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BACKGROUND: Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits. METHODS: To estimate the effect of womens exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries. RESULTS: Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics. CONCLUSIONS: The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

OBJECTIVE: Parental leave and breastfeeding breaks influence the ability to initiate and continue breastfeeding. We investigated how eligibility criteria in the Family and Medical Leave Act (FMLA) and Affordable Care Act (ACA) affect access to unpaid parental leave and breastfeeding breaks and assessed affordability and alternative policy models. METHODS: We used family income data to assess the affordability of unpaid leave by race and ethnicity. We used 2017-2018 US Current Population Survey data to determine the percentage of private sector workers aged 18-44 years who met the minimum hour (1250 hours of work during a 12-month period), tenure (12 months), and firm size (≥50 employees) requirements of FMLA and ACA. We analyzed eligibility by gender, race and ethnicity, and age. We also examined parental leave and breastfeeding break policies in 193 countries. RESULTS: Most Latinx (66.9%), Black (60.2%), and White (55.3%) workers were ineligible and/or unlikely to be able to afford to take unpaid FMLA leave. Of 69 534 workers, more women (16.9%) than men (10.3%) did not meet the minimum hour requirement. Minimum tenure excluded 23.7% of all workers and 42.2% of women aged 18-24 years. Minimum firm size excluded 30.3% of all workers and 37.7% of Latinx workers. Of 27 520 women, 28.8% (including 32.9% of Latina women) were excluded from ACA breastfeeding breaks because of firm size. Nearly all other countries guaranteed mothers paid leave regardless of firm size or minimum hours and guaranteed ≥6 months of paid leave or breastfeeding breaks. CONCLUSIONS: Adopting a comprehensive, inclusive paid parental leave policy and closing gaps in breastfeeding break legislation would remove work-related barriers to breastfeeding; reduce racial, ethnic, and gender inequities; and align US national policies with global norms.

In April 2020, nearly 1.6 billion learners were out of school. While a growing body of literature has documented the detrimental impact of these closures on children, less attention has been devoted to the steps countries took to mitigate the impact of these closures on working families. Paid leave is recognized as an important policy tool to enable working parents the time they need to respond to family needs without risking job or income loss. This article uses a novel data set to assess whether countries had policies in place prior to the pandemic to respond to increased care needs and the extent to which policies were introduced or expanded during the pandemic to fill the gap. Only 48 countries had policies in place prior to the pandemic that could be used to respond to the care needs created by school and childcare center closures. In the vast majority of these countries, the duration of leave in these policies was too short to meet the care needs of the pandemic or relied on parents reserving extended parental leave options. Only 36 countries passed new legislation during the pandemic, but the majority of those that did covered the full duration of closures. As countries continue to face COVID-19 and consider how to better prepare for the next pandemic, emergency childcare paid leave policies should be part of pandemic preparedness frameworks to prevent further exacerbating inequalities. The policies introduced during the pandemic offer a wide range of approaches for countries to identify feasible solutions.

Purpose: While only one aspect of fulfilling equal rights, effectively addressing workplace discrimination is integral to creating economies, and countries, that allow for everyone's full and equal participation. Design/methodology/approach: Labor, anti-discrimination, and other relevant pieces of legislation were identified through the International Labor Organization's NATLEX database, supplemented with legislation identified through country websites. For each country, two researchers independently coded legislation and answered questions about key policy features. Systematic quality checks and outlier verifications were conducted. Findings: More than 1 in 5 countries do not explicitly prohibit racial discrimination in employment. 54 countries fail to prohibit unequal pay based on race. 107 countries prohibit racial and/or ethnic discrimination but do not explicitly require employers to take preventive measures against discrimination. The gaps are even larger with respect to multiple and intersectional discrimination. 112 countries fail to prohibit discrimination based on both migration status and race and/or ethnicity; 103 fail to do so for foreign national origin and race and/or ethnicity. Practical implications: Both recent and decades-old international treaties and agreements require every country globally to uphold equal rights regardless of race. However, specific national legislation that operationalizes these commitments and prohibits discrimination in the workplace is essential to their impact. This research highlights progress and gaps that must be addressed. Originality/value: This is the first study to measure legal protections against employment discrimination based on race and ethnicity in all 193 UN countries. This study also examines protection in all countries from discrimination on the basis of characteristics that have been used in a number of settings as a proxy for racial/ethnic discrimination and exclusion, including SES, migration status, and religion.

