Project description:BackgroundThe relationship between exposure to conflict violence during pregnancy and the risks of miscarriage, stillbirth, and perinatal mortality has not been studied empirically using rigorous methods and appropriate data. We investigated the association between reduced exposure to conflict violence during pregnancy and the risks of adverse pregnancy outcomes in Colombia.Methods and findingsWe adopted a regression discontinuity (RD) design using the July 20, 2015 cease-fire declared during the Colombian peace process as an exogenous discontinuous change in exposure to conflict events during pregnancy, comparing women with conception dates before and after the cease-fire date. We constructed the cohorts of all pregnant women in Colombia for each day between January 1, 2013 and December 31, 2017 using birth and death certificates. A total of 3,254,696 women were followed until the end of pregnancy. We measured conflict exposure as the total number of conflict events that occurred in the municipality where a pregnant woman lived during her pregnancy. We first assessed whether the cease-fire did induce a discontinuous fall in conflict exposure for women with conception dates after the cease-fire to then estimate the association of this reduced exposure with the risks of miscarriage, stillbirth, and perinatal mortality. We found that the July 20, 2015 cease-fire was associated with a reduction of the average number of conflict events (from 2.64 to 2.40) to which women were exposed during pregnancy in their municipalities of residence (mean differences -0.24; 95% confidence interval [CI] -0.35 to -0.13; p < 0.001). This association was greater in municipalities where Fuerzas Armadas Revolucionarias de Colombia (FARC) had a greater presence historically. The reduction in average exposure to conflict violence was, in turn, associated with a decrease of 9.53 stillbirths per 1,000 pregnancies (95% CI -16.13 to -2.93; p = 0.005) for municipalities with total number of FARC-related violent events above the 90th percentile of the distribution of FARC-related conflict events and a decrease of 7.57 stillbirths per 1,000 pregnancies (95% CI -13.14 to -2.00; p = 0.01) for municipalities with total number of FARC-related violent events above the 75th percentile of FARC-related events. For perinatal mortality, we found associated reductions of 10.69 (95% CI -18.32 to -3.05; p = 0.01) and 6.86 (95% CI -13.24 to -0.48; p = 0.04) deaths per 1,000 pregnancies for the 2 types of municipalities, respectively. We found no association with miscarriages. Formal tests support the validity of the key RD assumptions in our data, while a battery of sensitivity analyses and falsification tests confirm the robustness of our empirical results. The main limitations of the study are the retrospective nature of the information sources and the potential for conflict exposure misclassification.ConclusionsOur study offers evidence that reduced exposure to conflict violence during pregnancy is associated with important (previously unmeasured) benefits in terms of reducing the risk of stillbirth and perinatal deaths. The findings are consistent with such beneficial associations manifesting themselves mainly through reduced violence exposure during the early stages of pregnancy. Beyond the relevance of this evidence for other countries beset by chronic armed conflicts, our results suggest that the fledgling Colombian peace process may be already contributing to better population health.

Project description:IntroductionGender-based violence (GBV) is prevalent among, though not specific to, conflict affected populations and related to multifarious levels of vulnerability of conflict and displacement. Colombia has been marked with decades of conflict, with an estimated 5.2 million internally displaced persons (IDPs) and ongoing violence. We conducted qualitative research to understand the contexts of conflict, displacement and dynamics with GBV. This as part of a multi-phase, mixed method study, in collaboration with UNHCR, to develop a screening tool to confidentially identify cases of GBV for referral among IDP women who were survivors of GBV.MethodsQualitative research was used to identify the range of GBV, perpetrators, contexts in conflict and displacement, barriers to reporting and service uptake, as well as to understand experiences of service providers. Thirty-five female IDPs, aged 18 years and older, who self-identified as survivors of GBV were enrolled for in-depth interviews in San Jose de Guaviare and Quibdo, Colombia in June 2012. Thirty-one service providers participated in six focus group discussions and four interviews across these sites.ResultsSurvivors described a range of GBV across conflict and displacement settings. Armed actors in conflict settings perpetrated threats of violence and harm to family members, child recruitment, and, to a lesser degree, rape and forced abortion. Opportunistic violence, including abduction, rape, and few accounts of trafficking were more commonly reported to occur in the displacement setting, often perpetrated by unknown individuals. Intrafamilial violence, intimate partner violence, including physical and sexual violence and reproductive control were salient across settings and may be exacerbated by conflict and displacement. Barriers to reporting and services seeking were reported by survivors and providers alike.ConclusionsFindings highlight the need for early identification of GBV cases, with emphasis on confidential approaches and active engagement of survivors in available, quality services. Such efforts may facilitate achievement of the goals of new Colombian laws, which seek to prevent and respond to GBV, including in conflict settings. Ongoing conflict and generalized GBV in displacement, as well as among the wider population, suggests a need to create sustainable solutions that are accessible to both IDPs and general populations.

Project description:Large population displacement in developing economies due to internal armed conflict and violence is of international concern. There has been relatively little research on the long-term consequences of displacement on older adult health among populations characterized by rapid demographic, epidemiological, and nutritional transitions during the 20th century. We examine displacement in the middle-income country of Colombia, which experienced these rapid transitions and a large population displacement over the last 50-60 years due to internal armed conflict and violence. Using a nationally representative survey of adults 60 years and older, SABE-Colombia (2014-2015, n = 23,694), we estimate the degree to which displacement relative to those never displaced is associated with older adult health (self-reported health, major illness/stress, at least one chronic condition, heart disease), controlling for age, gender, SES (socioeconomic status), residence, early life conditions (infectious diseases, poor nutrition, health, SES, family violence), and adult behavior (smoking, exercise, nutrition). We found (1) strong associations between poor early life conditions and older adult health with little attenuation of effects after controlling for displacement, adult SES, and lifestyle; (2) strong associations between displacement and self-reported health; along with poor early life conditions, displacement increases the chances of poor health at older ages; (3) significant positive interaction effects between childhood infections and displacement during young adulthood for older adult stress/major illness, suggesting the importance of the timing of displacement; (4) significant interaction effects between childhood infections and being displaced during childhood, indicating lower levels of older adult stress/major illness and suggesting the possibility of resilience due to childhood adversity. We conclude that displacement compounds the effects of poor early life conditions and that timing of displacement can matter. The results raise the possibility of similar patterns in the health of aging populations in low-income countries that also experience displacement and rapid demographic and epidemiological transitions.

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The effect of conflict-related violence intensity and alcohol use on mental health: The case of Colombia

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