Melissa Neuman

Demographic and health surveys: a profile

Demographic and Health Surveys (DHS) are comparable nationally representative household surveys that have been conducted in more than 85 countries worldwide since 1984. The DHS were initially designed to expand on demographic, fertility and family planning data collected in the World Fertility Surveys and Contraceptive Prevalence Surveys, and continue to provide an important resource for the monitoring of vital statistics and population health indicators in low- and middle-income countries. The DHS collect a wide range of objective and self-reported data with a strong focus on indicators of fertility, reproductive health, maternal and child health, mortality, nutrition and self-reported health behaviours among adults. Key advantages of the DHS include high response rates, national coverage, high quality interviewer training, standardized data collection procedures across countries and consistent content over time, allowing comparability across populations cross-sectionally and over time. Data from DHS facilitate epidemiological research focused on monitoring of prevalence, trends and inequalities. A variety of robust observational data analysis methods have been used, including cross-sectional designs, repeated cross-sectional designs, spatial and multilevel analyses, intra-household designs and cross-comparative analyses. In this profile, we present an overview of the DHS along with an introduction to the potential scope for these data in contributing to the field of micro- and macro-epidemiology. DHS datasets are available for researchers through MEASURE DHS at www.measuredhs.com.

Women's views on consent, counseling and confidentiality in PMTCT: a mixed-methods study in four African countries

BackgroundAmbitious UN goals to reduce the mother-to-child transmission of HIV have not been met in much of Sub-Saharan Africa. This paper focuses on the quality of information provision and counseling and disclosure patterns in Burkina Faso, Kenya, Malawi and Uganda to identify how services can be improved to enable better PMTCT outcomes.MethodsOur mixed-methods study draws on data obtained through: (1) the MATCH (Multi-country African Testing and Counseling for HIV) studys main survey, conducted in 2008-09 among clients (N = 408) and providers at health facilities offering HIV Testing and Counseling (HTC) services; 2) semi-structured interviews with a sub-set of 63 HIV-positive women on their experiences of stigma, disclosure, post-test counseling and access to follow-up psycho-social support; (3) in-depth interviews with key informants and PMTCT healthcare workers; and (4) document study of national PMTCT policies and guidelines. We quantitatively examined differences in the quality of counseling by country and by HIV status using Fishers exact tests.ResultsThe majority of pregnant women attending antenatal care (80-90%) report that they were explained the meaning of the tests, explained how HIV can be transmitted, given advice on prevention, encouraged to refer their partners for testing, and given time to ask questions. Our qualitative findings reveal that some women found testing regimes to be coercive, while disclosure remains highly problematic. 79% of HIV-positive pregnant women reported that they generally keep their status secret; only 37% had disclosed to their husband.ConclusionTo achieve better PMTCT outcomes, the strategy of testing women in antenatal care (perceived as an exclusively female domain) when they are already pregnant needs to be rethought. When scaling up HIV testing programs, it is particularly important that issues of partner disclosure are taken seriously.

Urban-rural differences in BMI in low- and middle-income countries: the role of socioeconomic status

BACKGROUND Urbanization is often cited as a main cause of increasing BMIs in low- and middle-income countries (LMICs), and urban residents in LMICs tend to have higher BMIs than do rural residents. However, urban-rural differences may be driven by differences in socioeconomic status (SES). OBJECTIVE Using nationally representative data collected at 2 time points in 38 LMICs, we assessed the association between urban residence and BMI before and after adjustment for measures of individual- and household-level SES. DESIGN We conducted a cross-sectional analysis of nationally representative samples of 678,471 nonpregnant women aged 15-49 y, with 225,312 women in the earlier round of surveys conducted between 1991 and 2004 and 453,159 women in the later round conducted between 1998 and 2010. We used linear and ordered multinomial analysis with a country fixed effect to obtain a pooled estimate and a country-stratified analysis. RESULTS We found that mean BMI (kg/m²) in less-developed countries was generally higher within urban areas (excess BMI associated with urban residence before wealth index adjustment: 1.55; 95% CI: 1.52, 1.57). However, the urban association was attenuated after SES was accounted for (association after adjustment: 0.44; 95% CI: 0.41, 0.47). Individual- and household-level SES measures were independently and positively associated with BMI. CONCLUSION The association between urban residence and obesity in LMICs is driven largely by higher individual- and community-level SES in urban areas, which suggests that urban residence alone may not cause increased body weight in developing countries.