This paper used longitudinal data from five studies conducted in Bangladesh, Bhutan, Cambodia, Ethiopia, and Rwanda to examine the links between family stimulation and early childhood development outcomes (N = 4904; M[subscript age] = 51.5; 49% girls). Results from random-effects and more conservative child-fixed effects models indicate that across these studies, family stimulation, measured by caregivers' engagement in nine activities (e.g., reading, playing, singing), predicted increments in children's early numeracy, literacy, social-emotional, motor, and executive function skills (standardized associations ranged from 0.05 to 0.11 SD). Study-specific models showed variability in the estimates, with null associations in two out of the five studies. These findings indicate the need for additional research on culturally specific ways in which caregivers may support early development and highlight the importance of promoting family stimulation to catalyze positive developmental trajectories in global contexts.

This review focuses on answering the research question: What can we learn from studies of interventions to address the implementation of inclusive education of students with disabilities in low- and lower middle-income countries? A systematic literature review was conducted to identify studies focused on interventions aiming to improve inclusive education in low- and lower-middle-income countries. The searches returned 1,266 studies for a title and abstract review. Only 31 studies evaluated interventions and included 20 or more respondents. Published between 2000 and 2019, these studies estimate the impact of a number of approaches that can be used to increase support for students with disabilities in general education settings including teacher trainings, improving facilities and educational materials, and forming partnerships within the community. Covering 19 of 84 low- and lower-middle-income countries, this systematic review underscores the limited amount of work on this critical topic and the need for further research.

Long-term PM2.5 exposure might predispose populations to SARS-CoV-2 infection and intervention policies might interrupt SARS-CoV-2 transmission and reduce the risk of COVID-19. We conducted an ecologic study across the United States, using county-level COVID-19 incidence up to 12 September 2020, to represent the first two surges in the U.S., annual average of PM2.5 between 2000 and 2016 and state-level facemask mandates and stay home orders. We fit negative binomial models to assess COVID-19 incidence in association with PM2.5 and policies. Stratified analyses by facemask policy and stay home policy were also performed. Each 1-µg/m3 increase in annual average concentration of PM2.5 exposure was associated with 7.56% (95% CI: 3.76%, 11.49%) increase in COVID-19 risk. Facemask mandates and stay home policies were inversely associated with COVID-19 with adjusted RRs of 0.8466 (95% CI: 0.7598, 0.9432) and 0.9193 (95% CI: 0.8021, 1.0537), respectively. The associations between PM2.5 and COVID-19 were consistent among counties with or without preventive policies. Our study added evidence that long-term PM2.5 exposure increased the risk of COVID-19 during each surge and cumulatively as of 12 September 2020, in the United States. Although both state-level implementation of facemask mandates and stay home orders were effective in preventing the spread of COVID-19, no clear effect modification was observed regarding long-term exposure to PM2.5 on the risk of COVID-19.

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

BACKGROUND:It is widely recognized that there are multiple risk factors for early-life mortality. In practice most interventions to curb early-life mortality target births based on a single risk factor, such as poverty. However, most premature deaths are not from the targeted group. Thus interventions target many births that are at not at high risk and miss many births at high risk. METHODS:Using data from the second wave of Demographic and Health Surveys from India and a hierarchical Bayesian model, we estimate infant mortality risk for 73.320 infants in India as a function of 4 risk factors. We show how this information can be used to improve program targeting. We compare our novel approach against common programs that target groups based on a single risk factor. RESULTS:A conventional approach that targets mothers in the lowest quintile of income correctly identifies only 30% of infant deaths. By contrast, using four risk factors simultaneously we identify a group of births of the same size that includes 57% of all deaths. Using the 2012 census to translate these percentages into numbers, there were 25.642.200 births in 2012 and 4.4% died before the age of one. Our approach correctly identifies 643.106 of 1.128.257 infant deaths while poverty only identifies 338.477 infant deaths. CONCLUSION:Our approach considerably improves program targeting by identifying more infant deaths than the usual approach that targets births based on a single risk factor. This leads to more efficient program targeting. This is particularly useful in developing countries, where resources are lacking and needs are high.

