Triangulating evidence for the causal impact of single-intervention zinc supplement on glycaemic control for type 2 diabetes: systematic review and meta-analysis of randomised controlled trial and two-sample Mendelian randomisation.

Although previous studies suggested the protective effect of Zn for type 2 diabetes (T2D), the unitary causal effect remains inconclusive. We investigated the causal effect of Zn as a single intervention on glycaemic control for T2D, using a systematic review of randomised controlled trials and two-sample Mendelian randomisation (MR). Four primary outcomes were identified: fasting blood glucose/fasting glucose, HbA1c, homeostatic model assessment for insulin resistance (HOMA-IR) and serum insulin/fasting insulin level. In the systematic review, four databases were searched until June 2021. Studies, in which participants had T2D and intervention did not comprise another co-supplement, were included. Results were synthesised through the random-effects meta-analysis. In the two-sample MR, we used single-nucleotide polymorphisms (SNP) from MR-base, strongly related to Zn supplements, to infer the relationship causally, but not specified T2D. In the systematic review and meta-analysis, fourteen trials were included with overall 897 participants initially. The Zn supplement led to a significant reduction in the post-trial mean of fasting blood glucose (mean difference (MD): -26·52 mg/dl, 95 % CI (-35·13, -17·91)), HbA1c (MD: -0·52 %, 95 % CI: (-0·90, -0·13)) and HOMA-IR (MD: -1·65, 95 % CI (-2·62, -0·68)), compared to the control group. In the two-sample MR, Zn supplement with two SNP reduced the fasting glucose (inverse-variance weighted coefficient: -2·04 mmol/l, 95 % CI (-3·26, -0·83)). From the two methods, Zn supplementation alone may causally improve glycaemic control among T2D patients. The findings are limited by power from the small number of studies and SNP included in the systematic review and two-sample MR analysis, respectively.

Factors affecting the frequency and contents of routine antenatal care in remote rural China in 2009-2016: An observational study.

OBJECTIVE: We assessed factors associated with the frequency and contents of antenatal care (ANC) in remote rural China, including the province of residence and individual-level factors. DESIGN: Survey-based cross-sectional study. SETTING: Five provinces in remote rural China: Guizhou, Hunan, Jilin, Ningxia and Shaanxi. SAMPLE: A cohort of 3918 women with a live birth in 2009-2016. METHODS: Poisson regression. MAIN OUTCOME MEASURES: ANC frequency: five or more visits, starting in the first trimester. ANC contents: coverage of six care components and overuse of ultrasound. RESULTS: Three-quarters (72.9%) of women had five or more ANC visits, starting in the first trimester; 68.8% received all six care components and 94.5% had three or more ultrasounds. Only 30.9% of women sought ANC from township hospitals, paying between $3.80 and $25.80 per visit. ANC frequency and contents were associated with the socio-economic characteristics of the women, but provincial effects were much greater, even after adjusting for individual factors. Women living in Guizhou and Ningxia, the two poorest provinces, with high proportions of ethnic minorities, were particularly underserved. Compared with women in Shaanxi, women in Guizhou were 33% (adjusted RR 0.67, 95% CI 0.61-0.74) less likely to receive five or more ANC visits, starting in the first trimester; women in Ningxia were 17% less likely (adjusted RR 0.83, 95% CI 0.76-0.90) to receive all six care components. CONCLUSIONS: The province of residence was a stronger predictor of ANC frequency and contents than the individual characteristics of women in China, suggesting that strengthening the decentralised system of the financing and organisation of ANC at the province level is crucial for achieving success. Future efforts are warranted to engage subregional administrations. TWEETABLE ABSTRACT: The province of residence was a stronger predictor of ANC frequency and contents than the individual characteristics of women.

Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records.

BACKGROUND: The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women's homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births. METHODS: We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019-20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019. RESULTS: The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days. CONCLUSIONS: The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

A systematic review of the profile and density of the maternal and child health workforce in China.

