Key drivers of hysterectomy among women of reproductive age in three states in India: comparative evidence from NFHS-4 and NFHS-5.

PURPOSE: According to the 4th and 5th rounds of National Family Health Survey (NFHS), there is high prevalence of hysterectomies in the three states of Andhra Pradesh Telangana and Bihar. The three said states have more than double the number of hysterectomies taking place than the national average. Our purpose is to analyse whether these rates are increasing, decreasing or have stabilized and their reasons thereof. Such an analyses will help the policy makers in recommending good clinical practices within their states. MATERIAL AND METHODS: We used data from NFHS-4 (2015-16) and NFHS-5 (2019-2021) rounds. We calculated the differences in predicted probabilities for various factors, performed a Fairlie Decomposition analyses to quantify the positive and negative contributors in the prevalence of hysterectomy across the three states over two time points, and assessed the association of various socio-demographic characteristics to hysterectomy through a multilevel logistic regression model. RESULTS AND CONCLUSION: The results show that out of a total of 80,976 eligible respondents from the states under study, 5826 respondents self-reported that they had a hysterectomy done. It was found that older age, living in rural areas, belonging to other backward classes and higher wealth quintile, and higher parity positively contributed to the increased prevalence of hysterectomies in the three states. Higher educational attainment and previous use of family planning methods acted as protective factors. Characteristics at the household level had the highest intra-class correlation value in the prevalence of hysterectomy among women, followed by the Primary Sampling Unit and District levels, indicating high clustering in the prevalence of hysterectomy at the household level in all three states. Heavy menstrual bleeding/pain was the leading cause of hysterectomies in all three states, followed by fibroids/cysts in Andhra Pradesh and Telangana and Uterine disorder/ prolapse in Bihar. Over 80% of hysterectomies took place in the private hospitals. RECOMMENDATIONS: The study recommends better, more efficient and accountable hysterectomy surveillance to ensure more sustainable woman's reproductive health services in India. Government should adopt and implement standard regulatory guidelines to prevent provider-driven avoidable hysterectomies. Moreover, we recommend informing primary care professionals about the long-term health effects of hysterectomy and promoting alternate therapies for treating uterine fibroids and heavy bleeding.

Sight impairment registration in Trinidad: trend in causes and population coverage in comparison to the National Eye Survey of Trinidad and Tobago.

BACKGROUND: Little was known about the population coverage and causes of sight impairment (SI) registration within the Caribbean, or the extent to which register studies offer insights into population eye health. METHODS: We compared causes of SI registration in the Trinidad and Tobago Blind Welfare Association (TTBWA) register with findings from the 2014 National Eye Survey of Trinidad and Tobago (NESTT), and estimated registration coverage. Cross-sectional validation studies of registered clients included interviews, visual function and cause ascertainment in July 2013, and interviews and visual function in July 2016. RESULTS: The TTBWA register included 863 people (all ages, 48.1%(n = 415) male) registered between 1951 and 2015. The NESTT identified 1.1%(75/7158) people aged ≥5years eligible for partial or severe SI registration, of whom 49.3%(n = 37) were male. Registration coverage was approximately 7% of the eligible population of Trinidad. Nevertheless, there was close agreement in the causes of SI comparing the register and population-representative survey. Glaucoma was the leading cause in both the register (26.1%,n = 225) and population-based survey (26.1%, 18/69 adults), followed by cataract and diabetic retinopathy. In the validation studies combined, 62.6%(93/151) clients had severe SI, 28.5%(43/151) had partial SI and 9.9%(15/151) did not meet SI eligibility criteria. SI was potentially avoidable in at least 58%(n = 36/62) adults and 50%(n = 7/14) children. CONCLUSION: We report very low register coverage of the SI population, but close agreement in causes of SI to a contemporaneous national population-based eye survey, half of which resulted from preventable or treatable eye disease.

Prevalence and associated factors of undiagnosed hypertension among women aged 15-49 years in India: an analysis of National Family Health Survey-4 data.