The poor stay thinner: stable socioeconomic gradients in BMI among women in lower- and middle-income countries

BACKGROUND Recent studies have shown a strong positive association between individual BMI (in kg/m(2)) or overweight prevalence and socioeconomic status (SES) in low- and middle-income countries (LMICs). However, it is not clear whether this association is weakening or reversing over time. OBJECTIVE With the use of nationally representative data collected at 2 time points in 37 LMICs, we compared the associations of SES with BMI and of SES with overweight between the earlier surveys and the later surveys. DESIGN We conducted a cross-sectional analysis of nationally representative samples of 547,056 ever-married nonpregnant women aged 15-49 y: 208,570 women in the earlier round of surveys conducted between 1991 and 2003 and 338,486 women in the later round conducted between 1998 and 2008. We used linear and modified Poisson analyses with a country fixed effect to obtain a pooled estimate and a country-stratified analysis for country-specific estimates. RESULTS In adjusted models, BMI was 2.32 units higher (95% CI: 2.23, 2.41 units) among women in the wealthiest quintile compared with women in the poorest quintile in the earlier surveys and was 3.00 units higher (95% CI: 2.92, 3.07 units) in the later surveys. The association between BMI and wealth was positive in 37 countries in the earlier round of surveys and in 36 countries in the later round. Patterns were similar for overweight prevalence. CONCLUSION The association between SES and BMI or overweight is positive in most LMICs and has not weakened over time. It appears that the burden of overweight is consistently greater among wealthier populations within LMICs.

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal

Objectives To describe the prevalence and determinants of births by caesarean section in private and public health facilities in underserved communities in South Asia. Design Cross-sectional study. Setting 81 community-based geographical clusters in four locations in Bangladesh, India and Nepal (three rural, one urban). Participants 45 327 births occurring in the study areas between 2005 and 2012. Outcome measures Proportion of caesarean section deliveries by location and type of facility; determinants of caesarean section delivery by location. Results Institutional delivery rates varied widely between settings, from 21% in rural India to 90% in urban India. The proportion of private and charitable facility births delivered by caesarean section was 73% in Bangladesh, 30% in rural Nepal, 18% in urban India and 5% in rural India. The odds of caesarean section were greater in private and charitable health facilities than in public facilities in three of four study locations, even when adjusted for pregnancy and delivery characteristics, maternal characteristics and year of delivery (Bangladesh: adjusted OR (AOR) 5.91, 95% CI 5.15 to 6.78; Nepal: AOR 2.37, 95% CI 1.62 to 3.44; urban India: AOR 1.22, 95% CI 1.09 to 1.38). We found that highly educated women were particularly likely to deliver by caesarean in private facilities in urban India (AOR 2.10; 95% CI 1.61 to 2.75) and also in rural Bangladesh (AOR 11.09, 95% CI 6.28 to 19.57). Conclusions Our results lend support to the hypothesis that increased caesarean section rates in these South Asian countries may be driven in part by the private sector. They also suggest that preferences for caesarean delivery may be higher among highly educated women, and that individual-level and provider-level factors interact in driving caesarean rates higher. Rates of caesarean section in the private sector, and their maternal and neonatal health outcomes, require close monitoring.

Associations between mode of HIV testing and consent, confidentiality, and referral: a comparative analysis in four African countries.

A study carried out by Carla Obermeyer and colleagues examines whether practices regarding consent, confidentiality, and referral vary depending on whether HIV testing is provided through voluntary counseling and testing or provider-initiated testing.

Socio-economic determinants of HIV testing and counselling : a comparative study in four African countries

Research indicates that individuals tested for HIV have higher socio‐economic status than those not tested, but less is known about how socio‐economic status is associated with modes of testing. We compared individuals tested through provider‐initiated testing and counselling (PITC), those tested through voluntary counselling and testing (VCT) and those never tested.

