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Background: Women's underage marriage (<18 years) is associated with adverse maternal and child health outcomes. Poverty in the natal household has been widely considered to be a key risk factor for underage marriage, but the evidence base is unreliable. When investigating this issue, most studies use marital wealth inappropriately, as a proxy for wealth in the natal household. In contrast, we investigated whether the timing of women's marriage was associated with the wealth of the households they marry into, and how this may vary by women's education level. This approach allows us to explore a different set of research questions which help to understand the economic value placed on the timing of women's marriage. Methods: We used data on 3,102 women aged 12–34 years, surveyed within 1 year of marriage, from the cluster-randomized Low Birth Weight South Asia Trial in lowland rural Nepal. Linear mixed-effects regression models investigated independent associations of women's marriage age and education level with marital household wealth, and their interactive effects. Models adjusted for marital household traits. We analysed the full sample, and then only the uneducated women, who comprised a substantial proportion in our sample. Results: In the full sample, we found that each later year of women's marriage was associated with 1.5% lower asset score for those with primary education, and with 0.3% and 1.3% higher asset score for those with lower secondary or secondary/higher education, respectively. For uneducated women, relative to marrying ≤14 years, marrying at 15, 16, 17 and ≥18 years was associated with 1.5%, 4.4%, 2.4% and 6.2% greater marital asset score respectively. Conclusion: On average, marrying ≥18 years was associated with greater marital assets for secondary-educated women. There were only very modest benefits in terms of marital household wealth for delaying marriage beyond 16 years for uneducated women or those with low education. These findings elucidate potential trade-offs faced by families, including decisions over how much education, if any, to provide to daughters. They may help to understand the economic rationale underpinning the timing of marriage, and why early marriage remains common despite efforts to delay it. [ABSTRACT FROM AUTHOR]

Marriage during childhood and adolescence adversely affects maternal and child health and well-being, making it a critical global health issue. Analysis of factors associated with women marrying ≥18 years has limited utility in societies where the norm is to marry substantially earlier. This paper investigated how much education Nepali women needed to delay marriage across the range of ages from 15 to ≥18 years. Data on 6,406 women aged 23-30 years were analysed from the Low Birth Weight South Asia Trial on the early-marrying and low-educated Maithili-speaking Madhesi population in Terai, Nepal. Multivariable logistic regression models assessed the associations of women's education with marrying aged ≥15, ≥16, ≥17 and ≥18 years. Cox proportional hazards regression models quantified the hazard of marrying. Models adjusted for caste affiliation. Women married at median age of 15 years and three-quarters were uneducated. Women's primary and lower-secondary education were weakly associated with delaying marriage, whether the cut-off to define early marriage was 15, 16, 17 or 18 years, with stronger associations for secondary education. Caste associations were weak. Overall, models explained relatively little of the variance in the likelihood of marriage at different ages. The joint effects of lower-secondary and higher caste affiliation and of secondary/higher education and mid and higher caste affiliation reduced the hazard of marrying. In early-marrying and low-educated societies, changing caste-based norms are unlikely to delay women's marriage. Research on broader risk factors and norms that are more relevant for delaying marriage in these contexts is needed. Gradual increases in women's median marriage age and increased secondary education may, over time, reduce child and adolescent marriage. [ABSTRACT FROM AUTHOR]

