Prevalence of and risk factors for iron deficiency among pregnant women with moderate or severe anaemia in Nigeria: a cross-sectional study.

BACKGROUND: Anaemia during pregnancy causes adverse outcomes to the woman and the foetus, including anaemic heart failure, prematurity, and intrauterine growth restriction. Iron deficiency anaemia (IDA) is the leading cause of anaemia and oral iron supplementation during pregnancy is widely recommended. However, little focus is directed to dietary intake. This study estimates the contribution of IDA among pregnant women and examines its risk factors (including dietary) in those with moderate or severe IDA in Lagos and Kano states, Nigeria. METHODS: In this cross-sectional study, 11,582 women were screened for anaemia at 20-32 weeks gestation. The 872 who had moderate or severe anaemia (haemoglobin concentration < 10 g/dL) were included in this study. Iron deficiency was defined as serum ferritin level < 30 ng/mL. We described the sociodemographic and obstetric characteristics of the sample and their self-report of consumption of common food items. We conducted bivariate and multivariable logistic regression analysis to identify risk factors associated with IDA. RESULTS: Iron deficiency was observed among 41% (95%CI: 38 - 45) of women with moderate or severe anaemia and the prevalence increased with gestational age. The odds for IDA reduces from aOR: 0.36 (95%CI: 0.13 - 0.98) among pregnant women who consume green leafy vegetables every 2-3 weeks, to 0.26 (95%CI: 0.09 - 0.73) among daily consumers, compared to those who do not eat it. Daily consumption of edible kaolin clay was associated with increased odds of having IDA compared to non-consumption, aOR 9.13 (95%CI: 3.27 - 25.48). Consumption of soybeans three to four times a week was associated with higher odds of IDA compared to non-consumption, aOR: 1.78 (95%CI: 1.12 - 2.82). CONCLUSION: About 4 in 10 women with moderate or severe anaemia during pregnancy had IDA. Our study provides evidence for the protective effect of green leafy vegetables against IDA while self-reported consumption of edible kaolin clay and soybeans appeared to increase the odds of having IDA during pregnancy. Health education on diet during pregnancy needs to be strengthened since this could potentially increase awareness and change behaviours that could reduce IDA among pregnant women with moderate or severe anaemia in Nigeria and other countries.

Childbirth care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys between 1995 and 2014 examining use of care, provider mix and immediate postpartum care content.

BACKGROUND: Egypt has achieved important reductions in maternal and neonatal mortality and experienced increases in the proportion of births attended by skilled professionals. However, substandard care has been highlighted as one of the avoidable causes behind persisting maternal deaths. This paper describes changes over time in the use of childbirth care in Egypt, focusing on location and sector of provision (public versus private) and the content of immediate postpartum care. METHODS: We used five Demographic and Health Surveys conducted in Egypt between 1995 and 2014 to explore national and regional trends in childbirth care. To assess content of care in 2014, we calculated the caesarean section rate and the percentage of women delivering in a facility who reported receiving four components of immediate postpartum care for themselves and their newborn. RESULTS: Between 1995 and 2014, the percentage of women delivering in health facilities increased from 35 to 87% and women delivering with a skilled birth attendant from 49 to 92%. The percentage of women delivering in a private facility nearly quadrupled from 16 to 63%. In 2010-2014, fewer than 2% of women delivering in public or private facilities received all four immediate postpartum care components measured. CONCLUSIONS: Egypt achieved large increases in the percentage of women delivering in facilities and with skilled birth attendants. However, most women and newborns did not receive essential elements of high quality immediate postpartum care. The large shift to private facilities may highlight failures of public providers to meet women's expectations. Additionally, the content (quality) of childbirth care needs to improve in both sectors. Immediate action is required to understand and address the drivers of poor quality, including insufficient resources, perverse incentives, poor compliance and enforcement of existing standards, and providers' behaviours moving between private and public sectors. Otherwise, Egypt risks undermining the benefits of high coverage because of substandard quality childbirth care.

Time trends in facility-based and private-sector childbirth care: analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from 2000 to 2016.

BACKGROUND: Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa. METHODS: We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population. RESULTS: The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest. CONCLUSIONS: The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

Length of Stay After Childbirth in 92 Countries and Associated Factors in 30 Low- and Middle-Income Countries: Compilation of Reported Data and a Cross-sectional Analysis from Nationally Representative Surveys.

BACKGROUND: Following childbirth, women need to stay sufficiently long in health facilities to receive adequate care. Little is known about length of stay following childbirth in low- and middle-income countries or its determinants. METHODS AND FINDINGS: We described length of stay after facility delivery in 92 countries. We then created a conceptual framework of the main drivers of length of stay, and explored factors associated with length of stay in 30 countries using multivariable linear regression. Finally, we used multivariable logistic regression to examine the factors associated with stays that were "too short" (<24 h for vaginal deliveries and <72 h for cesarean-section deliveries). Across countries, the mean length of stay ranged from 1.3 to 6.6 d: 0.5 to 6.2 d for singleton vaginal deliveries and 2.5 to 9.3 d for cesarean-section deliveries. The percentage of women staying too short ranged from 0.2% to 83% for vaginal deliveries and from 1% to 75% for cesarean-section deliveries. Our conceptual framework identified three broad categories of factors that influenced length of stay: need-related determinants that required an indicated extension of stay, and health-system and woman/family dimensions that were drivers of inappropriately short or long stays. The factors identified as independently important in our regression analyses included cesarean-section delivery, birthweight, multiple birth, and infant survival status. Older women and women whose infants were delivered by doctors had extended lengths of stay, as did poorer women. Reliance on factors captured in secondary data that were self-reported by women up to 5 y after a live birth was the main limitation. CONCLUSIONS: Length of stay after childbirth is very variable between countries. Substantial proportions of women stay too short to receive adequate postnatal care. We need to ensure that facilities have skilled birth attendants and effective elements of care, but also that women stay long enough to benefit from these. The challenge is to commit to achieving adequate lengths of stay in low- and middle-income countries, while ensuring any additional time is used to provide high-quality and respectful care.

Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using Demographic and Health Surveys.

OBJECTIVE: Maternal mortality rates have decreased globally but remain off track for Millennium Development Goals. Good-quality delivery care is one recognised strategy to address this gap. This study examines the role of the private (non-public) sector in providing delivery care and compares the equity and quality of the sectors. METHODS: The most recent Demographic and Health Survey (2000-2013) for 57 countries was used to analyse delivery care for most recent birth among >330 000 women. Wealth quintiles were used for equity analysis; skilled birth attendant (SBA) and Caesarean section rates served as proxies for quality of care in cross-sectoral comparisons. RESULTS: The proportion of women who used appropriate delivery care (non-facility with a SBA or facility-based births) varied across regions (49-84%), but wealth-related inequalities were seen in both sectors in all regions. One-fifth of all deliveries occurred in the private sector. Overall, 36% of deliveries with appropriate care occurred in the private sector, ranging from 9% to 46% across regions. The presence of a SBA was comparable between sectors (≥93%) in all regions. In every region, Caesarean section rate was higher in the private compared to public sector. The private sector provided between 13% (Latin America) and 66% (Asia) of Caesarean section deliveries. CONCLUSION: This study is the most comprehensive assessment to date of coverage, equity and quality indicators of delivery care by sector. The private sector provided a substantial proportion of delivery care in low- and middle-income countries. Further research is necessary to better understand this heterogeneous group of providers and their potential to equitably increase the coverage of good-quality intrapartum care.