Hypertension is a major risk factor for cardiovascular diseases globally. Fortunately, there is a vast armamentarium of effective therapeutic options at our disposal so undiagnosed hypertension represents a missed opportunity. In a previous analysis [1] of the NFHS-4 dataset for the prevalence and risk factors for undiagnosed hypertension and its associated risk factors among Indian women aged 15-49 years, we had overestimated prevalence by inclusion of self-reported cases. We have since retracted when this anomaly was highlighted [2]. We have now re-analyzed the same database and here present these data. The current analysis shows that the overall prevalence of undiagnosed hypertension was 8.05% among women aged 15-49 years in India. In rural areas, it was 7.89% compared with 8.38% for urban areas. Factors associated with undiagnosed hypertension in rural and urban areas were age, BMI, wealth quintiles, educational level, religion, caste and geographical zones. Nearly half the women aged 15-49 years in India with hypertension are unaware and this has implications for personal and reproductive health.

An analysis of factors associated with neonatal, post-neonatal and child mortality in Haiti, including breastfeeding as a time-dependent variable.

AIM: The main objective of the study was to identify factors associated with neonatal, post-neonatal and child mortality. The study also investigated breastfeeding status as a time-dependent variable. METHODS: The 2016-2017 Haitian Demographic and Health Survey was analysed. The analysis was done on 6530 live births. Time-constant and time-dependent multivariable Royston-Parmar spline models were used to identify associated factors for all three age groups. Restricted mean survival times were calculated for the different levels of the breastfeeding variable for each age group. RESULTS: Neonates and post-neonates who were not breastfed were associated with increased mortality, hazard ratio (HR) 22.13 (95% confidence interval (CI), 16.40-29.87) and HR 4.99 (95% CI, 3.29-7.56), respectively. Males in the child age group were associated with increased mortality, HR 2.04 (95% CI, 1.29-3.23) and HR 2.03 (95% CI, 1.28-3.21) under the time-constant and time-dependent models, respectively. CONCLUSIONS: Early initiation of breastfeeding and breastfeeding throughout the post-neonatal period is recommended. Outreach programmes that provide support and education for vulnerable families are also recommended.

The Role of 68 Ga-DOTA-SSA PET/CT in the Management and Prediction of Peptide Receptor Radionuclide Therapy Response for Patients With Neuroendocrine Tumors : A Systematic Review and Meta-analysis.

PURPOSE: The aim of this study was to identify and evaluate the role of 68 Ga-DOTA-somatostatin analog (SSA) PET/CT in guiding treatment for patients with neuroendocrine tumors (NETs) based on published literature, with specific focus on the ability of PET/CT to impact clinical management and predict peptide receptor radionuclide therapy (PRRT) response. PATIENTS AND METHODS: A systematic literature search of articles up to December 2021 was performed using PubMed and Scopus. Eligible studies included ≥10 patients with confirmed or suspected NETs who had undergone pretreatment staging 68 Ga-DOTA-SSA PET/CT. A meta-analysis using the random-effects model was conducted to determine the overall change in management after PET/CT, whereas PET/CT-derived parameters that correlated with PRRT outcome were summarized from studies that assessed its predictive capabilities. RESULTS: A total of 39 studies were included in this systemic review, of which 2266 patients from 24 studies were included for meta-analysis. We showed that PET/CT resulted in a change in clinical management in 36% (95% confidence interval, 31%-41%; range, 3%-66%) of patients. Fifteen studies consisting of 618 patients examined the prognostic ability of 68 Ga-DOTA-SSA PET/CT for PRRT. Of those, 8 studies identified a higher pretreatment SUV to favor PRRT, and 4 identified PET-based radiomic features for somatostatin receptor heterogeneity to be predictive of PRRT response. CONCLUSIONS: Along with its diagnostic abilities, 68 Ga-DOTA-SSA PET/CT can impact treatment decision-making and may predict PRRT response in patients with NETs. More robust studies should be conducted to better elucidate the prognostic role of somatostatin receptor PET/CT in optimizing treatment for clinical outcome.

