Teenage motherhood and infant mortality in Bangladesh: maternal age-dependent effect of parity one

Nuptiality norms in rural Bangladesh favour birth during the teenage years. An appreciable proportion of teenage births are, in fact, second births. This study examines the relationship between teenage fertility and high infant mortality. It is hypothesized that if physiological immaturity is responsible, then the younger the mother, the higher would be the mortality risk, and the effect of mother's 'teenage' on mortality in infancy, particularly in the neonatal period, would be higher for the second than the first births. Vital events recorded by the longitudinal demographic surveillance system in Matlab, Bangladesh, in 1990-92 were used. Logistic regression was used to estimate the effects on early and late neonatal (0-3 days and 4-28 days respectively) and post-neonatal mortality of the following variables: mother's age at birth, parity, education and religion, sex of the child, household economic status and exposure to a health intervention programme. The younger the mother, the higher were the odds of her child dying as a neonate, and the odds were higher for second children than first children of teenage mothers. First-born children were at higher odds of dying in infancy than second births if mothers were in their twenties. Unfavourable mother's socioeconomic conditions were weakly, but significantly, associated with higher odds of dying during late neonatal and post-neonatal periods. The results suggest that physical immaturity may be of major importance in determining the relationship between teenage fertility and high neonatal mortality.     

Determinants of the sex ratio at birth: review of recent literature

The fact that more boys are born than girls (104-107 boys for every 100 girls) has been known since 1662. Factors determining the sex ratio at birth rate are of 2 kinds: factors determining the primary sex ratio, i.e., sex ratio at conception, and factors determining the survival of the embryo in utero. Y-bearing and X-bearing sperm may have different motility or different survival time. The age of the ovum at fertilization and the chemical balance of the female genital tract have an effect on sex ratio at conception. High levels of circulating gonadotropins may imply a lower sex ratio at birth as well as a higher rate of dizygotic twinning. Male conception also appears to be higher early and late in the menstrual cycle. The fact that women exposed to higher coital rates conceive earlier in the menstrual cycle may account for the greater number of boys born during wars. Prenatal male mortality is reportedly highest between gestational months 3-5, lower between months 6-8, and higher again st term. Also, immunological interaction between mother and embryo may account for some sex selective spontaneous abortions. 3 sociodemographic determinants of sex ratio at birth are thought to be maternal age, paternal age, and birth order. Higher prenatal male mortality may be correlated with socioeconomic conditions, since higher socioeconomic status lowers prenatal mortality in general. The effects of parental age, birth order, and parity are less clear. Race is also a factor, since the sex ratio at birth for blacks is lower (102-104) than for whites (106). 14 univariate and 19 multivariate studies of effects of maternal age, paternal age, parity, birth order, race, and socioeconomic status on sex ratio at birth, with sample sizes in the millions from various countries have been analyzed. More boys are born to younger parents, and lower order births have a higher proportion of males than do higher order births. In the multivariate analyses, when the effects of paternal and and birth order are controlled for, the effect of maternal age weakens, and the effect of paternal age appears to be stronger. The effect of birth order remains but is very small, and the effect of race persists independent of any effect of other variables. Maternal age, parity, and birth order are positively correlated with proportion of male stillbirths. The results of the multivariate analyses show all of the effects to be very small, but that maternal age has no effect on sex ratio at birth; paternal age and birth order have a negative effect, and the racial effect persists independent of any other effect. The racial effect is clearly biologically determined at conception because blacks have higher levels of circulating gonadotropin and therefore a higher probability of conceiving girls. Parents in higher socioeconomic classes are more likely to have sons, but the effect is largely due to the excess male mortality during most of the gestational period.     

