Andersen's model on determining the factors associated with antenatal care services in Nepal: an evidence-based analysis of Nepal demographic and health survey 2016.

BACKGROUND: With the formulation of the National Safe Motherhood Policy in 1998, safe motherhood has forever been a priority program in Nepal. Under the safe motherhood program, every woman is provided with essential maternal health care services until now through the four-tire district health care system. There is a considerable increase in the utilization of antenatal care (ANC) by a skilled health provider from 2011 to 2016, 58 to 84%, respectively. However, inequality, exclusion, and under-utilization in health care services continue in many regions of Nepal. The present study aimed to explore the different types of socio-demographic factors associated with current ANC service utilization in Nepal. METHODS: A cross-sectional study was conducted using the Nepal Demographic and Health Surveys data (DHS-7, 2016-2017). We estimated the latest pregnancy and live births in recent 5 years with the utilization of ANC services, and socio-economic differentials in these indicators under the framework of the Andersen behavioral model. RESULTS: Two in three (69.8%) with last birth accessed at least four ANC visits. The rate of live birth was about 98.6% in the ANC4+ group, higher than that of 96.8% in the ANC4- group (χ2: 14.742, P <  0.001). In the multilevel logistic regression analysis, we found that women from province 2 (OR: 0.48; 95%CI: 0.32-0.74) and province 6 (OR: 0.46; 95%CI: 0.30-0.71) were significantly less likely to visit ANC 4 or more times. Age (OR: 0.95; 95%CI: 0.93-0.96) was also significantly associated with the frequency of ANC visits. Level of Women's education and education of her partner were both significantly associated with the ANC visits: women (OR: 4.64; 95%CI: 3.05-7.05) and her partner (OR: 1.45; 95%CI: 1.01-2.06) having higher education were most likely to go for the recommended number of ANC visits. Moreover, women having exposure to multimedia were more likely to go for four or more ANC check-ups. CONCLUSIONS: The results highlight the need for governments and health care providers to develop special health promotion program with a focus on the vulnerable and disadvantaged and to use multi-media for maternal health literacy improvement flexibly, and maternal health system strengthening.

Causal effects of dietary calcium, zinc and iron intakes on coronary artery disease in men: G-estimation and inverse probability of treatment weighting (IPTW) analyses.

BACKGROUND & AIMS: Dietary minerals have significant effects on the risk of cardiovascular disease. However, the results of previous studies were not uniform across different countries. The current study aims to determine the causal effects of dietary calcium, zinc, and iron intakes on coronary artery disease (CAD) among Nepalese men. METHODS: A matched case-control study was carried out at Shahid Gangalal National Heart Center. Dietary intakes of 466 male participants over the past 12 months were evaluated using a semi-quantitative customized food frequency questionnaire. G-estimation and inverse probability treatment weighting (IPTW) analyses were performed to determine the causal odds of CAD due to dietary calcium, zinc, and iron intakes. RESULTS: Daily dietary calcium, zinc, and iron intakes were categorized into two groups: less than versus more than the median value and less than versus equal or more than recommended daily allowance (RDA). In G-estimation, dietary calcium intake was inversely associated with CAD in both medians (OR: 91; 91%CI: 0.86, 95) and RDA categories (OR: 0.88: 95%CI: 0.84, 0.97). However, in IPTW analysis, only median calcium intake was significantly associated with CAD (OR: 7; 91%CI: 0.5, 98). We observed a significant inverse association of equal or more than RDA of dietary zinc intake with CAD (OR: 0.91: 95%CI: 0.87, 0.96 in G-estimation, OR: 0.73: 95%CI: 0.66, 0.82 in IPTW); however, more than median dietary zinc intake showed inverse but not significant association with CAD in both analyses. Dietary iron intake was inversely but not significantly associated with CAD in G-estimation in both groups. Nevertheless, in IPTW analysis, equal or more than RDA iron intake was significantly positively (OR: 1.4; 95%CI: 1.14, 1.73) related to CAD. CONCLUSIONS: A significant inverse association of dietary zinc intake above RDA indicates the potential protective effect of higher dietary zinc against CAD. However, causal odds of CAD are inconsistent across the median or RDA of calcium and iron intakes. Therefore, cohort and randomized clinical trial studies with a large sample size are recommended to substantiate these nutrients' causal link with CAD development in the Nepalese population.

Dietary nutrients of relative importance associated with coronary artery disease: Public health implication from random forest analysis.

Dietary nutrients have significant effects on the risk of cardiovascular diseases. However, the results were not uniform across different countries. The study aims to determine the relative importance of dietary nutrients associated with coronary artery disease (CAD) among the Nepalese population. A hospital-based matched case-control study was carried out at Shahid Gangalal National Heart Center in Nepal. In the present study, patients with more than seventy percent stenosis in any main coronary artery branch in angiography were defined as cases, while those presenting normal coronary angiography or negative for stressed exercise test were considered controls. Dietary intakes of 612 respondents over the past 12 months were evaluated using a semi-quantitative customized food frequency questionnaire. In conditional regression model, the daily average dietary intake of ß-carotene (OR: 0.54; 95%CI: 0.34, 0.87), and vitamin C (OR: 0.96; 95%CI: 0.93, 0.99) were inversely, whereas dietary carbohydrate (OR: 1.16; 95%CI: 1.1, 1.24), total fat/oil (OR: 1.47; 95%CI: 1.27, 1.69), saturated fatty acid (SFA) (OR: 1.2; 95%CI: 1.11, 1.3), cholesterol (OR: 1.01; 95%CI: 1.001, 1.014), and iron intakes (OR: 1.11; 95%CI: 1.03, 1.19) were positively linked with CAD. Moreover, in random forest analysis, the daily average dietary intakes of SFA, vitamin A, total fat/oil, ß-carotene, and cholesterol were among the top five nutrients (out of 12 nutrients variables) of relative importance associated with CAD. The nutrients of relative importance imply a reasonable preventive measure in public health nutrients specific intervention to prevent CAD in a resource-poor country like Nepal. The findings are at best suggestive of a possible relationship between these nutrients and the development of CAD, but prospective cohort studies and randomized control trials will need to be performed in the Nepalese population.