Observational data collected prior to the pandemic (between 2004 and 2019) were used to simulate the potential consequences of early childhood care and education (ECCE) service closures on the estimated 167 million preprimary-age children in 196 countries who lost ECCE access between March 2020 and February 2021. COVID-19-related ECCE disruptions were estimated to result in 19.01 billion person-days of ECCE instruction lost, 10.75 million additional children falling "off track" in their early development, 14.18 million grades of learning lost by adolescence, and a present discounted value of USD 308.02 billion of earnings lost in adulthood. Further burdens associated with ongoing closures were also forecasted. Projected developmental and learning losses were concentrated in low- and lower middle-income countries, likely exacerbating long-standing global inequities.

This article provides an analysis of laws across all 193 United Nations countries that protect workers from discrimination in access to employer-provided training. We assessed the overall level of protection and the characteristics most commonly protected, as well as the extent of variation across geographic regions and country income. Overall, 60% of countries were found to offer specific protections from discrimination in access to training for at least one of the seven protected characteristics, which was significantly less than the percentage of countries offering protections from discriminatory hiring or terminations. Gender was the most commonly protected characteristic, whereas sexual orientation was least commonly protected. These findings suggest that employer-provided training is less well-protected from discrimination when compared with other aspects of employment and that there is variation in protection across socio-demographic characteristics and geographic regions. Additional legislation may be needed to ensure equitable access to training for all workers.

ObjectiveTo examine changes in minimum wage associated with changes in women's weight status.DesignLongitudinal study of legislated minimum wage levels (per month, purchasing power parity-adjusted, 2011 constant US dollar values) linked to anthropometric and sociodemographic data from multiple Demographic and Health Surveys (2000-2014). Separate multilevel models estimated associations of a $10 increase in monthly minimum wage with the rate of change in underweight and obesity, conditioning on individual and country confounders. Post-estimation analysis computed predicted mean probabilities of being underweight or obese associated with higher levels of minimum wage at study start and end.SettingTwenty-four low-income countries.SubjectsAdult non-pregnant women (n 150 796).ResultsHigher minimum wages were associated (OR; 95 % CI) with reduced underweight in women (0·986; 0·977, 0·995); a decrease that accelerated over time (P-interaction=0·025). Increasing minimum wage was associated with higher obesity (1·019; 1·008, 1·030), but did not alter the rate of increase in obesity prevalence (P-interaction=0·8). A $10 rise in monthly minimum wage was associated (prevalence difference; 95 % CI) with an average decrease of about 0·14 percentage points (-0·14; -0·23, -0·05) for underweight and an increase of about 0·1 percentage points (0·12; 0·04, 0·20) for obesity.ConclusionsThe present longitudinal multi-country study showed that a $10 rise in monthly minimum wage significantly accelerated the decline in women's underweight prevalence, but had no association with the pace of growth in obesity prevalence. Thus, modest rises in minimum wage may be beneficial for addressing the protracted underweight problem in poor countries, especially South Asia and parts of Africa.

The marriage of children below 18 is widely recognized in international human rights agreements as a discriminatory global practice that hinders the development and well-being of hundreds of millions of girls. Using a new global policy database, we analyze national legislation regarding minimum marriage age, exceptions permitting marriage at earlier ages, and gender disparities in laws. While our longitudinal data indicate improvements in frequencies of countries with legal provisions that prohibit marriage below the age of 18, important gaps remain in eliminating legal exceptions and gender discrimination.