Determinants of neonatal, post-neonatal and child mortality in Afghanistan using frailty models.

BACKGROUND: Afghanistan has one of the highest under-five mortality rates in South Asia, 70.4 per 1000 live births. Determinants need to be identified to reduce this rate. Knowledge of the existence of familial and community frailty will also assist in the reduction of under-five mortality. METHODS: The 2015 Afghanistan Demographic Health Survey, including 32,712 live births, was analysed. Under-five mortality was disaggregated into neonatal, post-neonatal and child mortality and piecewise traditional Cox proportional hazard, variance-corrected and frailty models were developed. All the models identified determinants and the two frailty models examined the existence of familial and community frailty for each age group. RESULTS: There was statistically significant evidence of community frailty. Breastfeeding status was a highly significant determinant under univariable and multivariable analysis for neonatal and post-neonatal mortality. Post-neonates of employed mothers also experienced increased mortality, particularly those whose mother worked in agriculture where the hazard ratio was 2.77 (95% CI 2.10, 3.65). Birth order 5+ was associated with increased mortality for all three age groups. CONCLUSION: The Afghanistan Ministry of Public Health should identify frail communities. Support, such as daycare facilities, should be provided and early initiation of breastfeeding and breastfeeding throughout the post-neonatal period should also be encouraged. IMPACT: The study identified determinants of neonatal, post-neonatal and child mortality. The study also established the presence of community frailty with respect to under-five mortality in Afghanistan. The study shows that the association of not breastfeeding and mortality is more acute in the early neonatal age group and it extends into the post-neonatal age group. The study identified the association of high birth order and mortality in the neonatal, post-neonatal and child age groups in Afghanistan. Policies should be implemented that encourage early initiation of breastfeeding to continue throughout the post-neonatal period and support for vulnerable families should be provided.

Health status risk factors and quality of life in 75-84-year-old individuals assessed for dementia using the short 10/66 dementia diagnostic schedule.

BACKGROUND: Trinidad is an island that not only has a population at high vascular risk but also one that is in epidemiological transition with high dementia prevalence. The aim of the study was to investigate modifiable risk factors associated with dementia in middle-old (75-84 years) individuals. METHODS: As part of a large national community survey of dementia prevalence in Trinidad, 811 people aged 75-84 years were evaluated for dementia using the 10/66 short algorithm. Demographic data collected included information on age, gender, ethnicity, religion, education, occupation, living accommodation, smoking, alcohol consumption, self-reported medical conditions, impairments and ability to do instrumental activities of daily living (IADL). Data were analysed using multivariable logistic regression models. RESULTS: Of the 811 participants, nearly 55% were female. The mean age was 78.8 (SD = 2.8) years and dementia was present in 198 (24.4%). Having less than ten years of education, being an agricultural worker, skilled labourer or housewife and having more than four co-morbidities were significantly associated with dementia. The odds ratio for dementia for those having self-reported stroke was 4.93 (95% CI [2.64-9.23]) and for diabetes was 1.76 (95% CI [1.17-2.65]) adjusting for age, age2, gender, ethnicity, religion, education and occupation. Impairment in eyesight, hearing, climbing stairs, and walking were also more common in the group with dementia. Ability to perform IADLs was linked with dementia. Individuals with dementia were more likely to be unable to perform any of the eight IADLs. Those who did not exercise at all (OR 6.95, 95% CI [2.02-23.90]) and those who did low exercise (OR 1.83, 95% CI [1.07-3.13]) compared to those who did moderate to high exercise were also more likely to have dementia. CONCLUSION: In the middle-old population in Trinidad having diabetes and stroke, low IADL score, and no exercise were more common in people with dementia.

Time series data analysis and ARIMA modeling to forecast the short-term trajectory of the acceleration of fatalities in Brazil caused by the corona virus (COVID-19).

