Francesca L. Cavallaro

Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa

OBJECTIVE To examine temporal trends in caesarean delivery rates in southern Asia and sub-Saharan Africa, by country and wealth quintile. METHODS Cross-sectional data were extracted from the results of 80 Demographic and Health Surveys conducted in 26 countries in southern Asia or sub-Saharan Africa. Caesarean delivery rates were evaluated - as percentages of the deliveries that ended in live births - for each wealth quintile in each survey. The annual rates recorded for each country were then compared to see if they had increased over time. FINDINGS Caesarean delivery rates had risen over time in all but 6 study countries but were consistently found to be lower than 5% in 18 of the countries and 10% or less in the other eight countries. Among the poorest 20% of the population, caesarean sections accounted for less than 1% and less than 2% of deliveries in 12 and 21 of the study countries, respectively. In each of 11 countries, the caesarean delivery rate in the poorest 40% of the population remained under 1%. In Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria, the rate remained under 1% in the poorest 80%. Compared with the 22 African study countries, the four study countries in southern Asia experienced a much greater rise in their caesarean delivery rates over time. However, the rates recorded among the poorest quintile in each of these countries consistently fell below 2%. CONCLUSION Caesarean delivery rates among large sections of the population in sub-Saharan Africa are very low, probably because of poor access to such surgery.

Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using Demographic and Health Surveys.

Maternal mortality rates have decreased globally but remain off track for Millennium Development Goals. Good‐quality delivery care is one recognised strategy to address this gap. This study examines the role of the private (non‐public) sector in providing delivery care and compares the equity and quality of the sectors.

Responsiveness of emergency obstetric care systems in low‐ and middle‐income countries: a critical review of the “third delay”

We reviewed the evidence on the duration, causes and effects of delays in providing emergency obstetric care to women attending health facilities (the third delay) in low‐ and middle‐income countries. We performed a critical literature review using terms related to obstetric care, birth outcome, delays and developing countries. A manual search of reference lists of key articles was also performed. 69 studies met the inclusion criteria. Most studies reported long delays in providing care, and the mean waiting time for women admitted with complications was as much as 24 h before treatment. The three most cited barriers to providing timely care were shortage of treatment materials, surgery facilities and qualified staff. Existing evidence is insufficient to estimate the effect of delays on birth outcomes. Delays in providing emergency obstetric care seem common in resource‐constrained settings but further research is necessary to determine the effect of the third delay on birth outcomes.

Comparing the use and content of antenatal care in adolescent and older first-time mothers in 13 countries of west Africa: a cross-sectional analysis of Demographic and Health Surveys

BACKGROUND West Africa has the highest proportion of married adolescents, and the highest adolescent childbirth rate and maternal death rate in sub-Saharan Africa. However, few studies have focused on the type and quality of health care accessed by pregnant young women in countries in this subregion. METHODS We obtained data from Demographic and Health Surveys done between 2010 and 2014, to compare the use, timing, source, and components of antenatal care between adolescent and older first-time mothers in 13 west African countries. The sample included primiparous women who were aged 15-49 years with a livebirth in the 5-year survey recall period, and women were assigned to one of three groups on the basis of age at the time of childbirth: adolescent (10-19 years), young adults (20-24 years), or adults (25 years or older). We calculated the percentage of women who: attended at least one antenatal care visit, completed at least one visit during the first trimester of pregnancy, attended four or more appointments in antenatal care, and received four components of antenatal care (blood pressure measurement, urine tests, blood tests, and information on complications), as well as the sector where the women received care. We primarily report the comparison between adolescents and young adults. FINDINGS In 2016, we acquired data from the Demographic Health Surveys from 13 west African countries between 2010 and 2014 on primiparous women. The study sample was 19 211 women, of whom 10 025 (52%) were adolescents, 6099 (32%) were young adults, and 3087 (16%) were adults. Overall, 17 386 (91%) of 19 211 first-time mothers made use of antenatal care facilities on at least one occasion. 3597 (41%) of 8741 adolescents compared with 8202 (47%) of all 17 386 women began the use of antenatal care during the first trimester. Across west Africa, 5430 (62%) of 8741 adolescents had four or more antenatal care visits compared with 4067 (71%) of 5717 young adults and 2358 (81%) of 2928 adults. Of those who had four or more visits to antenatal care, 2779 (51%) of 5430 adolescents received all the antenatal care components examined compared with 2488 (61%) of 4067 young adults and 1600 (68%) of 2358 adults. Although most women received antenatal care in the public sector, in nine of the 13 countries, the proportion of women that used the private sector was higher in older mothers. INTERPRETATION Although a large percentage of west African adolescents use some antenatal care for their first birth, they seek care later, make fewer visits during pregnancy, and receive fewer components of care than older first-time mothers. Governments must ensure the pregnancy care accessed by adolescent mothers is of high quality and tailored to meet their needs. FUNDING MSD for Mothers.