BACKGROUND: To track progress in maternal and child health (MCH), understanding the health workforce is important. This study seeks to systematically review evidence on the profile and density of MCH workers in China. METHODS: We searched 6 English and 2 Chinese databases for studies published between 1 October 1949 and 20 July 2020. We included studies that reported on the level of education or the certification status of all the MCH workers in one or more health facilities and studies reporting the density of MCH workers per 100 000 population or per 1000 births. MCH workers were defined as those who provided MCH services in mainland China and had been trained formally or informally. RESULTS: Meta-analysis of 35 studies found that only two-thirds of obstetricians and paediatricians (67%, 95% CI: 59.6-74.3%) had a bachelor or higher degree. This proportion was lower in primary-level facilities (28% (1.5-53.9%)). For nurses involved in MCH care the proportions with a bachelor or higher degree were lower (20.0% (12.0-30.0%) in any health facility and 1% (0.0-5.0%) in primary care facilities). Based on 18 studies, the average density of MCH doctors and nurses was 11.8 (95% CI: 7.5-16.2) and 11.4 (7.6-15.2) per 100 000 population, respectively. The average density of obstetricians was 9.0 (7.9-10.2) per 1000 births and that of obstetric nurses 16.0 (14.8-17.2) per 1000 births. The density of MCH workers is much higher than what has been recommended internationally (three doctors and 20 midwives per 3600 births). CONCLUSIONS: Our review suggests that the high density of MCH workers in China is achieved through a mix of workers with high and low educational profiles. Many workers labelled as "obstetricians" or "paediatrician" have lower qualifications than expected. China compensates for these low educational levels through task-shifting, in-service training and supervision.

Does women's age matter in the SDGs era: coverage of demand for family planning satisfied with modern methods and institutional delivery in 91 low- and middle-income countries.

BACKGROUND: The Sustainable Development Goals (SDGs) include specific targets for family planning (SDG 3.7) and birth attendance (SDG 3.1.2), and require analyses disaggregated by age and other dimensions of inequality (SDG 17.18). We aimed to describe coverage with demand for family planning satisfied with modern methods (DFPSm) and institutional delivery in low- and middle-income countries across the reproductive age spectrum. We attempted to identify a typology of patterns of coverage by age and compare their distribution according to geographic regions, World Bank income groups and intervention coverage levels. METHODS: We used Demographic and Health Survey and Multiple Indicator Cluster Surveys. For DFPSm, we considered the woman's age at the time of the survey, whereas for institutional delivery we considered the woman's age at birth of the child. Both age variables were categorized into seven groups of 5 year-intervals, 15-19 up to 45-49. Five distinct patterns were identified: (a) increasing coverage with age; (b) similar coverage in all age groups; (c) U-shaped; (d) inverse U-shaped; and (e) declining coverage with age. The frequency of the five patterns was examined according to UNICEF regions, World Bank income groups, and coverage at national level of the given indicator. RESULTS: We analyzed 91 countries. For DFPSm, the most frequent age patterns were inverse U-shaped (53%, 47 countries) and increasing coverage with age (41%, 36 countries). Inverse-U shaped patterns for DFPSm was the commonest pattern among lower-middle income countries, while low- and upper middle-income countries showed a more balanced distribution between increasing with age and U-shaped patterns. In the first and second tertiles of national coverage of DFPSm, inverse U-shaped was observed in more than half of countries. For institutional delivery, declining coverage with age was the prevailing pattern (44%, 39 countries), followed by similar coverage across age groups (39%, 35 countries). Most (79%) upper-middle income countries showed no variation by age group while most low-income countries showed declining coverage with age (71%). CONCLUSION: Large inequalities in DFPSm and institutional delivery were identified by age, varying from one intervention to the other. Policy and programmatic approaches must be tailored to national patterns, and in most cases older women and adolescents will require special attention due to lower coverage and because they are at higher risk for maternal mortality and other poor obstetrical outcomes.

Global epidemiology of use of and disparities in caesarean sections.

In this Series paper, we describe the frequency of, trends in, determinants of, and inequalities in caesarean section (CS) use, globally, regionally, and in selected countries. On the basis of data from 169 countries that include 98·4% of the world's births, we estimate that 29·7 million (21·1%, 95% uncertainty interval 19·9-22·4) births occurred through CS in 2015, which was almost double the number of births by this method in 2000 (16·0 million [12·1%, 10·9-13·3] births). CS use in 2015 was up to ten times more frequent in the Latin America and Caribbean region, where it was used in 44·3% (41·3-47·4) of births, than in the west and central Africa region, where it was used in 4·1% (3·6-4·6) of births. The global and regional increases in CS use were driven both by an increasing proportion of births occurring in health facilities (accounting for 66·5% of the global increase) and increases in CS use within health facilities (33·5%), with considerable variation between regions. Based on the most recent data available for each country, 15% of births in 106 (63%) of 169 countries were by CS, whereas 47 (28%) countries showed CS use in less than 10% of births. National CS use varied from 0·6% in South Sudan to 58·1% in the Dominican Republic. Within-country disparities in CS use were also very large: CS use was almost five times more frequent in births in the richest versus the poorest quintiles in low-income and middle-income countries; markedly high CS use was observed among low obstetric risk births, especially among more educated women in, for example, Brazil and China; and CS use was 1·6 times more frequent in private facilities than in public facilities.