Influence of variation in birth weight within normal range and within sibships on IQ at age 7 years: cohort study

ObjectiveTo examine the relation between birth weight and measured intelligence at age 7 years in children within the normal range of birth weight and in siblings.DesignCohort study of siblings of the same sex.Setting12 cities in the United States.Subjects3484 children of 1683 mothers in a birth cohort study during the years 1959 through 1966. The sample was restricted to children born at ⩾37 weeks gestation and with birth weights of 1500-3999 g.ResultsMean IQ increased monotonically with birth weight in both sexes across the range of birth weight in a linear regression analysis of one randomly selected sibling per family (n= 1683) with adjustment for maternal age, race, education, socioeconomic status, and birth order. Within same sex sibling pairs, differences in birth weight were directly associated with differences in IQ in boys (812 pairs, predicted IQ difference per 100 g change in birth weight =0.50, 95% confidence interval 0.28 to 0.71) but not girls (871 pairs, 0.10, −0.09 to 0.30). The effect in boys remained after differences in birth order, maternal smoking, and head circumference were adjusted for and in an analysis restricted to children with birth weight ⩾ 2500 g.ConclusionThe increase in childhood IQ with birth weight continues well into the normal birth weight range. For boys this relation holds within same sex sibships and therefore cannot be explained by confounding from family social environment.

What is already known on this topic

IQ at school age is linked to birth weight among low birthweight babiesSome evidence suggests the association might also apply to children of normal birth weight

What this study adds

IQ at age 7 years is linearly related to birth weight among children of normal birth weightThe relation was not due to confounding by maternal or socioeconomic factorsIQ is also associated with differences in birth weight between boy sibling pairs but not girls     

Using Penalized Splines to Model Age‐ and Season‐of‐Birth‐Dependent Effects of Childhood Mortality Risk Factors in Rural Burkina Faso

Several previous studies have identified risk factors for childhood mortality in high risk areas, such as Sub‐Saharan Africa. Among these are lifestyle factors related for example to nutrition or sanitation. Other factors are related to social class, ethnicity and poverty in general. Few studies have investigated a dependence of these factors by age and season of birth which is the focus in this study. We perform a survival analysis of 9121 children born between 1998 and 2001 in a rural area of western Burkina Faso. The whole population is under demographic surveillance since 1993. All cause mortality is used as the endpoint and follow‐up information until the age of five years is available. Recently developed spline regression methods are used for the analysis. Ethnic group, religion, age of mother, twin status, sex, and distance to next health center are used as covariates all of which having a clear effect on survival in standard Cox regression analysis. With penalized spline regression, a more detailed risk pattern is observed. Ethnicity is more related to death at early age, as well as age of mother. The effect of the risk factors considered also appear to be related with season of birth (© 2009 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

Trends in sibling correlations for height and weight: the effect of age changes (0-24 months) and spacing between siblings (0-10 years)

Familial correlations were studied in a sample of 618 sibships from a western neighborhood of Jerusalem, whose height (H) and weight (W) were measured longitudinally at the same age, from birth to 3 years of age. Covariate adjustments were applied to correct for change in mean of H and W with the sex of child and age of mother and for the effect of origin, education, and socioeconomic status of the mother, parity, and calendar year at birth. The highest sibling correlations were observed at birth or 1 month later (r = 0.45-0.46). Pooled sibling correlations were lower 6 months later (r = 0.33; r = 0.26 for H and W, respectively) and tended to increase again 12-18 months after birth. A clear trend of decline in sib-sib correlation for H and W measured 3 and 12 months after birth with increased spacing between siblings was observed. Our data provide evidence for transient environmental factors as possible sources of the observed temporal variation in sibling correlation for height and weight.     

Stillbirth pattern in an isolated mediterranean population: La Alpujarra, Spain

This study attempted to analyze the effect of several factors on the stillbirth pattern in a relatively isolated rural population, La Alpujarra (Spain), during the first half of the 20th century. The study was a retrospective analysis from a total sample of 2199 births to 525 mothers, allowing for birth year of mother, maternal age, parental inbreeding, family size, birth order, sex, single/twin delivery, and birth interval. Binomial probability distribution of stillbirths provided no evidence for any significantly increased risk in relation to family size. Analysis of covariance (ANCOVA) of stillbirth risk in affected families indicated a significant effect for sex of the child, parental consanguinity, and birth year of mother. Logistic regression showed increased risk in twin delivery and pregnancy order one, but not for birth order other than one. Multivariate analysis of variance (MANOVA) testing for differences between affected and unaffected families supported a temporal decrease of stillbirths during the period studied. Although the birth interval average was significantly shorter in affected families (p < 0.0001), this association did not hold, in a more detailed analysis, for individual intervals in these families (p = 0.20). There was no significant effect of maternal age on stillbirths in the whole sample or limited to first pregnancies. These results suggest that birth order one and twin delivery were the main determinants of the stillbirth pattern in La Alpujarra. Furthermore, our data indicate that the decline in stillbirth rate began before medical facilities for perinatal care became available, which was not until after 1950. The temporal decrease in stillbirth rates may therefore be related to an increasing social attention to deliveries rather than to prenatal care medical facilities.     

