School of Public Health

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The collections in this community comprise faculty research works, as well as graduate theses and dissertations.

Note: Prior to July 1, 2007, the School of Public Health was named the College of Health & Human Performance.

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    WOMEN’S AUTONOMY AND REPRODUCTIVE AND PERINATAL HEALTH OUTCOMES IN AFGHANISTAN
    (2024) Ibrahimi, Sahra; Thoma, Marie; Family Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    Studies show that women’s autonomy (WA)--as measured by household decision making, healthcare decision making, and permission to go out--facilitates access to resources, including education, employment, and healthcare resources. In return, these resources determine maternal and child health. Prior studies, conducted in countries other than Afghanistan, have resulted in inconsistent findings because the degree and direction of the association between WA and health outcomes differ among countries based on their laws and cultural context. There is no research examining the impact of WA on reproductive and perinatal health outcomes in Afghanistan. Conducting this research in Afghanistan is critical given the country’s unique political and socio-cultural environment that shape its population health. For instance, less than one in two of Afghan women make decisions about their healthcare, while 53% of them have experienced physical domestic violence. The 2021 ruling of the country by the Taliban has exacerbated the violation of women’s rights in Afghanistan, making the examination of the impact of WA on reproductive health outcomes even more pertinent. My dissertation addresses these gaps in the literature by examining the association between women’s autonomy and 1. experience of domestic violence types (physical, sextual, and emotional), 2. unintended pregnancy, and 3. pregnancy loss. I also assess the moderating effect of education on the association of WA and domestic violence, and the mediating effect of domestic violence on the association of WA and unintended pregnancy and pregnancy loss. I used data from 19,098 married women aged 15-49, who completed the 2015 Afghanistan Demographic and Health Survey- the first and only national survey administered in the country. WA was measured across 5 domains (healthcare, visiting family, household purchases, spending, and contraceptive use). Adjusted odds ratios and 95% confidence intervals for the association between WA and the outcomes of interest were estimated using multiple logistic regression and adjusted for relevant confounders including age, ethnicity, education, wealth, residency, and parity. Additionally, to assess moderation and mediation, interaction terms and casual mediation models were used for each respective analysis. I found that about one in two Afghan women did not have autonomy in making decisions and experienced domestic violence, and approximately one in ten women experienced unintended pregnancy and pregnancy loss. In Aim 1, in the adjusted Model 2 (adjusting for confounders), women’s autonomy in healthcare decisions (Adjusted odds ratio [AOR]=0.70, CI: 0.60-0.81), spending (AOR=0.58, CI: 0.51-0.66), visiting families (AOR=0.69, CI: 0.60-0.80), household purchases (AOR=0.59, CI: 0.52-0.68), and not using contraception (AOR=0.66, CI: 0.46-0.93) were significantly associated with decreased experience of physical violence. In addition, women’s autonomy in healthcare decisions (AOR = 0.51, 95% CI: 0.39-0.65), spending (AOR=0.62, CI: 0.48-0.80), and household purchases (AOR=0.56, CI: 0.43-0.72) were significantly associated with decreased experience of sexual violence. Lastly, women’s autonomy in healthcare (AOR=0.82, CI: 0.72-0.94), spending (AOR=0.61, CI: 0.53-0.71), visiting families (AOR=0.79, CI: 0.70-0.88), and not using contraception (AOR=0.58, CI: 0.42-0.80) were significantly associated with decreased experience of emotional violence. We also found a greater protective effect of WA in visiting family among women with some education (vs. no education) across each domestic violence outcome. In Aim 2, Model 2, women’s autonomy in healthcare decisions (AOR=0.87, CI: 0.77 - 0.97) and spending (AOR=0.86, CI: 0.76 - 0.97) were significantly associated with decreased experience of unintended pregnancy. However, women’s autonomy in visiting families (AOR=1.15, CI: 1.02 - 1.29) was associated with slightly increased experience of unintended pregnancy. This association was partially mediated by physical and sexual domestic violence (21% of total effect mediated by domestic violence) in that the reduction of violence with WA attenuated the effect of WA on unintended pregnancy. Lastly, in Aim 3, Model 2, women’s autonomy in healthcare decisions (AOR=0.86, CI: 0.78 - 0.95), household purchases (AOR=0.87, CI: 0.79 - 0.97), and visiting families (AOR=0.90, CI: 0.82 - 1.00), were significantly associated with decreased experience of pregnancy loss. Some of the protective effects of autonomy in healthcare (18%) and household purchase (15%) on pregnancy loss were mediated through reduced experience of domestic violence during pregnancy. Beyond filling the gap in the literature, this study provides evidence and brings awareness (about the impact of the lack of women’s autonomy on adverse health outcomes) that is needed to urge policymakers and program implementers in targeting and improving women’s autonomy and health outcomes in Afghanistan. The findings of this study can also be translated into Dari and Pashto and be shared with the general public in Afghanistan. Interventions that may improve women’s autonomy and health outcomes in Afghanistan, such as establishing laws about women’s rights, granting access to education, awareness campaigns, microfinancing, and community-based distribution programs, could foster gender equity and improve maternal and child health – moving to more sustainable development, consistent with Sustainable Development Goal (SDG) 3 and 5.
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    DOMESTIC VIOLENCE EXPOSURE, MATERNAL EDUCATION, AND MATERNAL AUTONOMY AS PREDICTORS OF INDIAN WOMEN'S USE OF MATERNAL HEALTH SERVICES AND INFANT LOW BIRTH WEIGHT
    (2015) Duggal, Mili; Koblinsky, Sally A; Family Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    India contributes disproportionately to the world's maternal mortality ratio and rate of infant low birth weight. Securing adequate antenatal care and delivery in a hospital or health facility are key strategies aimed at improving India's maternal and infant health outcomes. This study utilized the National Family Health Survey-3 (NFHS-3) to investigate predictors of Indian women's use of maternal health care services and delivery of a low birth weight infant. The ecological model of health was used to examine how the individual level factor of maternal education and the relationship level factors of women's domestic violence exposure and maternal autonomy were related to maternal and infant outcomes. Specifically, the study examined the role of physical violence, psychological violence, sexual violence, maternal education, and maternal autonomy in predicting women's receipt of adequate antenatal care, institutional delivery, and likelihood of delivering a low birth weight child. The study utilized NFHS-3 data from 2005-06 with a sample of 4,983 Indian women who gave birth in the previous year. This survey was the first to include a module addressing three different types of domestic violence exposure within the marital relationship. Findings revealed that 19% of women reported experiencing physical violence, 10% reported psychological violence, and 8% reported sexual violence in the previous year. Multivariate logistic regression analyses examined the association between the targeted maternal variables and women's use of maternity health services and infant low birth weight. Domestic violence emerged as a risk factor, with physical violence predicting less adequate antenatal care and higher likelihood of low infant birth weight. Psychological violence predicted lower likelihood of adequate antenatal care and institutional delivery, and sexual violence was associated with a lower likelihood of institutional delivery. In contrast, both maternal education and maternal autonomy emerged as protective factors. Maternal education was predictive of adequate antenatal care, institutional delivery, and lower likelihood of infant low birth weight, while maternal autonomy predicted institutional delivery and lower likelihood of delivering a low birth weight infant. Implications of the findings for policy makers, public health practitioners, and educators seeking to improve maternal and infant outcomes in India are discussed.