Magnitude and trends in socio-economic and geographic inequality in access to birth by cesarean section in Tanzania: evidence from five rounds of Tanzania demographic and health surveys (1996-2015).

BackgroundMajority of maternal deaths are avoidable through quality obstetric care such as Cesarean Section (CS). However, in low-and middle-income countries, many women are still dying due to lack of obstetric services. Tanzania is one of the African countries where maternal mortality is high. However, there is paucity of evidence related to the magnitude and trends of disparities in CS utilization in the country. This study examined both the magnitude and trends in socio-economic and geographic inequalities in access to birth by CS.MethodsData were extracted from the Tanzania Demographic and Health Surveys (TDHSs) (1996-2015) and analyzed using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software. First, access to birth by CS was disaggregated by four equity stratifiers: wealth index, education, residence and region. Second, we measured the inequality through summary measures, namely Difference (D), Ratio (R), Slope Index of Inequality (SII) and Relative Index of Inequality (RII). A 95% confidence interval was constructed for point estimates to measure statistical significance.ResultsThe results showed variations in access to birth by CS across socioeconomic, urban-rural and regional subgroups in Tanzania from 1996 to 2015. Among the poorest subgroups, there was a 1.38 percentage points increase in CS coverage between 1996 and 2015 whereas approximately 11 percentage points increase was found among the richest subgroups within same period of time. The coverage of CS increased by nearly 1 percentage point, 3 percentage points and 9 percentage points among non-educated, those who had primary education and secondary or higher education, respectively over the last 19 years. The increase in coverage among rural residents was 2 percentage points and nearly 8 percentage points among urban residents over the last 19 years. Substantial disparity in CS coverage was recorded in all the studied surveys. For instance, in the most recent survey, pro-rich (RII = 15.55, 95% UI; 10.44, 20.66, SII = 15.8, 95% UI; 13.70, 17.91), pro-educated (RII = 13.71, 95% UI; 9.04, 18.38, SII = 16.04, 95% UI; 13.58, 18.49), pro-urban (R = 3.18, 95% UI; 2.36, 3.99), and subnational (D = 16.25, 95% UI; 10.02, 22.48) absolute and relative inequalities were observed.ConclusionThe findings showed that over the last 19 years, women who were uneducated, poorest/poor, living in rural settings and from regions such as Zanzibar South, appeared to utilize CS services less in Tanzania. Therefore, such subpopulations need to be the central focus of policies and programmes implemmentation to improve CS services coverage and enhance equity-based CS services utilization

Regional variations and socio-economic disparities in neonatal mortality in Angola: a cross-sectional study using demographic and health surveys.

BackgroundInequalities in neonatal mortality rates (NMRs) in low- and middle-income countries show key disparities at the detriment of disadvantaged population subgroups. There is a lack of scholarly evidence on the extent and reasons for the inequalities in NMRs in Angola.ObjectiveThe aim of this study was to assess the socio-economic, place of residence, region and gender inequalities in the NMRs in Angola.MethodsThe World Health Organization Health Equity Assessment Toolkit software was used to analyse data from the 2015 Angola Demographic and Health Survey. Five equity stratifiers: subnational regions, education, wealth, residence and sex were used to disaggregate NMR inequality. Absolute and relative inequality measures, namely, difference, population attributable fraction (PAF), population attributable risk (PAR) and ratio, were calculated to provide a broader understanding of the inequalities in NMR. Statistical significance was calculated at corresponding 95% uncertainty intervals.FindingsWe found significant wealth-driven [PAR = -14.16, 95% corresponding interval (CI): -15.12, -13.19], education-related (PAF = -22.5%, 95% CI: -25.93, -19.23), urban-rural (PAF = -14.5%, 95% CI: -16.38, -12.74), sex-based (PAR = -5.6%, 95% CI: -6.17, -5.10) and subnational regional (PAF = -82.2%, 95% CI: -90.14, -74.41) disparities in NMRs, with higher burden among deprived population subgroups.ConclusionsHigh NMRs were found among male neonates and those born to mothers with no formal education, poor mothers and those living in rural areas and the Benguela region. Interventions aimed at reducing NMRs, should be designed with specific focus on disadvantaged subpopulations