OBJECTIVE: This paper incorporates the concept of acceleration to fatalities caused by the coronavirus in Brazil from time series data beginning on 17th March 2020 (the day of the first death) to 3rd February 2021 to explain the trajectory of the fatalities for the next six months using confirmed infections as the explanatory variable. METHODS: Acceleration of the cases of confirmed infection and fatalities were calculated by using the concept of derivatives. Acceleration of fatality function was then determined from multivariate linear function and calculus chain rule for composite function with confirmed infections as an explanatory variable. Different ARIMA models were fitted for each acceleration of fatality function: the de-seasonalized Auto ARIMA Model, the adjusted lag model, and the auto ARIMA model with seasonality. The ARIMA models were validated. The most realistic models were selected for each function for forecasting. Finally, the short run six-month forecast was conducted on the trajectory of the acceleration of fatalities for all the selected best ARIMA models. RESULTS: It was found that the best ARIMA model for the acceleration functions were the seasonalized models. All functions suggest a general decrease in fatalities and the pace at which this change occurs will eventually slow down over the next six months. CONCLUSION: The decreasing fatalities over the next six-month period takes into consideration the direct impact of the confirmed infections. There is an early increase in acceleration for the forecast period, which suggests an increase in daily fatalities. The acceleration eventually reduces over the six-month period which shows that fatalities will eventually decrease. This gives health officials an idea on how the fatalities will be affected in the future as the trajectory of confirmed COVID-19 infections change.

Knowledge, Attitudes and Practices (KAP) regarding the Novel Coronavirus Disease (COVID-19) Post-lockdown in Trinidad and Tobago.

The Novel Coronavirus Disease (COVID-19) was declared a pandemic by the World Health Organization (WHO) in March 2020. Trinidad and Tobago reported its first infection on March 12th 2020. This study assessed knowledge, attitudes and practices toward COVID-19 among Trinidadians during the post-lockdown period. A validated questionnaire was used to conduct a cross-sectional survey from May 25th to June 6th 2020.Most respondents (512, 96.6%) knew that COVID-19 is highly infectious. Many (523, 98.7%) identified vulnerable groups as persons 65 years and older and those with preexisting co-morbidities (480, 90.6%). Respondents identified COVID-19 symptoms as fever (498, 94.0%), dry cough (495, 93.4%), myalgia (403, 76.0%) and sore throat (441, 83.2%). Most 504 (95.1%) acknowledged that COVID-19 threatened the country's economy. Dominant practices included regular hand washing (97.2%) and social distancing (512, 96.6%).Health authorities should continue public education efforts to increase knowledge and the adoption of recommended practices.

Prevalence and associated factors of undiagnosed hypertension among women aged 15-49 years in India: an analysis of National Family Health Survey-4 data.

Hypertension is a major risk factor for cardiovascular disease globally. Although Indian studies have addressed the prevalence of hypertension and its associated factors, this study focuses upon women in the reproductive age group, 15-49 years, who have undiagnosed hypertension. We use NFHS-4 data for secondary analyses of prevalence and factors associated with undiagnosed hypertension among women aged 15-49 years in India. Multiple logistic regression was undertaken to identify associated factors. Our analyses showed that overall prevalence of undiagnosed hypertension was 18.69% among women aged 15-49 years in India. In rural areas, it was 17.09% compared  and 21.73% in urban areas. By comparison, only 8.86% self-reported a diagnosis of hypertension. Factors associated with undiagnosed hypertension were age, less than or more than normal BMI, higher wealth quintiles, no education, religion, caste, and geographical zones. Almost one in five women aged 15-49 years in India has undiagnosed hypertension with implications for personal and reproductive health.

The Use of the Slipping Slipper Sign to Explore the Connection between the Feet and the Mouth in Patients with Diabetes Mellitus.

