Sabu S. Padmadas

Delivery settings and caesarean section rates in China

OBJECTIVE To quantify the influence of increasing use of health-care services on rising rates of caesarean section in China. METHODS We used data from a population-based survey conducted by the United Nations Population Fund during September 2003 in 30 selected counties in three regions of China. The study sample (derived from birth history schedule) consisted of 3803 births to mothers aged less than 40 years between 1993 and 2002. Multiple logistic regression models were used to estimate the effect of health-care factors on the odds of a caesarean section, controlling for time and selected variables. FINDINGS Institutional births increased from 53.5% in 1993-1994 to 82.2% in 2001-2002, while the corresponding increase in births by caesarean section was from 8.9% to 24.8%, respectively. Decomposition analysis showed that 69% of the increase in rates of caesarean section was driven by the increase in births within institutions. The adjusted odds of a caesarean section were 4.6 times (95% confidence interval, CI: 3.4-11.8) higher for recent births. The adjusted odds were also significantly higher for mothers who had at least one antenatal ultrasound test. Rates of caesarean section in secondary-level facilities markedly increased over the last decade to the same levels as in major hospitals (P < 0.001). CONCLUSION The upsurge in rates of births by caesarean section in this population cannot be fully explained by increases in institutional births alone, but is likely to be driven by medical practice within secondary-level hospitals and womens demand for the procedure.

Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries.

Caesarean section rates have risen dramatically in several developing countries, especially in Latin America and South Asia. This raises a range of concerns about the use of caesarean section for non-emergency cases, not least the progressive shift of resources to non-essential medical interventions in resource-poor settings and additional health risks to mothers and newborns following a caesarean section. There are only a few studies that have systematically examined the factors influencing the recent increase in caesarean rates. In particular, it is not clear whether high elective caesarean rates are driven by medical, institutional or individual and family decisions. Where a womans decisions predominate her interaction with peers and significant others have an impact on her caesarean section choices. Using random intercept logistic regression analyses, this paper analyses the institutional, socio-economic and community factors that influence caesarean section in six countries: Bangladesh, Colombia, Dominican Republic, Egypt, Morocco and Vietnam. The analyses, based on data from over 20,000 births, show that women of higher socio-economic background, who had better access to antenatal services are the most likely to undergo a caesarean section. Women who exchange reproductive health information with friends and family are less likely to experience a caesarean section than their counterparts. The study concludes that there is a need to pursue community-based approaches for curbing rising caesarean section rates in resource-poor settings.

Caesarean section delivery in Kerala, India: Evidence from a national family health survey

Ensuring safe pregnancy and motherhood occupies a pivotal role and has been considered as one of the key issues in the framework of reproductive and child health programmes. Evidence from research studies indicate that there is a growing tendency for caesarean section deliveries especially during complications confronted at the time of pregnancy and delivery. The present study focuses on the demographic, antenatal care, spatial and socio-economic variables associated with caesarean section delivery in Kerala, India. The data from the National Family Health Survey has been utilised for this purpose. The results from logistic regression models indicate that maternal age, birth order, current age, births in health institutions and spatial differences were significantly associated with caesarean section deliveries in Kerala. The older cohorts of mothers were found at higher risk to have caesarean section when compared to their younger counterparts. When controlled for demographic variables, the odds for caesarean section was about 1.7 times more likely to occur in private health institutions. The inclusion of spatial and socio-economic variables has neither influenced the demographic and antenatal care variables nor showed any significant association with caesarean section delivery in the state. The present study calls for that a detailed investigation on behavioural aspects of both the physician and the patient with regard to type of delivery in the state. Information related to pregnancy and health related aspects needs to be monitored more accurately, both in the public and private hospitals, to understand the determinants associated with caesarean section.