Parental age,birth order and tertiary sex ratio in the human population of Punjab,Pakistan

The data of this study, an extension of a previous study on secondary sex ratio in the human population of Muridke, Punjab, Pakistan, are based on the population of Muridke, 27 km north of Lahore, Punjab, Pakistan. Records of deaths of children, at later stages of birth, for different birth ranks, and that of maternal and paternal ages were made. 1000 families were scored for this study. Families providing the required information were included. Data for paternal age and maternal age combination consisted of 4807 total number of children of which 2586 were male. Paternal age and birth order combination was comprised of a total of 4405 children, containing 2316 males. Maternal age and birth order combination consisted of 4658 children, of which 2458 were males. The discrepancy in the number of children in the 3 types of combinations was due to the lack of required information in different groups. Sex ratio based on total number of males in relation to paternal age and maternal age was 0.54. Younger fathers (15-19 years) showed higher sex ratio (0.69). This dropped in paternal age groups 20-24 years (0.59) and 25-29 years (0.51). Younger mothers (15-19 years) showed higher sex ratio (0.62), declines in the age groups 20-24 years (0.52) and 25-29 years (0.51) and rise in age groups 35-39 years (0.55) and 40-44 years (0.54). Chi-square tests were carried out to compare the number of male and female offspring in the paternal age groups 15-19, 20-24, and 25-29 years. These showed highly significant deviation from the expected number. The higher age groups showed nonsignificant differences in the number of male and female offspring. Maternal age groups 15-19, 20-24, and 25-29 years showed highly significant differences in the male and female offspring and nonsignificant results in the higher age groups. Maternal age in relation to paternal age showed positive simple and partial correlations. Sex ratio for the total number of males based on paternal age and birth order was 0.52. 1st birth order showed higher sex ratio (0.55) and decreased in the 2nd (0.50) and 3rd birth orders (0.51), showed increase in the 4th birth order (0.53) and declines in the higher birth ranks. The number of male and female offspring in the birth orders 1, 2, and 3 showed significant differences, but in higher birth ranks the difference was insignificant. Paternal age and birth order indicated positive simple and partial correlations. Higher sex ratio (0.58) was seen in the 1st birth order and then it decreased in the 2nd (0.50) and 3rd (0.51) birth order. Chi-square tests carried out to compare the number of male and female offspring in borth orders 1, 2, and 3 showed highly significant differences but in higher birth ranks the difference was insignificant.     

Birth weight and cognitive function in the British 1946 birth cohort: longitudinal population based study

Objective: To examine the association between birth weight and cognitive function in the normal population. Design: A longitudinal, population based, birth cohort study. Participants: 3900 males and females born in 1946. Main outcome measures: Cognitive function from childhood to middle life (measured at ages 8, 11, 15, 26, and 43 years). Results: Birth weight was significantly and positively associated with cognitive ability at age 8 (with an estimated standard deviation score of 0.44 (95% confidence interval 0.28 to 0.59)) between the lowest and highest birthweight categories after sex, father's social class, mother's education, and birth order were controlled for. This association was evident across the normal birthweight range (>2.5 kg) and so was not accounted for exclusively by low birth weight. The association was also observed at ages 11, 15, and 26, and weakly at age 43, although these associations were dependent on the association at age 8. Birth weight was also associated with education, with those of higher birth weight more likely to have achieved higher qualifications, and this effect was accounted for partly by cognitive function at age 8. Conclusions: Birth weight was associated with cognitive ability at age 8 in the general population, and in the normal birthweight range. The effect at this age largely explains associations between birth weight and cognitive function at subsequent ages. Similarly, the association between birth weight and education was accounted for partly by earlier cognitive scores.     

Teenage childbearing: structural determinants in developing countries

Data for a sample of 50 developing countries are analysed to investigate the social correlates of the teenage birth rate. Of five major factors considered as predictors of national birth rates (socioeconomic development, family planning programmes, women's status, the sex ratio, and marriage patterns), regression analyses reveal that only the average age at marriage for women has a significant effect on the teenage birth rate. In contrast, all variables except the sex ratio and the average age at marriage for women have a significant effect on the total fertility rate.     