OBJECTIVE: Both periodontal disease and peripheral neuropathy are complications associated with poorly controlled diabetes. This study aimed to determine whether periodontal disease was more prevalent and more severe among patients with severe diabetic peripheral neuropathy. METHODS: A case-control study was performed; 46 patients with and 48 without the slipping slipper sign (SSS)-a surrogate clinical marker for severe peripheral neuropathy-were recruited from a diabetic outpatient clinic. Demography and data from the Basic Periodontal Examination (BPE) were assessed, in addition to the patients' periodontal health by 2 examiners blinded to patients' SSS status. Multivariate logistic regression was used to evaluate the associations between the risk factors for and the presence of the SSS, adjusting for age, gender, and ethnicity. RESULTS: The mean age of the sample was 55.8 years (±10.69 years). Most of the participants (77.7%) had either never been to a dentist or had last attended a dental clinic more than a year before this examination, and 83% did not have a dentist. Periodontal disease was advanced in 61.7%, and there was no association between the SSS and periodontal disease. Dental-service utilization variables were significantly associated with the SSS. Patients who did not have a regular dentist were more than 7 times more likely to have the SSS than were those who did (OR = 7.70; 95% CI: 1.12 53.21). CONCLUSION: In diabetic patients, oral health-related risk factors, such as not having a dentist, wearing a denture or dentures, and visiting a dentist once a year or more, may be associated with systemic complications, including peripheral neuropathy. Early collaboration between dentists and doctors on the care of patients with diabetes is recommended.

An evaluation of the public's Knowledge, Attitudes and Practices (KAP) in Trinidad and Tobago regarding sharks and shark consumption.

There is a global lack of data concerning shark consumption trends, consumer attitudes, and public knowledge regarding sharks. This is the case in Trinidad and Tobago, where shark is a popular culinary delicacy. A Knowledge, Attitudes, and Practices (KAP) survey was conducted in Trinidad and Tobago. Six hundred and seven questionnaires were administered. Univariate and stepwise multivariate logistic regressions were performed to test the association between KAP and demographic categories. The response rate was 93.4% with 567 questionnaires returned (473 from Trinidad and 94 from Tobago). Two hundred and seventeen (38.3%) participants were knowledgeable, 422 (74.4%) displayed attitudes in favour of shark conservation and sustainable use, and 270 (47.6%) displayed practices promoting shark conservation and sustainable use. Island (AOR = 2.81, CI = 1.78, 4.46) and tertiary education (AOR = 2.31, CI = 1.20, 4.46) significantly influenced knowledge level. Gender (AOR = 1.50, CI = 1.02, 2.20) and island (AOR = 0.56, CI = 0.35, 0.90) significantly influenced attitude. Gender (COR = 1.59, CI = 1.14, 2.22) was significantly associated with practices. Over 70% of respondents ate shark, and 54.7% ate shark infrequently enough to avoid risks from heavy metal toxicity. Our results may be useful to develop public awareness and practice improvement initiatives in order to improve KAP regarding shark meat consumption.

Prevalence and Factors Associated with Dentin Hypersensitivity among Adult Patients Attending a University Dental Clinic in Trinidad, West Indies. A Cross-Sectional Study.

Purpose: To assess the prevalence of dentin hypersensitivity (DH) in an adult population and explore its association with sociodemographic variables, dietary habits and oral health behaviours as there is very little data on this from the Caribbean.
Materials and Methods: A cross-sectional survey was conducted of consecutive dental patients (18 years and over) attending the UWI School of Dentistry polyclinic. Following informed consent, dental examinations were performed and the presence of DH was assessed clinically by sensitivity to an air blast on individual teeth. Patients were also given a questionnaire. Their answers were processed using statistical software (SPSS version 24). Associations between variables were analysed using the chi-squared test.
Results: 300 patients participated, with an age range of 18-81 years and a mean age of 44.7 years (SD 15.7). 68.8% were female and the main ethnic groups were African (45.8%), Indian (29.8%) and mixed (24.4%). Over half of the participants (54.9%) reported a history of sensitive teeth and 52% reported sensitivity to the air syringe on one or more teeth. Based on multivariate logistic regression, a history of sensitive teeth was significantly associated with Indo-Trinidadian ethnicity (OR 2.24, 95% CI: 1.23, 4.45), a history of tooth grinding or jaw clenching (OR 0.38, 95% CI: 0.19, 0.76) and consumption of citrus fruits one to two times daily (OR 0.22, 95% CI: 0.06, 0.85). Those who experienced vomiting irregularly were more likely (OR 2.31, 95% CI: 0.96, 5.54) to have DH.
Conclusion: Prevalence of dentin hypersensitivity was high among this sample of dental patients and was associated with ethnicity, tooth grinding and dietary practices.

