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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.

Fewer adolescents achieve viral suppression compared to adults. One impediment may be a history of adverse childhood experiences (ACEs). To better develop targets and timeframes for intervention, this study created more robust estimates of the impact of cumulative adversity on viral suppression, tested whether the association is sensitive to the timing of adversity, and simultaneously tested several potential mechanisms. We focus on males, who have lower viral suppression than females and who may contribute to disproportionate incidence among young women. We recruited 251 male perinatally HIV-infected adolescents aged 15–19 from HIV clinics in Soweto, South Africa. Adversity was captured using the Adverse Childhood Experience – International Questionnaire (ACE-IQ). Viral load was measured using blood samples; viral suppression was defined as <20 copies/mL. Indicators of medication adherence, depression, post-traumatic stress disorder (, and substance misuse were captured. A series of pathway analysis were performed. Our sample experienced a median of 7 lifetime and 4 past-year adversities. Less than half (44%) exhibited viral suppression. Adversity demonstrated a significant association with suppression; depression mediated the association. Primary prevention of adversity among children living with HIV is paramount, as is addressing the subsequent mental and behavioral health challenges that impede viral suppression among adolescents. [ABSTRACT FROM AUTHOR]

Young people who have lost parents to the pandemic need urgent support and long-term study to avert the cascade of adversity that can follow. Decades of research into the HIV epidemic provide a solid foundation. Young people who have lost parents to the pandemic need urgent support and long-term study to avert the cascade of adversity that can follow. Decades of research into the HIV epidemic provide a solid foundation., Author(s): Rachel Kidman Author Affiliations: Use HIV's lessons to help children orphaned by COVID-19 Three siblings from Pattapur in eastern India are among the thousands of children who have lost [...]

Child marriage has adverse consequences for young girls. Cross-sectional research has highlighted several potential drivers of early marriage. We analyse drivers of child marriage using longitudinal data from rural Malawi, where rates of child marriage are among the highest in the world despite being illegal. Estimates from survival models show that 26% of girls in our sample marry before age 18. Importantly, girls report high decision-making autonomy vis-à-vis the decision to marry. We use multivariate Cox proportional hazard models to explore the role of 1) poverty and economic factors, 2) opportunity or alternatives to marriage, 3) social norms and attitudes, 4) knowledge of the law and 5) girls’ agency. Only three factors are consistently associated with child marriage. First, related to opportunities outside marriage, girls lagging in school at survey baseline have significantly higher rates of child marriage than their counterparts who were at or near grade level. Second, related to social norms, child marriage rates are significantly lower among respondents whose caregivers perceive that members of their community disapprove of child marriage. Third, knowledge of the law has a positive coefficient, a surprising result. These findings are aligned with the growing qualitative literature describing contexts where adolescent girls are more active agents in child marriages. [ABSTRACT FROM AUTHOR]

One in five child deaths under age 5 are a result of severe wasting. Malnutrition at early ages is linked to lifelong consequences, such as reduced cognitive skills, reduced earnings in adulthood and chronic health conditions. Countries worldwide have committed to addressing child undernutrition, and ending hunger is foundational to the Millennium Development Goals. In this paper, we study the intergenerational effect of providing free tuition in secondary school on future children’s nutrition. We combined a novel longitudinal dataset that captures educational policies for 40 African countries from 1990 to 2019 with the Demographic and Health Survey (DHS). We identified three countries that introduced free secondary education several years after implementing free primary education. Exploiting this variation in timing we estimate the additional impact of providing free secondary education over free primary education. Using a difference-in-difference approach, we find that introducing free secondary education significantly reduced wasting. Cohorts exposed to free secondary had an 18% relative decrease in wasting. The impact on cohorts exposed only to free primary was smaller and not statistically significant. Expanding free secondary education has long-term, intergenerational benefits and is an effective path to reducing malnutrition. Results are robust to different specifications. [ABSTRACT FROM AUTHOR]

There are an estimated 15 million AIDS orphans worldwide. Families play an important role in safeguarding orphans, but they may be increasingly compromised by the HIV/AIDS epidemic. The international aid community has recognized the need to help families continue caring for orphaned children by strengthening their safety nets. Before we build new structures, however, we need to know the extent to which community and public safety nets already provide support to families with orphans. To address this gap, we analyzed nationally representative data from 27,495 children in the 2004-2005 Malawi Integrated Household Survey. We found that communities commonly assisted orphan households through private transfers; organized responses to the orphan crisis were far less frequent. Friends and relatives provided assistance to over 75% of orphan households through private gifts, but the value of such support was relatively low. Over 40% of orphans lived in a community with support groups for the chronically ill and approximately a third of these communities provided services specifically for orphans and other vulnerable children. Public programs, which form a final safety net for vulnerable households, were more widespread. Free/subsidized agricultural inputs and food were the most commonly used public safety nets by children's households in the past year (44 and 13%, respectively), and households with orphans were more likely to be beneficiaries. Malawi is poised to drastically expand safety nets to orphans and their families, and these findings provide an important foundation for this process.

There are an estimated 15 million AIDS orphans worldwide. Families play an important role in safeguarding orphans, but they may be increasingly compromised by the HIV/AIDS epidemic. The international aid community has recognized the need to help families continue caring for orphaned children by strengthening their safety nets. Before we build new structures, however, we need to know the extent to which community and public safety nets already provide support to families with orphans. To address this gap, we analyzed nationally representative data from 27,495 children in the 2004-2005 Malawi Integrated Household Survey. We found that communities commonly assisted orphan households through private transfers; organized responses to the orphan crisis were far less frequent. Friends and relatives provided assistance to over 75% of orphan households through private gifts, but the value of such support was relatively low. Over 40% of orphans lived in a community with support groups for the chronically ill and approximately a third of these communities provided services specifically for orphans and other vulnerable children. Public programs, which form a final safety net for vulnerable households, were more widespread. Free/subsidized agricultural inputs and food were the most commonly used public safety nets by children's households in the past year (44 and 13%, respectively), and households with orphans were more likely to be beneficiaries. Malawi is poised to drastically expand safety nets to orphans and their families, and these findings provide an important foundation for this process.

A sizeable literature has shown that child marriage is associated with an increased risk for intimate partner violence (IPV). However, this research has been cross-sectional, and the temporality of the association has not been investigated. Specifically, no study has yet examined whether IPV is a predictor of child marriage and adolescent pregnancy. This study uses prospective longitudinal data on a cohort of adolescent girls from the Malawi Longitudinal Study of Families and Health to evaluate whether IPV victimization predicts child marriage or adolescent pregnancy. Using survival models, we find that adolescent girls who experienced physical IPV (measured at survey baseline, in 2017–2018) are more likely to enter child marriages (measured at survey follow-up, in 2021) (hazard ratio [HR] = 2.7 [1.44, 5.08]). Experiencing sexual IPV is also significantly associated with adolescent pregnancy (HR = 1.97 [1.16, 3.33]). These findings indicate the need for greater intervention to ensure healthy adolescent relationships, as well as further research to understand how abusive relationships shape early transitions to adulthood. [ABSTRACT FROM AUTHOR]