Effect of birth spacing on infant and child mortality in rural Nepal

This examination of the effect of birth spacing on infant and child mortality in rural Nepal is based on data from the Nepal Fertility Survey 1976 carried out by the Nepal Family Planning and Maternal Child Health Project in collaboration with the World Fertility Survey. The study confirms that the higher risk of infant death to 1st born children is mainly due to the higher proportion of younger women having 1st births, rather than due to their being 1st order births per se. The effect of maternal age on infant and child mortality is largely associated with birth interval. Previous birth interval, therefore, stands out as the most important factor affecting infant mortality; the next most important factor is the survival of the preceding child. A child born after an interval of less than 18 months since the previous live birth has a 31% higher risk of dying during infancy than 1 born after an interval of 1 1/2 to 2 years. The risk of the index child's dying is only 50% of that when its preceding sibling is dead. Neither education of mother nor education of father has a significant effect on infant mortality in rural Nepal.     

School Performance: A Matter of Health or Socio-Economic Background? Findings from the PIAMA Birth Cohort Study

Background

Performance in primary school is a determinant of children’s educational attainment and their socio-economic position and health inequalities in adulthood. We examined the relationship between five common childhood health conditions (asthma symptoms, eczema, general health, frequent respiratory infections, and overweight), health related school absence and family socio-economic status on children’s school performance.

Methods

We used data from 1,865 children in the Dutch PIAMA birth cohort study. School performance was measured as the teacher’s assessment of a suitable secondary school level for the child, and the child’s score on a standardized achievement test (Cito Test). Both school performance indicators were standardised using Z-scores. Childhood health was indicated by eczema, asthma symptoms, general health, frequent respiratory infections, overweight, and health related school absence. Children’s health conditions were reported repeatedly between the age of one to eleven. School absenteeism was reported at age eleven. Highest attained educational level of the mother and father indicated family socio-economic status. We used linear regression models with heteroskedasticity-robust standard errors for our analyses with adjustment for sex of the child.

Results

The health indicators used in our study were not associated with children’s school performance, independently from parental educational level, with the exception of asthma symptoms (-0.03 z-score / -0.04 z-score with Cito Test score after adjusting for respectively maternal and paternal education) and missing more than 5 schooldays due to illness (-0.18 z-score with Cito Test score and -0.17 z-score with school level assessment after adjustment for paternal education). The effect estimates for these health indicators were much smaller though than the effect estimates for parental education, which was strongly associated with children’s school performance.

Conclusion

Children’s school performance was affected only slightly by a number of common childhood health problems, but was strongly associated with parental education.     

Spousal agreement on preferred waiting time to next birth in sub-Saharan Africa

This study investigates how various social, demographic and economic factors affect spousal agreement on preferred waiting time to next birth. Data for matched cohabiting couples from ten Demographic and Health Surveys in sub-Saharan Africa (Benin, Burkina Faso, Ghana, Guinea, Mali, Ethiopia, Kenya, Mozambique, Zambia and Zimbabwe), conducted between 2003 and 2006, were analysed to compare reported waiting time to next birth by the husband and the wife. Couples where the reported waiting time to next birth was the same for both partners (difference is 0 months) were defined as having agreement on waiting time to next birth. In sub-Saharan Africa, spousal agreement on waiting time to next birth was found to be associated with wanting the next child sooner. When the spouses disagree on waiting time to next birth, the wives want to wait longer than their husbands in most cases. Additionally, the study found that demographic factors are the primary determinants of spousal agreement on waiting time to next birth, not socioeconomic factors. The strongest predictors of spousal agreement on waiting time to next birth were number of living children, difference between the number of ideal and living children and wife's age. Couples with fewer children, a younger wife and those with a difference of five or more children between ideal and living number of children were more likely to agree on waiting time to next birth. Effects of socioeconomic factors, such as education and wealth status, on spousal agreement on waiting time to next birth were generally weak and inconsistent. The findings highlight some of the challenges in developing programmes to promote spousal communication and birth spacing and underscore the need for programmes to be gender-sensitive.     