Socio-Economic Inequalities in the Use of Postnatal Care in India

Objectives First, our objective was to estimate socio-economic inequalities in the use of postnatal care (PNC) compared with those in the use of care at birth and antenatal care. Second, we wanted to compare inequalities in the use of PNC between facility births and home births and to determine inequalities in the use of PNC among mothers with high-risk births. Methods and Findings Rich–poor ratios and concentration indices for maternity care were estimated using the third round of the District Level Household Survey conducted in India in 2007–08. Binary logistic regression models were used to examine the socio-economic inequalities associated with use of PNC after adjusting for relevant socio-economic and demographic characteristics. PNC for both mothers and newborns was substantially lower than the care received during pregnancy and child birth. Only 44% of mothers in India at the time of survey received any care within 48 hours after birth. Likewise, only 45% of newborns received check-up within 24 hours of birth. Mothers who had home births were significantly less likely to have received PNC than those who had facility births, with significant differences across the socio-economic strata. Moreover, the rich-poor gap in PNC use was significantly wider for mothers with birth complications. Conclusions PNC use has been unacceptably low in India given the risks of mortality for mothers and babies shortly after birth. However, there is evidence to suggest that effective use of pregnancy and childbirth care in health facilities led to better PNC. There are also significant socio-economic inequalities in access to PNC even for those accessing facility-based care. The coverage of essential PNC is inadequate, especially for mothers from economically disadvantaged households. The findings suggest the need for strengthening PNC services to keep pace with advances in coverage for care at birth and prenatal services in India through targeted policy interventions.

Compression of Women's Reproductive Spans in Andhra Pradesh, India

CONTEXT The total fertility rate in Andhra Pradesh, India, has recently decreased to near-replacement level; however, the reasons for the fertility decline are unknown. METHODS Data from the second round of the National Family Health Survey were used to examine the reproductive span-the duration between first marriage and menopause or sterilization-among 4,032 ever-married women aged 15-49 living in Andhra Pradesh in 1998-1999. RESULTS Between 1992-1993 and 1998-1999, the median age at which women married remained at 15.1, whereas the age at which they adopted sterilization decreased from 24.5 to 23.6. In life-table analyses, reproductive spans of successive cohorts of women decreased-from 22 years among those who married during the 1960s to 15 years among those who married in the 1970s, 10 years among those who married in the 1980s and five years among those who married in 1990-1996. Proportional hazards regression analyses that controlled for demographic and social characteristics, as well as reproductive attitudes, confirmed this cohort effect (hazard ratios, 1.5-2.6). CONCLUSIONS These findings suggest that women are making the decision to end childbearing faster than older generations did. The gradual compression in reproductive spans is attributable mainly to sterilization acceptance among younger women.

Fertility-limiting behavior and contraceptive choice among men in Nepal.

Context: Contraceptive choices among men who want no more children have been little explored in South Asia, particularly in Nepal, where fertility rates have remained high over the last few decades. Methods: Using the 2001 Nepal Demographic and Health Survey couple data set, multinomial logistic regression analyses were conducted for 1,041 married men aged 20 or older who had at least one living child and wanted no more children. Regression models examined relationships between selected characteristics and mens reported contraceptive use, and predicted probabilities were estimated to assess interactions between ecological zone, family composition and method choice. The primary goal was to determine whether the number and sex of living children influenced contraceptive use. Results: Twenty-four percent of men who wanted no more children were not using any contraceptive method at the time of the survey, 30% reported that their wives were sterilized, 12% had had a vasectomy, 7% were using condoms and 27% used other temporary methods. The probability of relying on permanent methods was highest among men who had at least two living sons and lowest among those who had only daughters, while the probability of using no method was highest among those who had only daughters. Conclusion: In Nepal, men who report a desire to have no more children are likely to choose permanent methods only after they have two living sons.

Disentangling women's responses on complex dietary intake patterns from an Indian cross-sectional survey: a latent class analysis.

