Social exclusion and mental health among older adults: cross-sectional evidence from a population-based survey in India.

BACKGROUND: Social exclusion has far-reaching consequences that extend beyond regular activities and access to resources and knowledge; social exclusion is a major social determinant of health. However, there is a lack of evidence on social exclusion and health outcomes among India's older adults. Thus, the current study investigates the association of social exclusion with depressive symptoms among Indian older adults. METHODS: This study used information on 30,366 older adults from Longitudinal Ageing Study in India (LASI) wave-1, 2017-2018. Social exclusion scores were calculated, and two broad domains of social exclusion, i.e., exclusion from civic activity & social relations and exclusion from services, were considered in the study. The depressive symptom was calculated using the CES-D score. Using logistic regression models, the average marginal effects of selected covariates and domains of social exclusion on depressive symptoms were estimated to assess the links between social exclusion and depressive symptoms. RESULTS: With the increase in the social exclusion score in the selected domains, the prevalence of depressive symptoms among older also increased. Elderly persons who do not vote or live alone in the domain of being excluded from civic & social activities and older adults excluded from services were observed to have a higher prevalence of depressive symptoms. Adjusting for sociodemographic factors, the average marginal effects suggested that older with four scores of civic activity & social relation exclusion, two scores of service exclusion and four scores of overall social exclusion were estimated to have a higher prevalence of depressive symptoms, respectively. CONCLUSIONS: This study's findings shed light on social exclusion and its relationship to depressive symptoms among older Indians. Older health care services should be expanded in breadth while also addressing social exclusion, resulting in considerable improvements in older individuals' mental health.

Distress financing in coping with out-of-pocket expenditure for maternity care in India.

BACKGROUND: The cost of maternity care is seen as the barrier in utilizing maternity care, resulting in high maternal deaths. This study focuses on the distress financing and its coping mechanisms associated with maternity care expenditure in India so that corrective measures can be taken to reduce the burden of maternity care. METHODS: This study used the National Sample Survey (NSS) data conducted in 20,014-15 (71st round of NSS) and 2017-18(75th round of NSS). We define distress financing as use of formal borrowing, borrowing from friends or family or sale of asser to finance maternity care. Percentage of pregnant/delivered females using distress financing were calculated.. The present study also used multinomial logistic regression with 95% to understand the impact of socio-economic variables on distress financing and concentration index to measure the inequality in maternity care expenditure. RESULTS: This study found that the maternity care expenditure has decreased from the INR. 9379 in 2014-15 to INR. 7835 in 2017-18. The percentage of households using distress financing is higher among the poorest (13.2%). Almost 14% of the SC households experience distress financing. Among EAG + A states, particularly in Madhya Pradesh and Uttarakhand, the percentage of households are which experience a high level of distress financing increased from 8.9 to 18.3 and 0.7 to 8.1 from 2014-15 to 2017-18 respectively. The study finds that more urban households (37%) utilized insurance than rural households (26%). Among EAG + A states, 67.9 percent of households were dependent upon household savings, and it was 63.6 percent in the non-EAG states. The households with a high burden of maternity care expenditure were at higher risk of borrowing money to finance the cost of maternity as compared to use of savings/income for the same (relative risk (RR) (R: 2.59; P < 0.01; 95% CI: 2.15-3.13). Mothers belonging to the SC caste were at significantly higher risk (RR: 1.43; P < 0.1; 95% CI: 1.07-1.91). of using borrowings as compared to the use of income/savings. Mothers with college education were 50% more likely to use health insurance as compared to those with primary education. CONCLUSIONS: The study found that even though many programs for maternity care services are there, the maternity care expenditure, particularly the delivery care expenses, is very high in many states. The study recommends that India should increase subsidized maternity care facilities to decrease catastrophic maternity expenditure among households.

Disparities in three critical maternal health indicators amongst Muslims: Vis-a-vis the results reflected on National Health Mission.

