Intimate partner violence (IPV) is associated with increased HIV risk and other adverse health and psychosocial outcomes. We assessed the impact of Unite for a Better Life (UBL), a gender-transformative, participatory intervention delivered to men, women, and couples in Ethiopia in the context of the coffee ceremony, a traditional community-based discussion forum. Villages (n = 64) in 4 Ethiopian districts were randomly allocated to control, men’s UBL, women’s UBL, or couples’ UBL, and approximately 106 households per village were randomly selected for inclusion in the trial. The intervention included 14 sessions delivered twice weekly by trained facilitators; control arm households were offered a short IPV educational session. Primary outcomes were women’s experience of past-year physical or sexual IPV 24 months postintervention. Secondary outcomes included male perpetration of past-year physical or sexual IPV, comprehensive HIV knowledge, and condom use at last intercourse. Additional prespecified outcomes included experience and perpetration of past-year physical and/or sexual IPV and emotional IPV, HIV/AIDs knowledge and behaviors, decision-making, and gender norms. An intention-to-treat (ITT) analysis was conducted, evaluating 6,770 households surveyed at baseline in 2014–2015 (1,680 households, 16 clusters in control; 1,692 households, 16 clusters in couples’ UBL; 1,707 households, 16 clusters in women’s UBL; 1,691 households, 16 clusters in men’s UBL). Follow-up data were available from 88% of baseline respondents and 87% of baseline spouses surveyed in 2017–2018. Results from both unadjusted and adjusted specifications are reported, the latter adjusting for age, education level, marriage length, polygamy, socioeconomic status, and months between intervention and endline. For primary outcomes, there was no effect of any UBL intervention compared to control on women’s past-year experience of physical (couples’ UBL arm adjusted odds ratio [AOR] = 1.00, 95% confidence interval [CI]: 0.77–1.30, p = 0.973; women’s UBL arm AOR = 1.11, 95% CI 0.87–1.42, p = 0.414; men’s UBL arm AOR = 1.02, 95% CI: 0.81–1.28, p = 0.865) or sexual IPV (couples’ UBL arm AOR = 0.86, 95% CI: 0.62–1.20, p = 0.378; women’s UBL arm AOR = 1.15, 95% CI: 0.89–1.50; p = 0.291; men’s UBL arm AOR = 0.80, 95% CI: 0.63–1.01, p = 0.062). For the secondary outcomes, only the men’s UBL intervention significantly reduced male perpetration of past-year sexual IPV (AOR: 0.73; 95% CI: 0.56–0.94, p = 0.014), and no intervention reduced perpetration of past-year physical IPV. Among women, the couples’ UBL intervention significantly improved comprehensive HIV knowledge, and both couples’ and women’s UBL significantly increased reported condom use at last intercourse. Among additional outcomes of interest, the men’s UBL intervention was associated with a significant reduction in women’s experience of past-year physical and/or sexual IPV (AOR = 0.81, 95% CI: 0.66–0.99, p = 0.036) and men’s perpetration of physical and/or sexual IPV (AOR = 0.78; 95% CI: 0.62–0.98, p = 0.037). UBL delivered to men and couples was associated with a significant reduction in HIV risk behaviors and more equitable intrahousehold decision-making and household task-sharing. The primary limitation is reliance on self-reported data. A gender-transformative intervention delivered to men was effective in reducing self-reported perpetration of sexual IPV but did not reduce IPV when delivered to couples or women. We found evidence of decreased sexual IPV with men’s UBL across men’s and women’s reports and of increased HIV knowledge and condom use at last intercourse among women. The men’s UBL intervention could help accelerate progress towards gender equality and combating HIV/AIDS. The trial was prospectively registered at clinicaltrials.gov (NCT02311699) and in the American Economic Association registry (AEARCTR-0000211).

Maternal mortality is extremely high in Nigeria. Accurate estimation of maternal mortality is challenging in low-income settings such as Nigeria where vital registration is incomplete. The objective of this study was to estimate the lifetime risk (LTR) of maternal death and the maternal mortality ratio (MMR) in Jigawa State, Northern Nigeria using the Sisterhood Method. Interviews with 7,069 women aged 15–49 in 96 randomly selected clusters of communities in 24 Local Government Areas (LGAs) across Jigawa state were conducted. A retrospective cohort of their sisters of reproductive age was constructed to calculate the lifetime risk of maternal mortality. Using most recent estimates of total fertility for the state, the MMR was estimated. The 7,069 respondents reported 10,957 sisters who reached reproductive age. Of the 1,026 deaths in these sisters, 300 (29.2%) occurred during pregnancy, childbirth or within 42 days after delivery. This corresponds to a LTR of 6.6% and an estimated MMR for the study areas of 1,012 maternal deaths per 100,000 live births (95% CI: 898–1,126) with a time reference of 2001. Jigawa State has an extremely high maternal mortality ratio underscoring the urgent need for health systems improvement and interventions to accelerate reductions in MMR. The trial is registered at clinicaltrials.gov ( NCT01487707 ). Initially registered on December 6, 2011.