Urban-rural disparities in wife-beating attitude among married women: a decomposition analysis from the 2017 Senegal Continuous Demographic and Health Survey

Background Globally, intimate partner violence is one of the most common forms of gender-based violence, and wife beating is one component of intimate partner violence, with the problem being more severe among women living in rural settings. Little is known about the factors that explain the urban-rural disparity in the prevalence of wife beating attitude in Senegal. In this paper, we aimed to decompose the urban-rural disparities in factors associated with wife beating attitude among married women in Senegal. Methods Data were derived from the 2017 Senegal Continuous Demographic and Health Survey. We used the Blinder-Oaxaca decomposition method to decompose and explain the variation in the prevalence of disagreement to wife beating between urban and rural areas in Senegal. Results The results show that 48.9% of married women in Senegal disagreed with wife-beating. About 69% of urban women disagreed with wife beating, but only 36% of rural women disagreed with wife beating. About 68.7% of women in the sample reported that they disagreed to wife beating by their husbands for burning food and nearly 50% of women reported that they disagreed with wife beating when they refuse to have sex with their husbands. About 86% of the urban-rural disparities in disagreement with wife beating are explained in this study. Economic status (45.2%), subnational region (22.4%), women’s educational status (13.3%), and husband’s educational status (10.7%) accounted for 91.6% of the disparities. Conclusions The study shows urban-rural disparities in the prevalence of wife-beating attitude (disagreement with wife beating) and this disfavored rural residents. We suggest the need for the government of Senegal to consider pro-rural equity strategies to narrow down the observed disparities. Moreover, socioeconomic empowerment and attitudinal changing interventions using existing socio-cultural institutions as platforms can be used to deliver such interventions

Inequality in fertility rate among adolescents: evidence from Timor-Leste demographic and health surveys 2009-2016.

BackgroundDespite a decline in global adolescent birth rate, many countries in South East Asia still experience a slower pace decline in adolescent birth rates. Timor-Leste is one of the countries in the region with the highest adolescent birth rate and huge disparities between socio-economic subgroups. Hence, this study assessed the magnitude and trends in adolescent fertility rates within different socio-demographic subgroups in Timor-Leste.MethodsUsing the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Timor-Leste Demographic and Health surveys (TLDHS) were analyzed between 2009 and 2016. We approached the inequality analysis in two steps. First, we disaggregated adolescent fertility rates by four equity stratifiers: wealth index, education, residence and region. Second, we measured the inequality through summary measures, namely Difference, Population Attributable Risk, Ratio and Population Attributable Fraction. A 95% confidence interval was constructed for point estimates to measure statistical significance.ResultsWe found large socio-economic and area-based inequalities over the last 7 years. Adolescent girls who were poor (Population Attributable Fraction: -54.87, 95% CI; - 57.73, - 52.02; Population Attributable Risk: -24.25, 95% CI; - 25.51, - 22.99), uneducated (Difference: 58.69, 95% CI; 31.19, 86.18; Population Attributable Fraction: -25.83, 95% CI; - 26.93, - 24.74), from rural areas (Ratio: 2.76, 95% CI; 1.91, 3.60; Population Attributable Risk: -23.10, 95% CI; - 24.12, - 22.09) and from the Oecussi region (Population Attributable Fraction: -53.37, 95% CI; - 56.07, - 50.67; Difference: 60.49, 95% CI; 29.57, 91.41) had higher chance of having more births than those who were rich, educated, urban residents and from the Dili region, respectively.ConclusionsThis study identified disproportionately higher burden of teenage birth among disadvantaged adolescents who are, poor, uneducated, rural residents and those living in regions such as Oecussi, Liquica and Manufahi, respectively. Policymakers should work to prevent child marriage and early fertility to ensure continuous education, reproductive health care and livelihood opportunities for adolescent girls. Specialized interventions should also be drawn to the subpopulation that had disproportionately higher adolescent childbirth

