Jenny A. Cresswell

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.

Effect of maternal obesity on neonatal death in sub-Saharan Africa: multivariable analysis of 27 national datasets

BACKGROUND Rates of obesity are increasing worldwide, including in sub-Saharan Africa. Neonates born to obese mothers in low-income settings are at increased risk of complications including admission to neonatal intensive care, macrosomia, low Apgar scores, and perinatal death. We investigated whether maternal obesity is a risk factor for neonatal death in sub-Saharan Africa and the effect on the detailed timing of death within the neonatal period. METHODS Cross-sectional Demographic and Health Surveys from 27 sub-Saharan countries (2003-09) were pooled. We used multivariable logistic regression to assess the risk of neonatal death (in womens most recent singleton livebirth in the 5 years preceding the survey) by maternal body-mass index (BMI) category (measured during the survey). Timing of death was investigated with a discrete-time survival model. FINDINGS 15,518 of 81,126 eligible women were overweight (4266 were obese), 52,006 had an optimum BMI, and 13,602 were underweight. Maternal obesity was associated with an increased odds of neonatal death after adjustment for confounding factors (adjusted odds ratio 1·46, 95% CI 1·11-1·91). Maternal obesity was a significant risk factor for neonatal deaths occurring during the first 2 days of life (1·62, 1·11-2·37). We noted no statistically significant relation later in the neonatal period (days 2-6 1·36, 0·84-2·21; days 7-27 1·19, 0·65-2·18), possibly because of low statistical power. INTERPRETATION Maternal obesity in sub-Saharan Africa is associated with increased risk of early neonatal death. Potential mechanisms include prematurity, intrapartum events, or infections. Strategies to prevent and reduce obesity need to be considered; obese women should be advised to deliver in a health-care facility that can provide emergency obstetric and neonatal care. FUNDING Economic and Social Research Council.

Prevalence of placenta praevia by world region: a systematic review and meta-analysis

(i) To estimate the prevalence burden of placenta praevia in each world region, and (ii) to investigate potential sources of heterogeneity.

Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK.

BackgroundIn the UK, women are recommended to engage with maternity services and establish a plan of care prior to the 12th completed week of pregnancy. The aim of this study was to identify predictors for late initiation of antenatal care within an ethnically diverse cohort in East London.MethodsCross-sectional analysis of routinely collected electronic patient record data from Newham University Hospital NHS Trust (NUHT). All women who attended their antenatal booking appointment within NUHT between 1st January 2008 and 24th January 2011 were included in this study. The main outcome measure was late antenatal booking, defined as attendance at the antenatal booking appointment after 12 weeks (+6 days) gestation. Data were analysed using multivariable logistic regression with robust standard errors.ResultsLate initiation of antenatal care was independently associated with non-British (White) ethnicity, inability to speak English, and non-UK maternal birthplace in the multivariable model. However, among those women who both spoke English and were born in the UK, the only ethnic group at increased risk of late booking were women who identified as African/Caribbean (aOR: 1.40: 95% CI: 1.11, 1.76) relative to British (White). Other predictors identified include maternal age younger than 20 years (aOR: 1.32; 95% CI: 1.13-1.54), high parity (aOR: 2.09; 95% CI: 1.77-2.46) and living in temporary accommodation (aOR: 1.71; 95% CI: 1.35-2.16).ConclusionsSocio-cultural factors in addition to poor English ability or assimilation may play an important role in determining early initiation of antenatal care. Future research should focus on effective interventions to encourage and enable these minority groups to engage with the maternity services.

Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco.