Background: Maternal and newborn mortality continue to be major challenges in Nigeria. While greater participation of men in maternal and newborn health has been associated with positive outcomes in many settings, male involvement remains low. The objective of this analysis was to investigate male involvement in maternal and newborn health in Jigawa state, northern Nigeria. Methods: This qualitative study included 40 event narratives conducted with families who had experienced a maternal or newborn complication or death, in-depth interviews with 10 husbands and four community leaders, and four focus group discussions with community health workers. The interviews focused on understanding illness recognition and care seeking as well as the role of husbands at each stage on the continuum of maternal and newborn health. Data were transcribed, translated to English, and coded and analyzed using Dedoose software and a codebook developed a priori. Results: This paper reports low levels of knowledge of obstetric and newborn complications among men and limited male involvement during pregnancy, childbirth and the post-partum period in Jigawa state. Men are key decision-makers around the location of the delivery and other decisions linked to maternal and newborn health, and they provide crucial resources including nutritious foods and transportation. However, they generally do not accompany their wives to antenatal visits, are rarely present for deliveries, and do not make decisions about complications arising during delivery and the immediate post-partum period. These gendered roles are deeply ingrained, and men are often ridiculed for stepping outside of them. Additional barriers for male involvement include minimal engagement with health programs and challenges at health facilities including a poor attitude of health providers towards men and accompanying family members. Conclusion: These findings suggest that male involvement is limited by low knowledge and barriers related to social norms and within health systems. Interventions engaging men in maternal and newborn health must take into account these obstacles while protecting women’s autonomy and avoiding reinforcement of gender inequitable roles and behaviors.

The COVID-19 outbreak has been declared a global pandemic and cases are being reported among displaced populations that are particularly vulnerable to infection. Humanitarian workers on the frontlines of the response are working in some of the most challenging contexts and also face elevated risk of contracting COVID-19 and potential stigmatization or violence in the community. Women humanitarians may be at even greater risk, but their protection is dependent on organization-specific policies and procedures. Without gender balance in leadership positions, the specific needs of women may not be prioritized and women may not be included in decision-making or design of responses. Ensuring gender equitable access to personal protective equipment and information is imperative, but additional measures must be put into place to ensure the protection of women on the frontlines while reducing COVID-19 deaths and adverse health effects among displaced populations.

Most impact evaluations of intimate partner violence (IPV) prevention interventions use binary measures of “any” versus “no” physical and/or sexual IPV as their primary outcome measure, missing opportunities to capture nuance. In this study, we reanalyzed secondary data from six randomized controlled trials conducted in low- and middle-income countries—Bandebereho (Rwanda), Becoming One (Uganda), Indashyikirwa (Rwanda), MAISHA CRT01, MAISHA CRT02 (Tanzania), Stepping Stones Creating Futures (South Africa), and Unite for a Better Life (Ethiopia), to assess how different conceptualizations and coding of IPV variables can influence interpretations of the impact of an intervention. We compared the standard outcome measures to new measures that reflect the severity and intensity of violence and whether interventions prevent new cases of IPV or reduce or stop ongoing violence. Results indicate that traditional binary indicators masked some of the more subtle intervention effects, and the use of the new indicators allowed for a better understanding of the impacts of the interventions. Conclusions on whether a program is perceived “to work” are highly influenced by the IPV outcomes that the investigators choose to report, and how they are measured and coded. Lack of attention to outcome choice and measurement could lead to prematurely abandoning strategies useful for violence reduction or missing essential insights into how programs may or may not affect IPV. While these results must be interpreted cautiously, given differences in intervention types, the underlying prevalence of violence, sociodemographic factors, sample sizes, and other contextual differences across the trial sites, they can help us move toward a new approach to reporting multiple outcomes that allow us to unpack the “impact” of an intervention by assessing intervention effect by the severity of violence and type of prevention, whether primary and secondary.

Background: Intimate partner violence (IPV) is the most common form of gender-based violence affecting women and girls worldwide and is exacerbated in humanitarian crises. There is evidence that substance use is associated with male perpetration of IPV. Consumption of khat —a plant containing amphetamines traditionally chewed in the horn of Africa and legal in some countries including Ethiopia—may increase risk of IPV toward women. This analysis aimed to assess perceptions on khat use among Somali refugees in Dollo Ado, Ethiopia and its association with IPV to inform an IPV and HIV prevention intervention. Methods: A descriptive qualitative study comprising individual interviews (n = 30) and focus group discussions (n = 10) was conducted in Bokolmayo refugee camp in Dollo Ado, Ethiopia in October 2016. A purposive sample of male and female Somali refugees, religious and community leaders, and service providers (n = 110 individuals; 44 women and 66 men) was included. Trained interviewers from the camp conducted the interviews and discussion, which were audio recorded, transcribed and translated. A content analysis was conducted on coded excerpts from the transcripts to identify factors contributing to IPV toward women, including khat use. Results: Participants reported that displacement has resulted in limited employment opportunities for men and increased idle time, which has led to increased khat use among men as a coping mechanism. Male khat use was perceived to be associated with perpetration of physical and sexual IPV through several mechanisms including increased anger and aggression and enhanced sexual desire. Khat use also contributes to intra-marital conflict as money allocated for a household is spent on purchasing khat. Conclusion: Khat use should be addressed as part of IPV prevention programming in this context. Livelihood interventions and other strategies to improve economic conditions, should be explored in collaboration with refugee camp authorities and community leaders as a potential avenue to mitigate the impact of khat use on women and families.