Beyond counting stillbirths to understanding their determinants in low-and middle-income countries: a systematic assessment of stillbirth data availability in household surveys

Objective: To systematically map data availability for stillbirths from all countries with DHS surveys to outline the limitations and challenges with using the data for understanding the determinants and causes of stillbirths, and for cross-country comparisons. Methods: We assessed data sources from the DHS program website, including published DHS reports and their associated questionnaires for surveys completed between 2005 and 2015. Results: Between 2005 and 2015, the DHS program completed 114 surveys across 70 LMICs. Ninety- eight (86.0%) surveys from 66 countries collected stillbirth data adequately to calculate a stillbirth rate, while 16 surveys from 12 countries did not. The method used to count stillbirths varied; 96 (84.2%) surveys used a live birth history with a reproductive calendar, while 16 (14.0%) surveys from 12 countries did a full pregnancy history. Based on assessment of questionnaires, antenatal and delivery care information for stillbirths was only available in 15 surveys (13.2%) from 12 countries (17.1%). Data on maternal conditions/complications were captured in 17 surveys (16.0%), but only in six could these be linked to stillbirths. Data on other recognized risk factors were scarce, varying considerably across surveys. Upon further examination of datasets from surveys with maternity care data on non-live births we found incomplete capture of these data; only two surveys had adequately and completely collected them for stillbirths. Conclusion: Substantial variation exists in DHS surveys in the measurement of stillbirths, with limited scope to examine risk factors or causes. Without immediate improvements our understanding of country-specific trends and determinants for stillbirths will remain hampered, limiting the development, and prioritization of programmatic interventions to prevent these deaths

Neonatal and perinatal mortality in the urban continuum:A geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania

Introduction Neonatal mortality might be higher in urban areas. This paper aims to minimize challenges related to misclassification of neonatal deaths and stillbirths, and oversimplification of the variation in urban environments to accurately estimate the direction and strength of the association between urban residence and neonatal/perinatal mortality in Tanzania. Methods The Tanzania Demographic and Health Survey (DHS) 2015-16 was used to assess birth outcomes for 8,915 pregnancies among 6,156 women of reproductive age, by urban or rural categorization in the DHS and based on satellite imagery. The coordinates of 527 DHS clusters were spatially overlaid with the 2015 Global Human Settlement Layer, showing the degree of urbanisation based on built environment and population density. A three-category urbanicity measure (core urban, semi-urban, and rural) was defined and compared to the binary DHS measure. Travel time to the nearest hospital was modelled using least-cost path algorithm for each cluster. Bivariate and multi-level multivariable logistic regression models were constructed to explore associations between urbanicity and neonatal/perinatal deaths. Results Both perinatal and neonatal mortality rates were highest in core urban and lowest in rural clusters. Bivariate models showed higher odds of neonatal death (OR=1.85; 95% CI: 1.12, 3.08) and perinatal death (OR=1.60; 95% CI 1.12, 2.30) in core urban compared to rural clusters. In multivariable models, these associations had the same direction and size, but were no longer statistically significant. Travel time to nearest hospital was not associated with neonatal or perinatal mortality. Conclusion Addressing the higher rates of neonatal and perinatal mortality in densely populated urban areas is critical for Tanzania to meet national and global reduction targets. Urban populations are diverse, and certain neighbourhoods or sub-groups may be disproportionately affected by poor birth outcomes. Research must sample within and across urban areas to differentiate, understand and minimize risks specific to urban settings. Key questions What is already known? - Urban advantage in health outcomes has been questioned, both for adult and child mortality - An analysis of neonatal mortality using Demographic and Health Survey data in Tanzania in 2015-16 showed double risk in urban compared to rural areas - This phenomenon might be occurring in other sub-Saharan African countries What are the new findings? - Categorisation of locations as urban or rural on the 2015-16 Demographic and Health Survey in Tanzania is both simplistic and inaccurate - Risks of neonatal and perinatal mortality are highest in core, densely populated urban areas in mainland Tanzania, and lowest in rural areas - Travel time to nearest public hospital was not associated with neonatal or perinatal mortality in mainland Tanzania What do the new findings imply? - Extent of urbanicity as an exposure follows a spectrum and needs to be measured and understood as such - Explanatory models specific to neonatal and perinatal mortality in core urban areas are urgently needed to guide actions toward reducing existing high rate - Known risk factors such as anaemia and young maternal age continue to play a role in neonatal and perinatal mortality and must be urgently addressed