Summary measures of socioeconomic and area-based inequalities in fertility rates among adolescents: evidence from Ethiopian demographic and health surveys 2000–2016

Background One of the highest rates of adolescent pregnancies in the world is in sub-Saharan Africa. Most adolescent pregnancies in the region are unintended or unwanted, due to poor access to information and services on sexual and reproductive health for adolescents. Ethiopia has high adolescent fertility rates (AFR) with disparities across socioeconomic subgroups and regions. This study assessed the magnitude and trends of socioeconomic and area-based AFR inequalities in Ethiopia. Methods The 2000 and 2016 Ethiopia Demographic and Health surveys (EDHS) was analyzed using the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software. Adolescent fertility rates were disaggregated using three equity stratifiers (economic status, education and residence) and analyzed through four summary measures (Difference (D), Population Attributable Risk (PAR), Ratio (R) and Population Attributable Fraction (PAF)) to assess inequality. To measure statistical significance, point estimates were constructed using a 95% Uncertainty Interval (UI). Results Large socio-economic and urban-rural inequalities were observed within the 16-year period. Adolescents in less well-off socio-economic groups (PAF: -62.9 [95% UI; − 64.3, − 61.4], D: 96.4 [95% UI; 47.7, 145.1]), uneducated (R: 8.5 [95% UI; 4.8, 12.2], PAR: -76.4 [95% UI;-77.7, − 75.0]) and those from rural areas (D: 81.2 [95% UI; 67.9, 94.6], PAF: -74.2 [95% UI, − 75.7, − 72.7]) had a higher chance of pregnancy and more births than their counterparts. Conclusions Socioeconomic (education and economic status) and place of residence determine adolescents’ pregnancy and childbearing. Policies and programs should be directed at preventing child marriage and early fertility so that adolescents continue to access education, sexual and reproductive health care as well as access employment opportunities. More emphasis should be placed on subpopulations with disproportionately higher adolescent pregnancy and childbirth

Utilization of Deworming Drugs and Its Individual and Community Level Predictors among Pregnant Married Women in Cameroon: A Multilevel Modeling

Background. Although deworming pregnant women is one of the strategies to reduce parasites (roundworms and hookworms) causing anemia and related perinatal and maternal complications, utilization of deworming medication among pregnant women in Cameroon is suboptimal. Comprehensive assessment of individual, household (including women’s autonomy), and community-level factors associated with utilization of deworming medication has not been done so far. Therefore, we investigated the individual/household and community-level factors associated with deworming among pregnant married women in Cameroon. Methods. Our study was limited to pregnant women because they have a greater risk due to increased chances of anemia. We used data from the 2018/19 Cameroon Demographic and Health Survey. Analysis on 5,013 pregnant married women was carried out using multilevel logistic regression. Odds ratios with a 95% confidence interval (CI) were reported. Results. Our findings showed that about 29.8% of pregnant married women received deworming medications. The individual/household level predictors of deworming medications utilization identified in this study were women’s educational level, wealth quintile, and skilled antenatal care. Distance to health facility and region were identified as community-level predictors of deworming medications utilization. Higher odds of receiving deworming medication occurred among educated and wealthier pregnant married women as well as among pregnant married women who had skilled antenatal care or lived in the south region, whereas lower odds were observed among pregnant married women living in the north region. Conclusion. Access to education and economic empowerment of pregnant married women in remote areas and the north region should be the primary focus of the Cameroon government to enhance deworming coverage in the country

Women empowerment and uptake of antenatal care services : A meta-analysis of Demographic and Health Surveys from 33 Sub-Saharan African countries

