Exploring spatial variations in level and predictors of unskilled birth attendant delivery in Bangladesh using spatial analysis techniques: Findings from nationally representative survey data.

BACKGROUND: Bangladesh has failed to meet the United Nations goal for reducing maternal mortality in the last decade. The high prevalence of unskilled birth attendant (UBA) delivery (47%) has resulted in negative consequences for the health of mothers and newborn babies in the country. Spatial variations in UBA delivery and its predictors are yet to be explored in Bangladesh, which could be very helpful in formulating cost-effective policies for reducing that. This study examines the spatial variations in UBA delivery and its predictors in Bangladesh. METHODS: This study analyzed the characteristics of 672 clusters extracted from the 2017/18 Bangladesh Demographic and Health Survey, and healthcare facility data from the 2017 Bangladesh Health Facility Survey. These data were analyzed using descriptive and spatial analyses (hot spot analysis, Ordinary Least Squares Regression, and Geographically Weighted Regression) techniques. RESULTS: Statistically significant hot spots of UBA delivery were concentrated in parts of the Mymensingh, Sylhet, Barishal, and Rangpur regions, while Khulna was the safest region. Predictive strengths of the statistically significant predictors of spatial variation in UBA delivery were observed to vary considerably across the regions. Poorest household wealth status and less than four antenatal care contacts emerged as strong predictors of UBA delivery in all the aforementioned hot spot-stricken regions, except Barisal. Additionally, primiparity and all secondary education or higher were strong predictors of lower UBA delivery rates in Mymensingh and Sylhet, while poorer household wealth status was also a strong predictor of UBA delivery in Sylhet. Multiparity was an additional strong predictor of UBA delivery in Rangpur. In Barisal, only poorer household wealth status exerted a strong positive influence on UBA delivery. CONCLUSIONS: The remarkable spatial variations in UBA delivery and its predictors' strengths indicate that geographically-targeted interventions could be a cost-effective method for reducing the UBA delivery prevalence in Bangladesh, thereby improve maternal and child health.

Conceptualizing Indigenous Human-Animal Relationships in Aotearoa New Zealand: An Ethical Perspective.

This article considers the complexity and diversity of ethical concepts and beliefs held by Maori, the indigenous people of Aotearoa New Zealand (hereafter New Zealand), relating to animals. A combination of interviews and focus group discussions were conducted with individuals who identify as Maori and were working with wildlife, primarily in an eco-tourism and conservation context. Two main themes emerged from the data: ethical concepts relating to the environment, and concepts relating to the spiritual relationships between people, animals and the environment. These findings highlight that the connections between humans and animals through a Maori lens are nuanced in ways not typically accounted for in Western philosophy. This is of particular importance because of the extent to which standard Western thought is embodied in law and policy related to human treatment of animals and the environment. In New Zealand, relationships and partnerships are informed by Te Tiriti o Waitangi, one of New Zealand's founding documents. Where these partnerships include activities and environments involving human-animal interaction, policy and legislation should account for Maori knowledge, and diverse of thought among different hapu (tribal groups). We conclude by exploring ways of including Maori ethical concepts around animals in general, and wild animals in particular, in law and policy, providing a case study relevant to other bicultural or multicultural societies.

Tapering Biologic Therapy for Rheumatoid Arthritis: A Qualitative Study of Patient Perspectives.

BACKGROUND AND OBJECTIVE: Biologic therapies are cost effective for active rheumatoid arthritis but have adverse effects and are costly. Tapering of biologics is emerging as an important consideration when sustained remission is achieved. Recent trials have highlighted the clinical feasibility of tapering, but there is little evidence on how proposed tapering would be received by patients. The aim of this study was to explore factors influencing hypothetical decisions of patients with rheumatoid arthritis on tapering their biologics and their perspectives on remission and flare when considering the possibility of tapering. METHODS: Patients with rheumatoid arthritis with diverse experiences of biologics with different modes of administration were purposively sampled to participate in one of six focus groups (n = 43) or an individual interview (n = 2). Transcripts were analyzed using inductive thematic analysis. RESULTS: Five overarching themes on what influences a participant's decision to taper their biologic were identified. First, participants were fearful of uncertain outcomes of tapering, especially flare and joint damage. Second, participants prioritized quality of life from continuing biologics over the risk of adverse effects. Third, tapering biologics was seen as providing relief from the inconvenience of taking biologics regularly. Fourth, participants wanted assurance of prompt access to healthcare if their rheumatoid arthritis were to flare when tapering. Fifth, preferences for involvement in decision making varied, but fulfilling information needs was desired to aid a patient's preferred role in decision making on tapering. CONCLUSIONS: This study provides novel insight into the perspectives of patients with rheumatoid arthritis on tapering biologics when sustained remission is achieved at a crucial juncture in global affordability for healthcare systems. These patient perspectives can inform the planning of decision aids and clinical trials of decision-making processes when tapering is proposed.