Public health interventions usually operate at the level of groups rather than individuals, and cluster randomized controlled trials (RCTs) are one means of evaluating their effectiveness. Using examples from six such trials in Bangladesh, India, Malawi and Nepal, we discuss our experience of the ethical issues that arise in their conduct. We set cluster RCTs in the broader context of public health research, highlighting debates about the need to reconcile individual autonomy with the common good and about the ethics of public health research in low-income settings in general. After a brief introduction to cluster RCTs, we discuss particular challenges we have faced. These include the nature of--and responsibility for--group consent, and the need for consent by individuals within groups to intervention and data collection. We discuss the timing of consent in relation to the implementation of public health strategies, and the problem of securing ethical review and approval in a complex domain. Finally, we consider the debate about benefits to control groups and the standard of care that they should receive, and the issue of post-trial adoption of the intervention under test. Les interventions de sante publique s'operent habituellement au niveau des groupes plutot qu'a celui des individus et les essais controles randomises (RCT) en grappes constituent un moyen d'evaluer leur efficacite. En utilisant celui exemples six de ces essais menes au Bangladesh, en Inde, au Malawi et au Nepal, nous evoquons notre experience des problemes ethiques intervenant dans la realisation de ces essais. Nous replacons les RCT en grappes dans le contexte plus large de la recherche en sante publique, en mettant en avant les debats sur la necessite de concilier autonomie individuelle et bien commun et sur les aspects ethiques de la recherche en sante publique dans les pays a faible revenu en general. Apres avoir brievement introduit les RCT en grappes, nous avons evoque les difficultes particulieres que nous avons rencontrees. Ces difficultes portaient notamment sur la nature--et sur la responsabilite--du consentement collectif et sur la necessite que les individus au sein des groupes consentent egalement a l'intervention et au recueil des donnees. Nous avons examine le moment ou devait intervenir le consentement dans la mise en oeuvre des strategies de sante publique et les difficultes pour garantir un examen et une approbation ethiques dans un domaine complexe. Enfin, nous avons debattu des benefices pour les groupes temoins et de la norme de soins a leur appliquer, ansi que du probleme de l'adoption de l'intervention testee apres l'essai. Las intervenciones de salud publica inciden por lo general en grupos mas que en individuos, y los ensayos controlados aleatorizados (ECA) por conglomerados son un instrumento para evaluar su eficacia. A partir de ejemplos de seis ensayos de ese tipo Ilevados a cabo en Bangladesh, la India, Malawi y Nepal, analizamos nuestra experiencia en cuanto a los dilemas eticos que plantea la realizacion de esos ensayos. Situamos los ECA por conglomerados en el contexto general de las investigaciones de salud publica, resaltando los debates sobre la necesidad de compaginar la autonomia individual y el bien comun, y sobre la etica de las investigaciones de salud publica en los entornos de ingresos bajos en general. Tras una breve introduccion a los ECA por conglomerados, examinamos los problemas particulares que hemos encontrado, entre los que cabe citar la naturaleza del consentimiento colectivo -y la responsabilidad de obtenerlo- y la necesidad de consentimiento de los individuos, dentro de los grupos, respecto a la realizacion de la intervencion y la recogida de datos. Analizamos el momento del consentimiento en relacion con la aplicacion de las estrategias de salud publica, asi como los problemas que surgen para garantizar el examen etico y la aprobacion en un dominio complejo. Por ultimo, se considera el debate sobre los beneficios para los grupos de control y el nivel de atencion que deberian recibir, asi como el tema de la adopcion de la intervencion sometida a ensayo una vez concluido este., Introduction 'I am because we are and because we are I am. A person is not a separated and isolated individual but a community of related individuals. Despite all this, [...]

Objective: To provide a comprehensive seasonal analysis of pregnant mothers' eating behaviour and maternal/newborn nutritional status in an undernourished population from lowland rural Nepal, where weather patterns, agricultural labour, food availability and disease prevalence vary seasonally. Design: Secondary analysis of cluster-randomised Low Birth Weight South Asia Trial data, applying cosinor analysis to predict seasonal patterns. Outcomes: Maternal mid-upper arm circumference (MUAC), BMI, dietary diversity, meals per day, eating down and food aversion in pregnancy (≥31 weeks' gestation) and neonatal z-scores of length-for-age (LAZ), weight-for-age (WAZ) and head circumference-for-age (HCAZ) and weight-for-length (WLZ). Setting: Rural areas of Dhanusha and Mahottari districts in plains of Nepal. Participants: 2831 mothers aged 13–50 and 3330 neonates. Results: We found seasonal patterns in newborn anthropometry and pregnant mothers' anthropometry, meal frequency, dietary diversity, food aversion and eating down. Seasonality in intake varied by food group. Offspring anthropometry broadly tracked mothers'. Annual amplitudes in mothers' MUAC and BMI were 0·27 kg/m2 and 0·22 cm, with peaks post-harvest and nadirs in October when food insecurity peaked. Annual LAZ, WAZ and WLZ amplitudes were 0·125, 0·159 and 0·411 z-scores, respectively. Neonates were the shortest but least thin (higher WLZ) in winter (December/January). In the hot season, WLZ was the lowest (May/June) while LAZ was the highest (March and August). HCAZ did not vary significantly. Food aversion and eating down peaked pre-monsoon (April/May). Conclusions: Our analyses revealed complex seasonal patterns in maternal nutrition and neonatal size. Seasonality should be accounted for when designing and evaluating public heath nutrition interventions. [ABSTRACT FROM AUTHOR]