Summary indices for monitoring universal coverage in maternal and child health care.

OBJECTIVE: To compare two summary indicators for monitoring universal coverage of reproductive, maternal, newborn and child health care. METHODS: Using our experience of the Countdown to 2015 initiative, we describe the characteristics of the composite coverage index (a weighted average of eight preventive and curative interventions along the continuum of care) and co-coverage index (a cumulative count of eight preventive interventions that should be received by all mothers and children). For in-depth analysis and comparisons, we extracted data from 49 demographic and health surveys. We calculated percentage coverage for the two summary indices, and correlated these with each other and with outcome indicators of mortality and undernutrition. We also stratified the summary indicators by wealth quintiles for a subset of nine countries. FINDINGS: Data on the component indicators in the required age range were less often available for co-coverage than for the composite coverage index. The composite coverage index and co-coverage with 6+ indicators were strongly correlated (Pearson r  = 0.73, P < 0.001). The composite coverage index was more strongly correlated with under-five mortality, neonatal mortality and prevalence of stunting (r =  -0.57, -0.68 and -0.46 respectively) than was co-coverage (r = -0.49, -0.43 and -0.33 respectively). Both summary indices provided useful summaries of the degrees of inequality in the countries' coverage. Adding more indicators did not substantially affect the composite coverage index. CONCLUSION: The composite coverage index, based on the average value of separate coverage indicators, is easy to calculate and could be useful for monitoring progress and inequalities in universal health coverage.

Inequalities in full immunization coverage: trends in low- and middle-income countries.

OBJECTIVE: To investigate disparities in full immunization coverage across and within 86 low- and middle-income countries. METHODS: In May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage - i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine - in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries. FINDINGS: In each of the World Health Organization's regions, it appeared that about 56-69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations. CONCLUSION: Most low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.

Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa.

OBJECTIVE: To examine temporal trends in caesarean delivery rates in southern Asia and sub-Saharan Africa, by country and wealth quintile. METHODS: Cross-sectional data were extracted from the results of 80 Demographic and Health Surveys conducted in 26 countries in southern Asia or sub-Saharan Africa. Caesarean delivery rates were evaluated - as percentages of the deliveries that ended in live births - for each wealth quintile in each survey. The annual rates recorded for each country were then compared to see if they had increased over time. FINDINGS: Caesarean delivery rates had risen over time in all but 6 study countries but were consistently found to be lower than 5% in 18 of the countries and 10% or less in the other eight countries. Among the poorest 20% of the population, caesarean sections accounted for less than 1% and less than 2% of deliveries in 12 and 21 of the study countries, respectively. In each of 11 countries, the caesarean delivery rate in the poorest 40% of the population remained under 1%. In Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria, the rate remained under 1% in the poorest 80%. Compared with the 22 African study countries, the four study countries in southern Asia experienced a much greater rise in their caesarean delivery rates over time. However, the rates recorded among the poorest quintile in each of these countries consistently fell below 2%. CONCLUSION: Caesarean delivery rates among large sections of the population in sub-Saharan Africa are very low, probably because of poor access to such surgery.