BackgroundAcross the Africa region and beyond, the last decade has seen many countries introducing policies aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso, Mali and Morocco.MethodsThe study uses a comparative case study design with mixed methods, including realist evaluation components. This article presents results across 14 different data collection tools, used in 4–6 research sites in each of the four study countries over 2011-13. The methods included: document review; interviews with key informants; analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff; interviews with patients and observation of care processes.ResultsThe article finds that the policies have contributed to continued increases in skilled birth attendance and caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households after the policy, suggesting that the financial protection objectives may have been met, at least in the short term, although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative effects on technical quality of care, or of unintended negative effects on untargeted services.ConclusionsWe conclude that the policies were effective in meeting financial protection goals and probably health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and equity. These include broadening the exempted package (especially for those countries which focused on caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for indigents, and paying more attention to quality of care, especially for newborns.RésuméIntroductionCes dix dernières années de nombreux pays africains ont introduit des politiques visant à réduire les barrières financières aux soins obstétricaux. Cet article fournit des informations sur les coûts et les effets des politiques nationales axées sur l’amélioration de l’accès financier aux césariennes et plus largement aux accouchements au Bénin, Burkina Faso, Mali et Maroc.MéthodesUne étude comparative d’études de cas, avec des composantes d’évaluation réaliste, a été réalisée en utilisant des méthodes mixtes (quantitatives et qualitatives). Cet article présente les résultats de 14 outils de collecte différents, utilisés dans 4 à 6 sites de recherche dans chacun des quatre pays de l’étude entre 2011 et 2013.RésultatsL’étude a montré une augmentation croissante de l’assistance qualifiée à l’accouchement et du taux de césariennes ainsi qu’une diminution des inégalités dans les quatre pays, mais ces tendances étaient déjà en cours avant l’introduction des politiques d’exemption de sorte qu’un changement ne peut pas être attribué seulement à ces dernières. Une réduction significative des charges financières sur les ménages - après l’introduction des politiques - a été trouvée, ce qui suggère que les objectifs de protection financière ont été en partie remplis, au moins à court terme, bien qu’aucun site n’ait réussi à maintenir une exonération totale des coûts ciblés. Dans les quatre pays les politiques sont financées sur le budget national et donc potentiellement pérennes et ont été relativement bien mises en œuvre. En outre, aucune preuve d’effets négatifs sur la qualité technique des soins ou sur les services non ciblés n’a été mise en évidence.ConclusionsLes politiques ont permis d’atteindre les objectifs de protection financière et probablement les objectifs de santé et d’équité, à un coût pérenne, mais une série de mesures pourrait augmenter leur efficacité. Celles-ci comprennent l’élargissement du paquet de soins exemptés (en particulier pour les pays ciblant uniquement les césariennes), un système de paiement des hôpitaux mieux calibré, des informations plus claires sur les politiques, une meilleure gestion du système de santé local pour faire face à des faiblesses systémiques sous-jacentes, et plus d’attention à la qualité des soins, en particulier pour les nouveau-nés.

Women's knowledge and attitudes surrounding abortion in Zambia: a cross-sectional survey across three provinces

Objectives In Zambia, despite a relatively liberal legal framework, there remains a substantial burden of unsafe abortion. Many women do not use skilled providers in a well-equipped setting, even where these are available. The aim of this study was to describe womens knowledge of the law relating to abortion and attitudes towards abortion in Zambia. Setting Community-based survey in Central, Copperbelt and Lusaka provinces. Participants 1484 women of reproductive age (15–44 years). Primary and secondary outcome measures Correct knowledge of the legal grounds for abortion, attitudes towards abortion services and the previous abortions of friends, family or other confidants. Descriptive statistics and multivariable logistic regression were used to analyse how knowledge and attitudes varied according to sociodemographic characteristics. Results Overall, just 16% (95% CI 11% to 21%) of women of reproductive age correctly identified the grounds for which abortion is legal. Only 40% (95% CI 32% to 45% of women of reproductive age knew that abortion was legally permitted in the extreme situation where the pregnancy threatens the life of the mother. Even in urban areas of Lusaka province, only 55% (95% CI 41% to 67%) of women knew that an abortion could legally take place to save the mothers life. Attitudes remain conservative. Women with correct knowledge of abortion law in Zambia tended to have more liberal attitudes towards abortion and access to safe abortion services. Neither correct knowledge of the law nor attitudes towards abortion were associated with knowing someone who previously had an induced abortion. Conclusions Poor knowledge and conservative attitudes are important obstacles to accessing safe abortion services. Changing knowledge and attitudes can be challenging for policymakers and public health practitioners alike. Zambia could draw on its previous experience in dealing with its large HIV epidemic to learn cross-cutting lessons in effective mass communication on what is a difficult and sensitive issue.

Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012.

To examine trends in the utilisation of facility‐based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor, and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care.

Incidence of abortion-related near-miss complications in Zambia: cross-sectional study in Central, Copperbelt and Lusaka Provinces

OBJECTIVES To describe the magnitude and severity of abortion-related complications in health facilities and calculate the incidence of abortion-related near-miss complications at the population level in three provinces in Zambia, a country where abortion is legal but stigmatized. STUDY DESIGN We conducted a cross-sectional study in 35 district, provincial and tertiary hospitals over 5 months. All women hospitalized for abortion-related complications were eligible for inclusion. Cases of abortion-related near-miss, moderate and low morbidity were identified using adapted World Health Organization (WHO) near-miss and the prospective morbidity methodology criteria. Incidence was calculated by annualizing the number of near-misses and dividing by the population of women of reproductive age. We calculated the abortion-related near-miss rate, abortion-related near-miss ratio and the hospital mortality index. RESULTS Participating hospitals recorded 26,723 births during the study. Of admissions for post-abortion care, 2406 (42%) were eligible for inclusion. Near-misses constituted 16% of admitted complications and there were 14 abortion-related maternal deaths. The hospital mortality index was 3%; the abortion-related near-miss rate for the three provinces was 72 per 100,000 women, and the near-miss ratio was 450 per 100,000 live births. CONCLUSIONS Abortion-related near-miss and mortality are challenges for the Zambian health system. Adapted to reflect health systems capabilities, the WHO near-miss criteria can be applied to routine hospital records to obtain useful data in low-income settings. Reducing avoidable maternal mortality and morbidity due to abortion requires efforts to de-stigmatize access to abortion provision, and expanded access to modern contraception. IMPLICATIONS The abortion-related near-miss rate is high in Zambia compared with other restrictive contexts. Our results suggest that near-miss is a promising indicator of unsafe abortion; can be measured using routine hospital data, conveniently defined using the WHO criteria; and can be incorporated into the frequently utilized prospective morbidity methodology.

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.

‘Rowing against the current’: the policy process and effects of removing user fees for caesarean sections in Benin

Background In 2009, the Benin government introduced a user fee exemption policy for caesarean sections. We analyse this policy with regard to how the existing ideas and institutions related to user fees influenced key steps of the policy cycle and draw lessons that could inform the policy dialogue for universal health coverage in the West African region. Methods Following the policy stages model, we analyse the agenda setting, policy formulation and legitimation phase, and assess the implementation fidelity and policy results. We adopted an embedded case study design, using quantitative and qualitative data collected with 13 tools at the national level and in seven hospitals implementing the policy. Results We found that the initial political goal of the policy was not to reduce maternal mortality but to eliminate the detention in hospitals of mothers and newborns who cannot pay the user fees by exempting a comprehensive package of maternal health services. We found that the policy development process suffered from inadequate uptake of evidence and that the policy content and process were not completely in harmony with political and public health goals. The initial policy intention clashed with the neoliberal orientation of the political system, the fee recovery principles institutionalised since the Bamako Initiative and the prevailing ideas in favour of user fees. The policymakers did not take these entrenched factors into account. The resulting tension contributed to a benefit package covering only caesarean sections and to the variable implementation and effectiveness of the policy. Conclusion The influence of organisational culture in the decision-making processes in the health sector is often ignored but must be considered in the design and implementation of any policy aimed at achieving universal health coverage in West African countries.