.1%). Social group engagement was higher for individuals reporting depressive or anxiety symptoms during pregnancy and postpartum. Discussion The findings confirm the importance of social support, especially postpartum, for health, how mobile support groups can impact these outcomes, and needs and areas of improvement for group prenatal care. Integration of a social media support component to the evolving post-COVID Centering Pregnancy ® model may be an important addition to improve participating parent wellbeing.

It has been hypothesized that uneven sex ratios in the population could lead to increased violence. The objective of this analysis is to explore the relationship between uneven sex ratios in the population and violence. This analysis uses data collected from men in six Asian countries about their experiences and perpetration of violence. We combine this with region- and age specific sex ratios calculated from Census data to explore the relationship between sex ratios and violence using multilevel models. We find that men from region-age brackets with higher ratios of men to women are significantly more likely to report ever having raped a woman, having perpetrated intimate partner violence, or having used a weapon. We find no evidence for an association between sex ratios and reports of ever having raped a man.

Lower empowerment of women is a critical social issue with adverse public health implications. In India, deeply ingrained gender norms shape a patriarchal structure that creates systemic disadvantages for women relative to men. These gender norms-socially constructed expectations about the roles, behaviors, and attributes of men and women-perpetuate inequality and limit women's opportunities. The aim of this study was to examine the association between community-level men's and women's gender norms on women's empowerment in India. Women's empowerment was defined using four measures: freedom of movement, decision-making power, economic empowerment, and health empowerment. Using a nationally representative demographic health survey data from 2019-21 of 63,112 married women who participated in the women's empowerment module and 101,839 men surveyed, we constructed community-level men's and women's inequitable gender norms variables as our independent variable using attitudes towards wife-beating questions. We used random effects logistic regression models to examine if community-level men's and women's inequitable gender norms were independently associated with the different dimensions of women's empowerment. One standard deviation increase in community-level men's and women's inequitable gender norms was associated with reduced odds of freedom of movement, decision-making power, and health empowerment. No statistically significant association was observed between community-level men's and women's gender norms and economic empowerment. Inequitable gender norms are a risk factor that is negatively associated with several dimensions of women's empowerment. Our findings support our hypotheses that women's empowerment is impacted separately by men's and women's gender norms. Our study underscores the pressing need for concerted efforts to challenge and transform inequitable gender norms, paving the way for achieving gender equality and women's empowerment, as envisioned by the Sustainable Development Goals.

Introduction Extensive evidence suggests that family planning programs are second only to education in providing returns on dollars spent with improvements in long-term maternal and child health outcomes. However, no current research synthesis to date has robustly examined whether use of family planning results in increased empowerment and greater agency of women, despite theoretical, but not empirical, support that family planning influences this outcome as well. Our objective was to conduct a systematic review of the evidence on how women’s access to and/or use of family planning methods impacts their agency and empowerment, including mechanisms and effect modifiers important to this relationship. Methods We searched 20 global and regional databases for interventional and observational research published from January 2000 through January 2022 which reviewed the relationship between family planning use and subsequent women’s empowerment. Titles/abstracts and full-text articles were screened in duplicate, and key data were extracted using a standardized form. We evaluated risk of bias using the Newcastle-Ottawa Scale and rated the certainty of evidence for four outcomes (decision-making, labor force participation, wages, and schooling) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Findings were analyzed and summarized in both tabular and narrative format. Results We identified 3,170 articles after de-duplication, of which 14 quantitative and three qualitative studies met inclusion criteria. Studies were in both high income and low- and middle-income countries, with the largest proportion being from South Asia. Studies ranged from randomized controlled trials of programs at the community level to quasi-experimental studies of policies. The GRADE framework yielded low and very low confidence in the findings. Outcomes were categorized into domains using Kabeer’s framework of Resources, agency and achievements. Most studies measured the impact of family planning on resources or agency. Combining measures across all domains of empowerment, 47% had positive, 39% null, and 14% negative results. Discussion Overall, this systematic review suggests that family planning access has a positive impact on a variety of empowerment measures across different domains of empowerment. However, the quality ratings indicate that while our synthesis suggests potential benefits of family planning for women’s empowerment, the current evidence base provides limited confidence for definitive conclusions. One of the main challenges in understanding the impact of family planning on empowerment is the diversity of conceptualizations and measures of empowerment used. In addition, the geographic coverage of studies was limited to few countries, with only one study from Latin America. Further research using a process-oriented measure of empowerment comparable across contexts could add to our understanding. In addition to being a fundamental human right, investing in family planning likely contributes to women’s empowerment in multiple domains.

Background Significant disruptions in the perinatal continuum of care occur postpartum in India, despite it being a critical time to optimize maternal health and wellbeing. Group-oriented mHealth approaches may help mitigate the impact of limited access to care and the lack of social support that characterize this period. Our team developed and pilot tested a provider-moderated group intervention to increase education, communication with providers, to refer participants to in-person care, and to connect them with a virtual social support group of other mothers with similarly aged infants through weekly calls and text chat. Methods We analyzed the preliminary effectiveness of the pilot intervention on maternal health knowledge through 6 months postpartum among 135 participants in Punjab, India who responded to baseline and endline surveys. We described change in knowledge of maternal danger signs, birth preparedness, postpartum care use, postpartum physical and mental health, and family planning use over time between individuals in group call (synchronous), other intervention (asynchronous), and control groups. Results Participant knowledge regarding danger signs was low overall regarding pregnancy, childbirth and the postpartum period (mean range of 1.13 to 2.05 at baseline and 0.79 to 2.10 at endline). Synchronous participants had a significantly higher increase over time in knowledge of danger signs than asynchronous and control group participants. Birth preparedness knowledge ranged from mean 0.89–1.20 at baseline to 1.31–2.07 at follow-up, with synchronous participants having significantly greater increases in comparison to the control group. Synchronous participants had nearly three-fold increased odds of postpartum health check with a clinical provider than asynchronous participants (OR 2.88, 95% CI 1.07–7.74). No differences were noted in postpartum depressive and anxiety symptoms. Conclusions Preliminary effectiveness results are promising, yet further robust testing of the MeSSSSage intervention effectiveness is needed. Further development of strategies to support health knowledge and behaviors and overcoming barriers to postpartum care access can improve maternal health among this population.