Obstetricians’ Opinions of the Optimal Caesarean Rate: A Global Survey

Background The debate surrounding the optimal caesarean rate has been ongoing for several decades, with the WHO recommending an “acceptable” rate of 5–15% since 1997, despite a weak evidence base. Global expert opinion from obstetric care providers on the optimal caesarean rate has not been documented. The objective of this study was to examine providers’ opinions of the optimal caesarean rate worldwide, among all deliveries and within specific sub-groups of deliveries. Methods A global online survey of medical doctors who had performed at least one caesarean in the last five years was conducted between August 2013 and January 2014. Respondents were asked to report their opinion of the optimal caesarean rate—defined as the caesarean rate that would minimise poor maternal and perinatal outcomes—at the population level and within specific sub-groups of deliveries (including women with demographic and clinical risk factors for caesareans). Median reported optimal rates and corresponding inter-quartile ranges (IQRs) were calculated for the sample, and stratified according to national caesarean rate, institutional caesarean rate, facility level, and respondent characteristics. Results Responses were collected from 1,057 medical doctors from 96 countries. The median reported optimal caesarean rate was 20% (IQR: 15–30%) for all deliveries. Providers in private for-profit facilities and in facilities with high institutional rates reported optimal rates of 30% or above, while those in Europe, in public facilities and in facilities with low institutional rates reported rates of 15% or less. Reported optimal rates were lowest among low-risk deliveries and highest for Absolute Maternal Indications (AMIs), with wide IQRs observed for most categories other than AMIs. Conclusions Three-quarters of respondents reported an optimal caesarean rate above the WHO 15% upper threshold. There was substantial variation in responses, highlighting a lack of consensus around which women are in need of a caesarean among obstetric care providers worldwide.

The role of the private sector in delivery in low-income and middle-income countries: a retrospective, observational analysis of Demographic and Health Surveys from 57 countries

Abstract Background Maternal mortality rates have decreased worldwide in recent decades but remain offtrack for the Millennium Development Goals. Strategies to achieve equitable maternal outcomes will need to effectively reach the most socioeconomically vulnerable women. We assessed the role of the private sector in the provision of institutional delivery care, and compare equity and quality of private sector care with the public sector. Methods We used data from the 57 countries in the Demographic and Health Survey 2000–12 to analyse delivery care for the most recent birth among 337 208 women. We created weighted estimates for each geographical region, using wealth quintile for equity analysis. We used the presence of a skilled birth attendant and caesarean section as proxies for cross-sector comparisons of delivery care quality. Findings The proportion of women delivering in health facilities varied widely between regions (from 201 057 [42%] in south and southeast Asia, to 25 193 [79%] in north Africa, west Asia, and Europe) and increased with wealth quintile in every region. The largest difference in the proportion of births delivered in a facility between poorest and richest quintiles was in south and southeast Asia (67%) and the lowest was in the north Africa, west Asia, and Europe region (41%). The proportion of all facility deliveries occurring in private sector facilities ranged from 10% in Latin America and the Caribbean to 57% in south and southeast Asia. Depending on region, the wealthiest women were 4–13-times more likely to deliver in private facilities than were the poorest. Inequalities based on wealth also existed for the care women received in facilities. Among women delivering in public sector facilities in all countries (n=95 547), 94% in the poorest and 98% in the richest quintile delivered with a skilled birth attendant. In private sector facilities, 86% of the poorest and 98% of the richest women had a skilled birth attendant. In every region, the proportion of deliveries by caesarean section increased with rising wealth and caesarean section was more common in the private sector than in the public sector. The difference for the proportion of caesarean sections between the two sectors was smallest in sub-Saharan Africa (2%) and largest in north Africa, west Asia, Europe (21%). Interpretation This study is the largest analysis of the role of the private sector in delivery care. More information is needed about whether the role of the private sector in various countries is a reaction to the failures within the public health system or a substitution effect. Future research should describe countries that achieved rapid improvements in facility delivery rates and assess the contribution of the private sector to this trend. Funding MSD for Mothers.

Who delivers where? The effect of obstetric risk on facility delivery in East Africa

Skilled attendance at birth is key for the survival of pregnant women. This study investigates whether women at increased risk of maternal and newborn complications in four East African countries are more likely to deliver in a health facility than those at lower risk.

Examining trends in family planning among harder-to-reach women in Senegal 1992-2014.

Recent increases in family planning (FP) use have been reported among women of reproductive age in union (WRAU) in Senegal. However, trends have not been monitored among harder-to-reach groups (including adolescents, unmarried and rural poor women), key to understanding whether FP progress is equitable. We combined data from six Demographic and Health Surveys conducted in Senegal between 1992/93 and 2014. We examined FP trends over time among WRAU and subgroups, and trends in knowledge of FP and intention to use among women with unmet need for FP. Our results show that percent demand satisfied is lower among rural poor women and adolescents than WRAU, although higher among unmarried women. Marked recent increases have been observed in all subgroups, however fewer than 50% of women in need of FP use modern contraception in Senegal. Knowledge of FP has risen steadily among women with unmet need; however, intention to use FP has remained stable at around 40% since 2005 for all groups except unmarried women (75% of whom intend to use). Significant progress in meeting the need for FP has been achieved in Senegal, but more needs to be done particularly to improve acceptability of FP, and to strategically target interventions toward adolescents and rural poor women.

Donor funding for family planning: levels and trends between 2003 and 2013

Abstract The International Conference on Population and Development in 1994 set targets for donor funding to support family planning programmes, and recent initiatives such as FP2020 have renewed focus on the need for adequate funding to rights-based family planning. Disbursements supporting family planning disaggregated by donor, recipient country and year are not available for recent years. We estimate international donor funding for family planning in 2003–13, the period covering the introduction of reproductive health targets to the Millennium Development Goals and up to the beginning of FP2020, and compare funding to unmet need for family planning in recipient countries. We used the dataset of donor disbursements to support reproductive, maternal, newborn and child health developed by the Countdown to 2015 based on the Organization for Economic Cooperation and Development Creditor Reporting System. We assessed levels and trends in disbursements supporting family planning in the period 2003–13 and compared this to unmet need for family planning. Between 2003 and 2013, disbursements supporting family planning rose from under

Caesarean section provision and readiness in Tanzania: analysis of cross-sectional surveys of women and health facilities over time.

400 m prior to 2008 to