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries

BackgroundPersistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region.MethodsWe conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality.ResultsThe percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor.ConclusionsAddressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed

Birth preparedness and complication readiness (BPCR) among pregnant women in hard-to-reach areas in Bangladesh:BPCR in hard-to-reach areas of Bangladesh

Birth preparedness and complication readiness aims to reduce delays in care seeking, promote skilled birth attendance, and facility deliveries. Little is known about birth preparedness practices among populations living in hard-to-reach areas in Bangladesh.To describe levels of birth preparedness and complication readiness among recently delivered women, identify determinants of being better prepared for birth, and assess the impact of greater birth preparedness on maternal and neonatal health practices.A cross-sectional survey with 2,897 recently delivered women was undertaken in 2012 as part of an evaluation trial done in five hard-to-reach districts in rural Bangladesh. Mothers were considered well prepared for birth if they adopted two or more of the four birth preparedness components. Descriptive statistics and multivariable logistic regression were used for analysis.Less than a quarter (24.5%) of women were considered well prepared for birth. Predictors of being well-prepared included: husband's education (OR = 1.3; CI: 1.1-1.7), district of residence, exposure to media in the form of reading a newspaper (OR = 2.2; CI: 1.2-3.9), receiving home visit by a health worker during pregnancy (OR = 1.5; CI: 1.2-1.8), and receiving at least 3 antenatal care visits from a qualified provider (OR = 1.4; CI: 1.0-1.9). Well-prepared women were more likely to deliver at a health facility (OR = 2.4; CI: 1.9-3.1), use a skilled birth attendant (OR = 2.4, CI: 1.9-3.1), practice clean cord care (OR = 1.3, CI: 1.0-1.5), receive post-natal care from a trained provider within two days of birth for themselves (OR = 2.6, CI: 2.0-3.2) or their newborn (OR = 2.6, CI: 2.1-3.3), and seek care for delivery complications (OR = 1.8, CI: 1.3-2.6).Greater emphasis on BPCR interventions tailored for hard to reach areas is needed to improve skilled birth attendance, care seeking for complications and essential newborn care and facilitate reductions in maternal and neonatal mortality in low performing districts in Bangladesh

Australia's National Bowel Cancer Screening Program: does it work for Indigenous Australians?

<p>Abstract</p> <p>Background</p> <p>Despite a lower incidence of bowel cancer overall, Indigenous Australians are more likely to be diagnosed at an advanced stage when prognosis is poor. Bowel cancer screening is an effective means of reducing incidence and mortality from bowel cancer through early identification and prompt treatment. In 2006, Australia began rolling out a population-based National Bowel Cancer Screening Program (NBCSP) using the Faecal Occult Blood Test. Initial evaluation of the program revealed substantial disparities in bowel cancer screening uptake with Indigenous Australians significantly less likely to participate in screening than the non-Indigenous population.</p> <p>This paper critically reviews characteristics of the program which may contribute to the discrepancy in screening uptake, and includes an analysis of organisational, structural, and socio-cultural barriers that play a part in the poorer participation of Indigenous and other disadvantaged and minority groups.</p> <p>Methods</p> <p>A search was undertaken of peer-reviewed journal articles, government reports, and other grey literature using electronic databases and citation snowballing. Articles were critically evaluated for relevance to themes that addressed the research questions.</p> <p>Results</p> <p>The NBCSP is not reaching many Indigenous Australians in the target group, with factors contributing to sub-optimal participation including how participants are selected, the way the screening kit is distributed, the nature of the test and comprehensiveness of its contents, cultural perceptions of cancer and prevailing low levels of knowledge and awareness of bowel cancer and the importance of screening.</p> <p>Conclusions</p> <p>Our findings suggest that the population-based approach to implementing bowel cancer screening to the Australian population unintentionally excludes vulnerable minorities, particularly Indigenous and other culturally and linguistically diverse groups. This potentially contributes to exacerbating the already widening disparities in cancer outcomes that exist among Indigenous Australians. Modifications to the program are recommended to facilitate access and participation by Indigenous and other minority populations. Further research is also needed to understand the needs and social and cultural sensitivities of these groups around cancer screening and inform alternative approaches to bowel cancer screening.</p