Uptake of maternal care and childhood immunization among ethnic minority and Han populations in Sichuan province: a study based on the 2003, 2008 and 2013 health service surveys.

BACKGROUND: China has made remarkable progress in maternal and child health (MCH) over the last thirty years, but socio-economic inequalities persist. Ethnicity has become an important determinant of poor MCH outcomes, but little rigorous analytical work has been done in this area. To understand the socio-economic factors that explain ethnic variation in uptake of MCH care, we report the findings from an analysis in Sichuan province. METHODS: We linked data from the 2003, 2008 and 2013 National Health Service Surveys in Sichuan Province. The ethnic disparities in uptake of maternal care (completing 5 antenatal visits, giving birth in hospital and receiving a caesarean section) and childhood immunization (Bacillus Calmette Guerin (BCG), three doses of diphtheria (DPT) and measles immunization) were examined by geographical (Han district/county vs. ethnic minority county) and individual-based (Han women/children vs. ethnic minority women/children) comparisons. We also examined variation by distance to township and county hospitals, women's education, parity and age using weighted multilevel Poisson regressions with random intercept at district/county level. RESULTS: Ethnic inequalities in maternal care were marked, both at the geographical (district/county) and the individual level. The % of births in hospital was 90.7% among women in Han districts, compared to 83.3% among women living in Han counties (crude RR 0.93; 95% CI 0.75-1.15), 53.8% among Han women living in ethnic minority counties (crude RR 0.57; 95% CI 0.36-0.93), and 13.5% among ethnic minority women living in ethnic minority counties (crude RR 0.18; 95% CI 0.06-0.57). Adjusting the analysis for survey year, education, parity and distance to county level hospital weakened the association between geographical/individual ethnicity and uptake of maternity care, but associations remained remarkably strong. Coverage of childhood immunization was much higher than uptake of maternity care, and inequalities by ethnicity were much less pronounced. CONCLUSION: Lessons can be learned from China's successful immunization programme to further reduce inequalities in access to maternity care among ethnic minority populations in remote areas. Bringing the services closer to the women's homes and strengthening health promotion from the township to the village level may encourage more women to seek antenatal care and give birth in hospital.

Testing the assumptions of an indicator of unmet need for obstetric surgery in Ghana: A cross-sectional study of linked hospital and population-based delivery data.

BACKGROUND: The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life-saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%-2% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications. METHODS: We used linked hospital and population-based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education. RESULTS: A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women with no AMI diagnosis died of AMI-related causes. Among the 50 148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post-secondary education (P < .001). However, there was no association between AMI-related mortality and education (P = .546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%-0.92%), below the assumed 1% minimum threshold. DISCUSSION: Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life-saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.

The scale, scope, coverage, and capability of childbirth care.

All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Access to maternal health services: geographical inequalities, United Republic of Tanzania.

OBJECTIVE: To determine if improved geographical accessibility led to increased uptake of maternity care in the south of the United Republic of Tanzania. METHODS: In a household census in 2007 and another large household survey in 2013, we investigated 22 243 and 13 820 women who had had a recent live birth, respectively. The proportions calculated from the 2013 data were weighted to account for the sampling strategy. We examined the association between the straight-line distances to the nearest primary health facility or hospital and uptake of maternity care. FINDINGS: The percentages of live births occurring in primary facilities and hospitals rose from 12% (2571/22 243) and 29% (6477/22 243), respectively, in 2007 to weighted values of 39% and 40%, respectively, in 2013. Between the two surveys, women living far from hospitals showed a marked gain in their use of primary facilities, but the proportion giving birth in hospitals remained low (20%). Use of four or more antenatal visits appeared largely unaffected by survey year or the distance to the nearest antenatal clinic. Although the overall percentage of live births delivered by caesarean section increased from 4.1% (913/22 145) in the first survey to a weighted value of 6.5% in the second, the corresponding percentages for women living far from hospital were very low in 2007 (2.8%; 35/1254) and 2013 (3.3%). CONCLUSION: For women living in our study districts who sought maternity care, access to primary facilities appeared to improve between 2007 and 2013, however access to hospital care and caesarean sections remained low.