Determinants of Low Birth Weight in Malawi: Bayesian Geo-Additive Modelling

Studies on factors of low birth weight in Malawi have neglected the flexible approach of using smooth functions for some covariates in models. Such flexible approach reveals detailed relationship of covariates with the response. The study aimed at investigating risk factors of low birth weight in Malawi by assuming a flexible approach for continuous covariates and geographical random effect. A Bayesian geo-additive model for birth weight in kilograms and size of the child at birth (less than average or average and higher) with district as a spatial effect using the 2010 Malawi demographic and health survey data was adopted. A Gaussian model for birth weight in kilograms and a binary logistic model for the binary outcome (size of child at birth) were fitted. Continuous covariates were modelled by the penalized (p) splines and spatial effects were smoothed by the two dimensional p-spline. The study found that child birth order, mother weight and height are significant predictors of birth weight. Secondary education for mother, birth order categories 2-3 and 4-5, wealth index of richer family and mother height were significant predictors of child size at birth. The area associated with low birth weight was Chitipa and areas with increased risk to less than average size at birth were Chitipa and Mchinji. The study found support for the flexible modelling of some covariates that clearly have nonlinear influences. Nevertheless there is no strong support for inclusion of geographical spatial analysis. The spatial patterns though point to the influence of omitted variables with some spatial structure or possibly epidemiological processes that account for this spatial structure and the maps generated could be used for targeting development efforts at a glance.     

Positive Effect of Large Birth Intervals on Early Childhood Hemoglobin Levels in Africa Is Limited to Girls: Cross-Sectional DHS Study

Background

Short birth intervals are independently associated with increased risk of adverse maternal, perinatal, infant and child outcomes. Anemia in children, which is highly prevalent in Africa, is associated with an increased risk of morbidity and mortality. Birth spacing is advocated as a tool to reduce anemia in preschool African children, but the role of gender differences and contextual factors has been neglected. The present study aims to determine to what extent the length of preceding birth interval influences the hemoglobin levels of African preschool children in general, as well as for boys and girls separately, and which contextual factors thereby play a crucial role.

Methods and Findings

This cross-sectional study uses data from Demographic and Health Surveys (DHS) conducted between 2003 and 2011 in 20 African countries. All preschool children aged 6–59 months with a valid hemoglobin measurement and a preceding birth interval of 7–72 months as well as their corresponding multigravida mothers aged 21–49 years were included in the study. Hemoglobin levels of children and mothers were measured in g/l, while birth intervals were calculated as months difference between consecutive births. Multivariate analyses were done to examine the relationship between length of preceding birth interval and child hemoglobin levels, adjusted for factors at the individual, household, community, district, and country level. A positive linear relationship was observed between birth interval and the 49,260 included children’s hemoglobin level, whereby age and sex of the child, hemoglobin level of the mother, household wealth, mother’s education and urbanization of place of residence also showed positive associations. In the interaction models, the effect of a month increase in birth interval is associated with an average increase of 0.025 g/l in hemoglobin level (P = 0.001) in girls, while for boys the effect was not significant. In addition, for girls, the effect of length of preceding birth interval was highest in young mothers and mothers with higher hemoglobin levels, while for boys, the highest effect was noticed for those living in more highly educated regions. Finally, significantly higher hemoglobin levels of girls compared to boys were observed at birth but with increasing age, the sex difference in hemoglobin level gradually becomes smaller.

Conclusions

A longer birth interval has a modest positive effect on early childhood hemoglobin levels of girls, and this effect is strongest when their mothers are in their early twenties and have a high hemoglobin level. Remarkably, although the physiological iron requirement is higher for boys than girls, birth spacing has little influence on hemoglobin levels of preschool boys. We speculate that the preference for male offspring in large parts of Africa significantly influences nutritional patterns of African preschool boys and girls, and as such also determines the different effect of birth spacing. Finally, gender aspects should be considered in intervention programs that aim to improve anemia in African children.     