The Impact of Sociodemographic and Socioeconomic Factors on the Burden of Cataract in Small Island Developing States (SIDS) in the Caribbean from 1990 to 2016.

Purpose: To study the impact of sociodemographic and socioeconomic factors on the cataract burden in Caribbean small island developing states (SIDS) using disability-adjusted life-years (DALYs).Methods: National and regional age and sex specific cataract DALY numbers and rates from 1990 to 2016 for Caribbean SIDS, were extracted from the Global Burden of Disease Study 2016. The human development index (HDI), healthcare access and quality (HAQ) index, and the World Bank's classification of economies were used as socioeconomic status indicators. The Gini coefficient, Atkinson, Theil and concentration indices were used to measure health inequality. Paired Wilcoxon signed rank test, Pearson correlation, and linear regression analyses were performed to evaluate the sociodemographic and socioeconomic factors associated with differences in cataract burden.Results: Men had higher age-standardized DALY rates than women (P < .001) with median rates of 90.72 (Interquartile range [IQR], 87.8-94.2) and 83.94(IQR, 80.9-86.5), respectively. The burden of cataract increased with age. Upper-middle income countries had higher age-standardized DALY rates than high income countries (P < .001), with median rates of 90.1 (IQR, 86.8-93.4) and 79.8 (IQR, 77.5-81.8), respectively. Age-standardized DALY rates were inversely correlated with HDI (r = - 0.61, ß = - 51.56 [P < .05]) and HAQ (r = - 0.68, ß = - 0.46 [P < .01). Between-country inequality was negligible, and the burden of cataract is greater among the poor.Conclusion: Global trends of socioeconomic factors were confirmed. Significantly, men had higher age-standardized DALY rates than women. This is an area for further research.

Cancer driver genes: a guilty by resemblance doctrine.

A major benefit of expansive cancer genome projects is the discovery of new targets for drug treatment and development. To date, cancer driver genes have been primarily identified by methods based on gene mutation frequency. This approach fails to identify culpable genes that are not mutated, rarely mutated, or contribute to the development of rare forms of cancer. Due to the complexity of the disease and the sheer volume of data, computational methods may encounter a NP-complete problem. We have developed a novel pathway and reach (PAR) method that employs a guilty by resemblance approach to identify cancer driver genes that avoids the above problems. Essentially PAR sifts through a list of genes of biological pathways to find those that are common to the same pathways and possess a similar 2-reach topology metric as a reference set of recognized driver genes. This approach leads to faster processing times and eliminates any dependency on gene mutation frequency. Out of the three pathways, signal transduction, immune system, and gene expression, a set of 50 candidate driver genes were identified, 30 of which were new. The top five were HGF, E2F1, C6, MIF, and CDK2.

Association of Place of Residence and Under-Five Mortality in Middle- and Low-Income Countries: A Meta-Analysis.

This review evaluated the association of place of residence (urban/rural) and under-five mortality in middle- and low-income countries. Both English and Spanish language studies conducted during the Millennium Development Goal (MDG) period (1990 to 2015) were reviewed. Twenty-six cross-sectional studies, all in the English language, were selected for further review. Published data were used for this analysis. A funnel plot was produced to ascertain the presence of publication bias. The combined relative risk for under-five mortality was estimated using a random-effects model and a meta-regression was conducted on 15 of the 26 studies. The studies had a combined effect size of 1.47 (95% confidence interval, 1.27–1.67). The results of the meta-regression showed a positive association between the relative risk and the percentage of the rural population for the various regions/countries. The coefficient for the variable rural population percentage was 0.007, indicating that for every one percent increase in the rural population percentage, there was a 0.007 increase in the relative risk for under-five mortality. However, this was not significant (p-value = 0.3). Rural disadvantage persists in middle- and low-income countries. This is important to evaluate policies and programmes designed to remove the gap in under-five mortality rates between urban and rural areas.