Background: Women empowerment has been linked to increased skilled antenatal care (ANC) service use. However, there is no evidence on the net effect of women empowerment on ANC in the Sub-saharan African (SSA) region. We aim to address the knowledge gap on whether or not women empowerment positively influences the uptake of ANC at the SSA regional level. Methods: We analyzed the Demographic Health Survey (DHS) datasets from 33 SSA countries. Following the DHS data analysis guideline, we measured women empowerment using two indicators. The first indicator is an index, which comprises decision-making on women’s own health, household purchase and visit to family or relatives whilst disagreeing statements that husband is justified in beating his wife constitutes the second indictor. We performed confounder-adjusted logistic regression analysis for the two indicators with ANC attendance in each of the 33 countries. Then, we pooled the adjusted Odds Ratios (OR) using the random effect model through the two-stage Individual Participant Data meta-analysis technique. Summary findings are reported in OR and corresponding 95 %CI and are presented in a forest plot. Results: Moderately empowered women had marginally higher odd of skilled ANC service across the SSA region (aOR = 1.19; 95 %CI: 1.03, 1.38, with a prediction interval of 0.58, 2.45). Conversely, being involved in the three decisions (aOR = 1.15; 95 %CI: 0.99, 1.33, with prediction interval 0.57, 2.31), and attitude towards wife-beating (aOR = 0.97; 95 %CI: 0.88, 1.06, with prediction interval of 0.63, 1.48) had no statistically significant relationship with ANC. Conclusions: Women empowerment did not predict the use of skilled ANC in the context of the SSA region. We recommend that further studies be conducted in order to understand how women empowerment affects skilled ANC service utilization in the region

Sub-regional disparities in the use of antenatal care service in Mauritania: findings from nationally representative demographic and health surveys (2011-2015).

BACKGROUND: Skilled antenatal care (ANC) has been identified as a proven intervention to reducing maternal deaths. Despite improvements in maternal health outcomes globally, some countries are signaling increased disparities in ANC services among disadvantaged sub-groups. Mauritania is one of sub-Saharan countries in Africa with a high maternal mortality ratio. Little is known about the inequalities in the country's antenatal care services. This study examined both the magnitude and change from 2011 to 2015 in socioeconomic and geographic-related disparities in the utilization of at least four antenatal care visits in Mauritania. METHODS: Using the World Health Organization's Health Equity Assessment Toolkit (HEAT) software, data from the 2011 and 2015 Mauritania Multiple Indicator Cluster Surveys (MICS) were analyzed. The inequality analysis consisted of disaggregated rates of antenatal care utilization using four equity stratifiers (economic status, education, residence, and region) and four summary measures (Difference, Population attributable risk, Ratio and Population attributable fraction). A 95% Uncertainty Interval was constructed around point estimates to measure statistical significance. RESULTS: Substantial absolute and relative socioeconomic and geographic related disparities in attending four or more ANC visits (ANC4+ utilization) were observed favoring women who were richest/rich (PAR = 19.5, 95% UI; 16.53, 22.43), educated (PAF = 7.3 95% UI; 3.34, 11.26), urban residents (D = 19, 95% UI; 14.50, 23.51) and those living in regions such as Nouakchott (R = 2.1, 95% UI; 1.59, 2.56). While education-related disparities decreased, wealth-driven and regional disparities remained constant over the 4 years of the study period. Urban-rural inequalities were constant except with the PAR measure, which showed an increasing pattern. CONCLUSION: A disproportionately lower ANC4+ utilization was observed among women who were poor, uneducated, living in rural areas and regions such as Guidimagha. As a result, policymakers need to design interventions that will enable disadvantaged subpopulations to benefit from ANC4+ utilization to meet the Sustainable Development Goal (SDG) of reducing the maternal mortality ratio (MMR) to 140/100, 000 live births by 2030