OBJECTIVE To investigate the degree of individual heterogeneity related to complex dietary behaviour and to further examine the associations of different dietary compositions with selected characteristics. DESIGN Latent class analysis was applied to data from the recent cross-sectional National Family Health Survey that collected information on the intake frequency of selected foods. Different responses regarding intake frequency were condensed into a set of five meaningful latent clusters representing different dietary patterns and these clusters were then labelled based on the reported degree of diet mixing. SETTING Indian states. Subjects In total, 90,180 women aged 15-49 years. RESULTS Three clusters were predominantly non-vegetarian and two were vegetarian. A very high or high mixed-diet pattern was observed particularly in the southern and a few north-eastern states. Many women in the very high mixed-diet cluster consumed mostly non-green/leafy vegetables on a daily basis, and fruits and other non-vegetarian diet on a weekly basis. In contrast, those in the low mixed-diet cluster consumed more than three-fifths of the major vegetarian diet ingredients alone on a daily basis. The affluent group that represented the low mixed-diet cluster were primarily vegetarians and those who represented the very high mixed-diet cluster were mostly non-vegetarians. The significant interrelationships of different characteristics highlight not only socio-economic, spatial and cultural disparities related to dietary practices, but also the substantial heterogeneity in diet mixing behaviour. CONCLUSIONS The results of this study confirmed our hypothesis of heterogeneous dietary behaviour of Indian women and yielded useful policy-oriented results which might be difficult to establish otherwise.

On the Spatial Inequalities of Institutional Versus Home Births in Ghana: A Multilevel Analysis

Spatial inequalities related to the choice of delivery care have not been studied systematically in Sub-Saharan Africa where maternal and perinatal health outcomes continue to worsen despite a range of safe motherhood interventions. Using retrospective data from the 1998 and 2003 Demographic and Health Surveys, this paper investigates the extent of changes in spatial inequalities associated with type of delivery care in Ghana with a focus on rural–urban differentials within and across the three ecological zones (Savannah, Forest and Coastal). More than one-half of births in Ghana continue to occur outside health institutions without any skilled obstetric care. While this is already known, we present evidence from multilevel analyses that there exist considerable and growing inequalities, with regard to birth settings between communities, within rural and urban areas and across the ecological zones. The results show evidence of poor and disproportionate use of institutional care at birth; the inequalities remained high and unchanged in both urban and rural communities within the Savannah zone and widening in urban communities of the Forest and Coastal zones. The key policy challenges in Ghana, therefore, include both increasing the uptake of institutional delivery care and ensuring equity in access to both public and private health institutions.

Antenatal care use in Brazil and India: scale outreach and socioeconomic inequality.

This paper investigates the extent of socioeconomic inequalities in antenatal care use and related medical procedures in Brazil and India, which represent transition economies with contrasting geographical and sociocultural composition and health care provision. Concentration indices and regression analyses applied on recent Demographic Health Survey data reveal high and proportionate distribution of antenatal coverage in Brazil, whereas the Indian case present problems of both scale and equity. Inequalities in access to four or more antenatal visits are significantly pronounced in India, and in Brazil the differences are significant only for those who had six or more visits. Brazils universal healthcare model which proved effective in promoting equitable distribution of antenatal care could be implemented in India. Future interventions should emphasis quality of care in monitoring essential antenatal services especially targeting the poor and deprived communities.

Disentangling the complex association between female genital cutting and HIV among Kenyan women

Female genital cutting (FGC) is a widespread cultural practice in Africa and the Middle East, with a number of potential adverse health consequences for women. It was hypothesized by Kun (1997) that FGC increases the risk of HIV transmission through a number of different mechanisms. Using the 2003 data from the Kenyan Demographic and Health Survey (KDHS), this study investigates the potential association between FGC and HIV. The 2003 KDHS provides a unique opportunity to link the HIV test results with a large number of demographic, social, economic and behavioural characteristics of women, including womens FGC status. It is hypothesized that FGC increases the risk of HIV infection if HIV/AIDS is present in the community. A multilevel binary logistic regression technique is used to model the HIV status of women, controlling for selected individual characteristics of women and interaction effects. The results demonstrate evidence of a statistically significant association between FGC and HIV, after controlling for the hierarchical structure of the data, potential confounding factors and interaction effects. The results show that women who had had FGC and a younger or the same-age first-union partner have higher odds of being HIV positive than women with a younger or same-age first-union partner but without FGC; whereas women who had had FGC and an older first-union partner have lower odds of being HIV positive than women with an older first-union partner but without FGC. The findings suggest the behavioural pathway of association between FGC and HIV as well as an underlying complex interplay of bio-behavioural and social variables being important in disentangling the association between FGC and HIV.