The use of gene interaction networks to improve the identification of cancer driver genes.

Bioinformaticians have implemented different strategies to distinguish cancer driver genes from passenger genes. One of the more recent advances uses a pathway-oriented approach. Methods that employ this strategy are highly dependent on the quality and size of the pathway interaction network employed, and require a powerful statistical environment for analyses. A number of genomic libraries are available in R. DriverNet and DawnRank employ pathway-based methods that use gene interaction graphs in matrix form. We investigated the benefit of combining data from 3 different sources on the prediction outcome of cancer driver genes by DriverNet and DawnRank. An enriched dataset was derived comprising 13,862 genes with 372,250 interactions, which increased its accuracy by 17% and 28%, respectively, compared to their original networks. The study identified 33 new candidate driver genes. Our study highlights the potential of combining networks and weighting edges to provide greater accuracy in the identification of cancer driver genes.

Regional differences in usage of antenatal care and safe delivery services in Indonesia: findings from a nationally representative survey.

BACKGROUND: Indonesia has shown a nominal increase in antenatal care (ANC) coverage from 93% to 96% in the Indonesia Demographic Health Survey (IDHS)-2012. This is high but for a comprehensive assessment of maternal health coverage in Indonesia, safe delivery services need to be assessed in conjunction with ANC coverage. MATERIALS AND METHODS: The study uses survey data from the IDHS-2012 that was conducted among women aged 15-49 years who gave birth during the past 3 years preceding the survey. Socioeconomic and demographic factors affecting ANC coverage and safe delivery services are analysed by segregating the data into 7 regions of Indonesia. RESULTS: Multivariate results show that besides wealth and education differentials, regional differences significantly affect the usage of ANC and safe delivery services across the 7 regions. Univariate analyses show that Sulawesi, Maluku and Western New Guinea islands are at a disadvantage in accessing ANC and safe delivery services. CONCLUSIONS: The study recommends that disaggregated regional targets be set in order to further reduce maternal mortality rates in Indonesia.

Ecological and socio-demographic differences in maternal care services in Nepal.

Background. Nepal is set to achieve MDG-5 goals by end of 2015. However, maternal health parameters will remain way below those of developed countries. This study was conducted to assess the factors contributing to utilization of ANC and safe delivery services with the aim of furthering overall maternal health parameters in Nepal. Material and Methods. Using survey data from the Nepal Demographic and Health Survey 2011, socio-economic and demographic factors associated with the utilization of ANC and safe delivery services among women aged 15-49 years who gave births during the last three years preceding the survey are examined. Data was segregated into three ecological zones: Mountain, Hill and Terai zones for univariate analyses. Data from all three zones was then pooled for univariate and multivariate logistic regression analyses of Antenatal Care and Safe Delivery services in Nepal. Results and Conclusion. The analyses show that rural place of residence is at a disadvantage in receiving ANC (OR, 0.8; 95% CI [0.7-0.9]) and ensuring safe delivery (OR, 0.6; 95% CI [0.5-0.7]). Woman's education, husband's education and wealth quintile are significant factors in ensuring ANC and safe delivery services. Further, the analyses show that Budh/Muslim/Kirat/Christians are at a significant disadvantage in ensuring safe delivery (OR, 0.8; 95% CI [0.7-0.9]) as compared with Hindus. Though ecological zones lost their significance in receiving ANC, women in the Terai region are at a significant advantage in ensuring safe delivery (OR, 1.7; 95% CI [1.2-2.1]). Recommendation. Segregated targets should be set for the different ecological zones for further improvement in maternal mortality rates in Nepal.