Towards Improved Data and Understanding of Stillbirth Determinants in Low- and Middle-Income Countries: Insights from Afghanistan

The limited availability and low-quality of national-level data to understand stillbirth determinants in low- and middle-income countries is a major barrier to stillbirth prevention efforts globally. Data for producing stillbirth estimates in these settings generally come from national household surveys due to the high proportion of women that give birth at home, and because of inadequate or absent civil and vital registration systems. There are several quality concerns with stillbirth data from household surveys, particularly around under-reporting and misclassification, which affect the reliability of estimates. What also remains underexplored is to what extent social and cultural factors affect the disclosure and reporting of stillbirth, as these have important implications for stillbirth data quality. This thesis sought to review the availability of country-level data on stillbirth from nationally-representative household surveys in low- and middle-income countries to outline what data exists, where the limitations are, and potential for improvement. Analysis of data from a national mortality survey in Afghanistan is used to describe the key determinants of stillbirth in this setting and demonstrate how better data could be generated to understand stillbirth risk factors globally. Qualitative methods are used to further explore how community and healthcare provider experiences, perceptions and practices might impact stillbirth data quality and contribute to pathways leading to stillbirth in Afghanistan. The findings of this thesis can inform future efforts to improve stillbirth data in low- and middle-income countries and identifies where interventions can begin to focus to facilitate stillbirth reduction in Afghanistan

Weaved into the fabric of life: A qualitative exploration on impact of water-related disasters in the Char Community of Assam, India

Disasters have a significant social, economic and health impact. This study explores the community perception on drivers of risk, vulnerability, disaster management practices and health impact of water-related disasters in Assam, a north-east state of India. In this qualitative study semi-structured focus-group discussions (n = 5) and in-depth interviews (n = 11) were conducted in the Char region of lower Assam. Participants were residents and community leaders of the area. Framework analysis was used for data analysis, iteratively modifying the framework, based on the data. The results of the study show a complex interplay of factors that increased the disaster risk of the Char community. Poverty, illiteracy, inequality, vulnerable livelihoods, changing social aspirations, and land erosion in the context of the recurring nature of flood meant disasters were part of the lived reality of the community. Life in the Chars revolved around personal loss due to disasters, coping and recovering from the impact, preparing for the future and then ‘losing everything to the river’. Community perspectives also highlighted the focus on disaster response and relief practices rather than ‘building back better’ during the recovery, rehabilitation and reconstruction phase; or addressing long-term critical requirements of the community. The findings of the study highlight the impact of water related disasters and key social dimensions of vulnerability, social justice, and equity. Current disaster management practices need to be guided by community needs and build community and systems resilience in alignment with the Sendai Framework (2015–2030) to which India is a signatory

Health-related quality of life and function after paediatric injuries in India:A longitudinal study

Paediatric injuries can lead to long-term functional impairment and reduced health-related quality of life, and are a growing public health issue in India. To date, however, the burden has been poorly characterized. This study assessed the impact of non-fatal injuries on health-related quality of life in a prospective cohort study of 373 children admitted to three hospitals in Chandigarh and Haryana states in India. The Pediatric Quality of Life Inventory (PedsQL) and King’s Outcome Scale for Childhood Head Injury (KOSCHI) were administered at baseline (pre-injury) and at 1, 2, 4, and 12 months post-injury by telephone interview. Follow-up at all-time points was completed for 277 (77%) of all living participants. Less than one percent reported ongoing disability at 4 months, and no disability was reported at 12 months. PedsQL physical health scores were below healthy child norms (83.4) at 1 month in the cohort for ages 8–12 years and 13–16 years. Although injuries are prevalent, ongoing impact on functioning and disability from most childhood injuries at 12 months was reported to be low. The results raise questions about reliability of generic, Western-centric tools in low- and middle-income settings, and highlight the need for local context-specific tools