Characteristics of neonatal near miss in hospitals in Benin, Burkina Faso and Morocco in 2012-2013.

OBJECTIVE: The objective of this study is to explore the usefulness of neonatal near miss in low- and middle-income countries by examining the incidence of neonatal near miss and pre-discharge neonatal deaths across various obstetric risk categories in 17 hospitals in Benin, Burkina Faso and Morocco. METHODS: Data were collected on all maternal deaths, maternal near miss, neonatal near miss (based on organ-dysfunction markers), Caesarean sections, stillbirths, neonatal deaths before discharge and non-cephalic presentations, and on a sample of births not falling in any of the above categories. RESULTS: The burden of stillbirth, pre-discharge neonatal death or neonatal near miss ranged from 23 to 129 per 1000 births in Moroccan and Beninese hospitals, respectively. Perinatal deaths (range 17-89 per 1000 births) were more common than neonatal near miss (range 6-43 per 1000 live births), and between a fifth and a third of women who had suffered a maternal near miss lost their baby. Pre-discharge neonatal deaths and neonatal near miss had a similar distribution of markers of organ dysfunction, but unlike pre-discharge neonatal deaths most neonatal near miss (63%, 81% and 71% in Benin, Burkina Faso and Morocco, respectively) occurred among babies who were not considered premature, low birthweight or with a low 5-min Apgar score as defined by WHO's pragmatic markers of severe neonatal morbidity. CONCLUSION: Whether the measurement of neonatal near miss adds useful insights into the quality of perinatal or newborn care in settings where facility-based intrapartum and early newborn mortality is very high is uncertain. Perhaps the greatest advantage of adding near miss is the shift in focus from failure to success so that lessons can be learned on how to save lives even when clinical conditions are life-threatening.

Pregnancy and HIV disease progression: a systematic review and meta-analysis.

OBJECTIVE: To assess whether pregnancy accelerates HIV disease progression. METHODS: Studies comparing progression to HIV-related illness, low CD4 count, AIDS-defining illness, HIV-related death, or any death in HIV-infected pregnant and non-pregnant women were included. Relative risks (RR) for each outcome were combined using random effects meta-analysis and were stratified by antiretroviral therapy (ART) availability. RESULTS: 15 studies met the inclusion criteria. Pregnancy was not associated with progression to HIV-related illness [summary RR: 1.32, 95% confidence interval (CI): 0.66-2.61], AIDS-defining illness (summary RR: 0.97, 95% CI: 0.74-1.25) or mortality (summary RR: 0.97, 95% CI: 0.62-1.53), but there was an association with low CD4 counts (summary RR: 1.41, 95% CI: 0.99-2.02) and HIV-related death (summary RR: 1.65, 95% CI: 1.06-2.57). In settings where ART was available, there was no evidence that pregnancy accelerated progress to HIV/AIDS-defining illnesses, death and drop in CD4 count. In settings without ART availability, effect estimates were consistent with pregnancy increasing the risk of progression to HIV/AIDS-defining illnesses and HIV-related or all-cause mortality, but there were too few studies to draw meaningful conclusions. CONCLUSIONS: In the absence of ART, pregnancy is associated with small but appreciable increases in the risk of several negative HIV outcomes, but the evidence is too weak to draw firm conclusions. When ART is available, the effects of pregnancy on HIV disease progression are attenuated and there is little reason to discourage healthy HIV-infected women who desire to become pregnant from doing so.

Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012.

OBJECTIVES: To examine trends in the utilisation of facility-based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor, and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care. METHODS: Using data from nationally representative household surveys and routine statistics, our analysis focused on whether women delivered within a facility, and whether the delivery was by caesarean; analyses were stratified by relative wealth quintile and public/private sector where possible. A segmented Poisson regression model was used to assess whether trends changed at key events. RESULTS: Uptake of facility-based deliveries and caesareans in Morocco has risen considerably over the past two decades, particularly among the poor. The rate of increase in facility deliveries was much faster in the poorest quintile (annual increase RR: 1.09; 95% CI: 1.07-1.11) than the richest quintile (annual increase RR: 1.01; 95% CI: 1.02-1.02). A similar pattern was observed for caesareans (annual increase among poorest RR: 1.13; 95% CI: 1.07-1.19 vs. annual increase among richest RR: 1.08; 95% CI: 1.06-1.10). We found no significant acceleration in trend coinciding with any of the events investigated. CONCLUSIONS: Morocco's success in improving uptake of facility deliveries and caesareans is likely to be the result of the synergistic effects of comprehensive demand and supply-side strategies, including a major investment in human resources and free delivery care. Equity still needs to be improved; however, the overall trend is positive.

Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA).

BACKGROUND: Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa. METHODS: The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum. FINDINGS: 138,074 women aged 15-49 years contributed 636,213 person-years of observation. 49,568 women had 86,963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17.2% (95% CI 17.0-17.3), but 60 of 118 (50.8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20.5 (18.9-22.4) in women who were not pregnant or post partum and 8.2 (5.7-11.8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51.8 (47.8-53.8) per 1000 person-years in women who were not pregnant or post partum and 11.8 (8.4-15.3) per 1000 person-years in pregnant or post-partum women. INTERPRETATION: HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women. FUNDING: Wellcome Trust, Health Metrics Network (WHO).

A probabilistic method to estimate the burden of maternal morbidity in resource-poor settings: preliminary development and evaluation.

BACKGROUND: Maternal morbidity is more common than maternal death, and population-based estimates of the burden of maternal morbidity could provide important indicators for monitoring trends, priority setting and evaluating the health impact of interventions. Methods based on lay reporting of obstetric events have been shown to lack specificity and there is a need for new approaches to measure the population burden of maternal morbidity. A computer-based probabilistic tool was developed to estimate the likelihood of maternal morbidity and its causes based on self-reported symptoms and pregnancy/delivery experiences. Development involved the use of training datasets of signs, symptoms and causes of morbidity from 1734 facility-based deliveries in Benin and Burkina Faso, as well as expert review. Preliminary evaluation of the method compared the burden of maternal morbidity and specific causes from the probabilistic tool with clinical classifications of 489 recently-delivered women from Benin, Bangladesh and India. RESULTS: Using training datasets, it was possible to create a probabilistic tool that handled uncertainty of women's self reports of pregnancy and delivery experiences in a unique way to estimate population-level burdens of maternal morbidity and specific causes that compared well with clinical classifications of the same data. When applied to test datasets, the method overestimated the burden of morbidity compared with clinical review, although possible conceptual and methodological reasons for this were identified. CONCLUSION: The probabilistic method shows promise and may offer opportunities for standardised measurement of maternal morbidity that allows for the uncertainty of women's self-reported symptoms in retrospective interviews. However, important discrepancies with clinical classifications were observed and the method requires further development, refinement and evaluation in a range of settings.

Cesarean section in Shanghai: women's or healthcare provider's preferences?

BACKGROUND: Cesarean section (CS) rate has increased rapidly over the past two decades in China mainly driven by non-medical factors. This study was to compare recalled preferences for CS among first-time mothers in early and late pregnancy with actual delivery mode; to explore factors related to CS preference and CS performed without medical indications; and to consider the role of healthcare providers in delivery mode preferences. METHODS: An anonymous questionnaire survey, combined with data on CS indications taken from the patient record, was conducted among 272 first-time mothers having their first postnatal check-up in one university affiliated obstetrics and gynecology hospital in Shanghai, China, between September 2006 and January 2007. Logistic regression was used to study factors related to the recalled preference for CS and CS performed without medical indication, adjusting for maternal age, education and income. RESULTS: The CS rate was 57% (151/263) among all women, 17% with medical indications and 40% without medical indications. For women without medical indications for CS (n = 215), there was no significant difference between women's preference for CS in early (25%) and late pregnancy (28%); 48% of women actually had CS. Women recalled preferring a vaginal delivery but who had CS were more likely to have had a CS suggested by a prenatal care doctor [OR (95% CI): 20 (3.88-107.1)] or by a delivery obstetrician [OR (95% CI): 26 (6.26-105.8)]. Among women recalled preferring and having CS, a suggestion from the prenatal care doctor to have CS was very common. CONCLUSIONS: In the primiparous women without a medical indication for CS, women recall of a provider suggestion for CS was a strong predictor of CS both among women who recalled a preference for CS and among women who recalled a preference for vaginal delivery. Public health education needs strengthening, including discussion of the risks associated with CS and psychological and social support given to women to help them prepare for and cope with childbirth.

Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries.

BACKGROUND: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country. METHODS: We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. FINDINGS: Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. INTERPRETATION: We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. FUNDING: Bill & Melinda Gates Foundation, Norad, The World Bank.

How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.

BACKGROUND: Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. METHODS: We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. FINDINGS: We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. INTERPRETATION: Equity should be accounted for when planning the scaling up of interventions and assessing national progress. FUNDING: Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.