BackgroundThe Sustainable development goals (SDGs) have the potential to have a significant impact on maternal and child health through their commitments both to directly addressing health services and to improving factors that form the foundation of social determinants of health. To achieve change at scale, national laws and policies have a critical role to play in implementing the SDGs' commitments. One particular policy that could advance a range of SDGs and importantly improve maternal and infant health is paid parental leave.MethodsThis article analyzes literature on paid leave and related policies relevant to SDG 1 (poverty), SDG 3 (health), SDG 5 (gender equality), SDG 8 (decent work), and SDG 10 (inequality). In addition, this article presents global data on the prevalence of policies in all 193 UN Member States.ResultsA review of the literature finds that paid parental leave may support improvements across a range of SDG outcomes relevant to maternal and child health. Across national income levels, paid leave has been associated with lower infant mortality and higher rates of immunizations. In high-income countries, studies have found that paid leave increases exclusive breastfeeding and may improve women's economic outcomes. However, factors including the duration of leave, the wage replacement rate, and whether leave is made available to both parents importantly shape the impacts of paid leave policies. While most countries now offer at least some paid maternal leave, many provide less than the 6 months recommended for exclusive breastfeeding, and only around half as many provide paternal leave.ConclusionsTo accelerate progress on the SDGs' commitments to maternal and child health, we should monitor countries' actions on enacting or strengthening paid leave policies. Further research is needed on the duration, wage replacement rate, and availability of leave before and after birth that would best support both child and parental health outcomes and social determinants of health more broadly. In addition, further work is needed to understand the extent to which paid leave policies extend to the informal economy, where the majority of women and men in low- and middle-income countries work.

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

BackgroundResearch exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent. This study aimed to identify and examine the interaction between structural, organisational and relational factors influencing Zambian women prisoners' health and healthcare access.MethodsWe conducted in-depth interviews of 23 female prisoners across four prisons, as well as 21 prison officers and health care workers. The prisoners were selected in a multi-stage sampling design with a purposive selection of prisons followed by a random sampling of cells and of female inmates within cells. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems.ResultsWe identified compounding and generally negative effects on health and access to healthcare from three factors: i) systemic health resource shortfalls, ii) an implicit prioritization of male prisoners' health needs, and iii) chronic and unchecked patterns of both officer- and inmate-led victimisation. Specifically, women's access to health services was shaped by the interactions between lack of in-house clinics, privileged male prisoner access to limited transport options, and weak responsiveness by female officers to prisoner requests for healthcare. Further intensifying these interactions were prisoners' differential wealth and access to family support, and appointments of senior 'special stage' prisoners which enabled chronic victimisation of less wealthy or less powerful individuals.ConclusionsThis systems-oriented analysis revealed how Zambian women's prisoners' health and access to healthcare is influenced by weak resourcing for prisoner health, administrative biases, and a prevailing organisational and inmate culture. Findings highlight the urgent need for investment in structural improvements in health service availability but also interventions to reform the organisational culture which shapes officers' understanding and responsiveness to women prisoners' health needs.

Disability-inclusive laws and policies – while not sufficient on their own to advance substantive equality – are an essential step that all countries can take to advance non-discrimination and equity in education for children and youth with disabilities. This is the first study to comprehensively review national law and policy guarantees in 193 countries to assess the extent to which countries have harmonized national laws and policies with international commitments to inclusive education articulated in the Convention on the Rights of Persons with Disabilities and the Sustainable Development Goals. While strong guarantees exist across diverse countries, we find that notable gaps remain. Forty-six percent of countries do not broadly prohibit disability-based discrimination through the completion of secondary education. Legislation in 35% of countries does not guarantee persons with disabilities access to integrated education in mainstream education environments along with necessary individualized accommodations through the completion of secondary school. Thirty-one percent of countries that make primary education compulsory do not pair compulsory education with guarantees to integration in mainstream education environments and individualized supports for students with disabilities. These findings can inform reforms in countries without national guarantees and bolster support for implementation in countries where strong legal guarantees to inclusive education already exist. [ABSTRACT FROM AUTHOR]