The effect of birth interval on malnutrition in Bangladeshi infants and young children

This study was undertaken to investigate the independent effect of the length of birth interval on malnutrition in infants, and children aged 6-39 months. Data for this study were drawn from a post-flood survey conducted during October-December 1988 at Sirajganj of the Sirajgani district and at Gopalpur of the Tangail district in Bangladesh. The survey recorded the individual weights of 1887 children. Cross-tabulations and logistic regression procedures were applied to analyse the data. The proportion of children whose weight-for-age was below 70% (moderate-to-severely malnourished) and 60% (severely malnourished) of the NCHS median was tabulated against various durations of previous and subsequent birth intervals. The odds of being moderately or severely malnourished were computed for various birth intervals, controlling for: the number of older surviving siblings; maternal education and age; housing area (a proxy for wealth); age and sex of the index child; and the prevalence of diarrhoea in the previous 2 weeks for the index child. About one-third of infants and young children were moderately malnourished and 15% were severely malnourished. The proportion of children who were under 60% weight-for-age decreased with the increase in the length of the subsequent birth interval, maternal education and housing area. The proportion of malnourished children increased with the number of older surviving children. Children were at higher risk of malnutrition if they were female, their mothers were less educated, they had several siblings, and either previous or subsequent siblings were born within 24 months. This study indicates the potential importance of longer birth intervals in reducing malnutrition in children.     

Determinants of chronic malnutrition among preschool children in Bangladesh

This study investigated the impact of some socioeconomic, demographic and health and community factors on chronic malnutrition or stunting in Bangladeshi children aged less than 5 years. The analysis revealed that the overall prevalence of stunting was 44%, of which 18% of children were severely stunted, and the demographic characteristics appeared to be the most significant factors for chronic malnutrition. Multinomial logistic regression analysis showed that parents' education, household economic status, media exposure, number of under-5 children, place of delivery, child's age, birth order, months of breast-feeding, birth size, mother's BMI, mother's height, age of household head, measles vaccine, supplementation of diet with liquids and regional differentials were significantly associated with severe as well as moderate stunting.     

Maternal and neonatal factors influencing premature birth and low birth weight in Australia

This study identified the influences of neonatal and maternal factors on premature birth and low birth weight in New South Wales, Australia. Bivariate and multivariate analyses were used to explore the association of selected neonatal and maternal characteristics with premature birth and low birth weight. The findings of this study showed that premature birth and low birth weight rate significantly varied by infant sex, maternal age, marital status, Aboriginality, parity, maternal smoking behaviour during pregnancy and maternal hypertension. First-born infants, and infants born to mothers aged less than 20 years, or who were single, separated/divorced, Aboriginal or who smoked during the pregnancy, were at increased risk of being premature or of low birth weight. This study also found that risk factors for premature births and low birth weight were similar in both singleton and multiple births. Gestational age was confirmed to be the single most important risk factor for low birth weight. The findings of this study suggest that in order to reduce the incidence of low birth weight and premature births, health improvement strategies should focus on anti-smoking campaigns during pregnancy and other healthcare programmes targeted at the socially disadvantaged populations identified in the study.     

‘Mommy,I miss daddy’. The effect of family structure on children's health in Brazil

This paper studies the relationship between single motherhood and children's height-for-age z-scores in Brazil. In order to isolate the causal effect between family structure and children's condition, we estimate an econometric model that uses male preference for firstborn sons and local sex ratios to instrument the probability of a woman becoming a single mother. Our results have a local average treatment effect interpretation (LATE). We find that children being raised by a single mother (whose marital status is affected by a firstborn girl and a low sex ratio) have a height-for-age z-score that is lower than that of children of similar characteristics that cohabit with both progenitors. We claim that the increasing trend of single motherhood in Brazil should be of concern in health policy design.     

Social structure and dynamics of wild chimpanzees at Bossou,Guinea

A small population of wild chimpanzees was studied at Bossou, Guinea, for six months from November 1976 to May 1977. All the chimpanzees except dependent infants were identified without artificial feeding and were observed from within 20 m almost every day. The population size of 21 chimpanzees was little changed from 1967. Although the sex ratio (male/female) of immatures (infants, juveniles, and adolescents) was 0.833 in January 1977, the adult sex ratio was 0.429. More than half of the males must therefore have disappeared. No desertion of males from the Bossou group was confirmed during the study period but two emigrated males from other groups did come to join the Bossou group for a short period. Four out of six mothers had two or three children. From the age discrepancy of brothers/sisters, the mean birth interval from a mother was estimated to be about four years. An elder sister of two infants who had an age-gap of only three years, or perhaps less, disappeared without receiving sufficient care from her mother. Mothers who had infants aged about 1 year or more showed swelling of their sexual skin and were confirmed to mate with males.