Do support groups members disclose less to their partners? The dynamics of HIV disclosure in four African countries

BackgroundRecent efforts to curtail the HIV epidemic in Africa have emphasised preventing sexual transmission to partners through antiretroviral therapy. A component of current strategies is disclosure to partners, thus understanding its motivations will help maximise results. This study examines the rates, dynamics and consequences of partner disclosure in Burkina Faso, Kenya, Malawi and Uganda, with special attention to the role of support groups and stigma in disclosure.MethodsThe study employs mixed methods, including a cross-sectional client survey of counselling and testing services, focus groups, and in-depth interviews with HIV-positive individuals in stable partnerships in Burkina Faso, Kenya, Malawi and Uganda, recruited at healthcare facilities offering HIV testing.ResultsRates of disclosure to partners varied between countries (32.7% – 92.7%). The lowest rate was reported in Malawi. Reasons for disclosure included preventing the transmission of HIV, the need for care, and upholding the integrity of the relationship. Fear of stigma was an important reason for non-disclosure. Women reported experiencing more negative reactions when disclosing to partners. Disclosure was positively associated with living in urban areas, higher education levels, and being male, while being negatively associated with membership to support groups.ConclusionsUnderstanding of reasons for disclosure and recognition of the role of support groups in the process can help improve current prevention efforts, that increasingly focus on treatment as prevention as a way to halt new infections. Support groups can help spread secondary prevention messages, by explaining to their members that antiretroviral treatment has benefits for HIV positive individuals and their partners. Home-based testing can further facilitate partner disclosure, as couples can test together and be counselled jointly.

Global trends in body-mass index

1916 www.thelancet.com Vol 377 June 4, 2011 Mariel Finucane and colleagues used population-representative data on measured weight and height from 199 countries and territories to estimate national, regional, and worldwide trends in body-mass index (BMI) in adult men and women from 1980 to 2008. They found an increase in mean BMI in all regions worldwide; in 2008, an estimated 1·46 billion adults were overweight (BMI ≥25 kg/m2), including 500 million who were obese (BMI ≥30 kg/m2). Estimated prevalences for higher BMI categories, however, were not reported. Although the risks of disease and premature death increase progressively with BMI, few reliable data exist for population-based trends in extreme BMI ranges (eg, BMI ≥40 kg/m2 and BMI ≥50 kg/m2) owing to the large sample sizes required. Telephone survey data from the USA suggest that the prevalence of adults with extreme BMIs has increased several times faster than have the pre valences of overweight and moderate obesity. Population distri butions of BMI do not follow a bell-shaped form but are rightskewed, particularly in women. In a study of 4776 people who had had bariatric surgery, in which 33% had a BMI of 50 kg/m2 or more, 3767 (79%) were women. A disproportionately rapid increase in the prevalence of extreme BMI highlights the need to prevent obesity in the general population and to enable health-care services to tackle increasing numbers of patients with severe obesity. Finucane and col leagues could use their unique dataset to assess sex-specifi c trends for higher BMI categories on national, regional, and global levels.

Cause-specific neonatal mortality: analysis of 3772 neonatal deaths in Nepal, Bangladesh, Malawi and India

Objective Understanding the causes of death is key to tackling the burden of three million annual neonatal deaths. Resource-poor settings lack effective vital registration systems for births, deaths and causes of death. We set out to describe cause-specific neonatal mortality in rural areas of Malawi, Bangladesh, Nepal and rural and urban India using verbal autopsy (VA) data. Design We prospectively recorded births, neonatal deaths and stillbirths in seven population surveillance sites. VAs were carried out to ascertain cause of death. We applied descriptive epidemiological techniques and the InterVA method to characterise the burden, timing and causes of neonatal mortality at each site. Results Analysis included 3772 neonatal deaths and 3256 stillbirths. Between 63% and 82% of neonatal deaths occurred in the first week of life, and males were more likely to die than females. Prematurity, birth asphyxia and infections accounted for most neonatal deaths, but important subnational and regional differences were observed. More than one-third of deaths in urban India were attributed to asphyxia, making it the leading cause of death in this setting. Conclusions Population-based VA methods can fill information gaps on the burden and causes of neonatal mortality in resource-poor and data-poor settings. Local data should be used to inform and monitor the implementation of interventions to improve newborn health. High rates of home births demand a particular focus on community interventions to improve hygienic delivery and essential newborn care.