BACKGROUND: The post national health mission era has been recognized for India's accelerating improvement in maternal health care utilization. Concurrent investigations with the purview of examining inequalities in maternal care utilisation have rigorously examined across various socio-economic groups, focusing on Muslim women. The present study examined socio-economic differentials in maternal health care utilisation among Muslims and the delineated factors which are contributing for these inequalities. METHODS: Study used the data from National Family Health Survey (NFHS) conducted in 2005-06 and 2015-16. the present study applied concentration index and Wagstaff-type decomposition analysis to measure and decompose the inequality in maternal health services. RESULTS: This study found that utilisation of full antenatal care (full ANC), skilled attendants at birth (SBAs) and postnatal care was increased during 2005-06 to 2015-16. However, the least improvement was observed in full antenatal care whereas substantial improvement was achieved in utilising skilled attendants at birth. Further, the poor and non-poor gap in maternal health care utilisation mostly prevailed among the educated, urban resident, other backward castes among Muslims. The inequality has been declined largely in SBA utilisation compared to full ANC and PNC, especially in the southern India. Higher education, mass media exposure, higher birth order and urban residence contribute and explain most of these inequalities in maternal care among Muslim women CONCLUSIONS: Despite the fact that free and cash benefitted health programmes, wealth, mass media exposure and education etc welfare programs benefitted a large number of citizens, it also produced most of the inequalities among Muslims in India. The results focus on the significance of wealth, education, and mass media exposure in bridging the socioeconomic gap in maternal health care utilization among Muslims.

Deaths during pregnancy, childbirth and puerperium: Exploring causes, context and evidence from Eastern India.

AIM: The study was aimed to identify the specific reasons and circumstances of maternal deaths in West Bengal. METHODS: The present study is a retrospective study of 317 maternal deaths, conducted between November 2013 and October 2015 at two major referral hospitals of eastern India, West Bengal. The frequencies, proportions, measures of central tendency and dispersion were used to describe the data. The data were analyzed using the statistical software spss version 20.0. ArcGIS 10.1 was also employed to show the distributional pattern of maternal deaths. RESULTS: The overall maternal mortality ratio was estimated as 561 per 100 000 live births. Eclampsia or hypertensive disorders of pregnancy contributed to one-third (33.1%, n = 105/317) of maternal deaths. The maternal deaths were more common (41%) among women belonging to the age group of 20-24 years and primiparous (36.9%) group. The average distance for traveling to reach the final hospital was 47.37 km. Approximately, three-fourths (72.2%) of maternal deaths were in the post-partum period. Half of the women (50.5%) sought medical care after 12 hrs of developing complications. The majority of the cases (80.1%) were referred and about 45% of patients had a cesarean section. CONCLUSION: The result suggests there was a shift in causes of maternal deaths from hemorrhage to eclampsia. Establishment of separate eclampsia units at lower-level health facilities may be a more plausible pathway to prevent eclampsia-related maternal deaths in West Bengal.

Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India.

BACKGROUND: A disproportionately high proportion of maternal deaths (99 percent) in the world occur in low and middle income countries, of which 90 percent is contributed by Sub-Saharan Africa and South Asia. This study uses the effective "Three Delays" model to assess the socio-cultural barriers associated with maternal mortality in West Bengal, India. METHODS: It was a retrospective mixed methods study, which used facility-based as well as community-based approaches to explore factors associated with maternal deaths. We reviewed 317 maternal death cases wherein a verbal autopsy technique was applied on 40 cases. The Chi-square test (χ2) and multivariable logistic regression model were employed to accomplish the study objectives. RESULTS: The delay in seeking care (Type 1 delay) was the most significant contributor to maternal deaths (48.6 percent, 154/317). The second major impacting contributor to maternal deaths was the delay in reaching first level health facility (Type 2 delay) (33.8 percent, 107/317), while delay in receiving adequate care at the health facility (Type 3 delay) had a role in 18.9 percent maternal deaths. Women staying at long distance from the health facilities have reported [AOR with 95 % CI; 1.7 (1.11-1.96)] higher type 2 delay as compared to their counterparts. The study also exhibited that the women belonged to Muslim community were 2.5 times and 1.6 times more likely to experience type 1 and 2 delays respectively than Hindu women. The verbal autopsies revealed that the type 1 delay is attributed to the underestimation of the gravity of the complications, cultural belief and customs. Recognition of danger signs, knowledge and attitude towards seeking medical care, arranging transport and financial constraints were the main barriers of delay in seeking care and reaching facility. CONCLUSIONS: The study found that the type-1 and type-2 delays were major contributors of maternal deaths in the study region. Therefore, to prevent the maternal deaths effectively, action will be required in areas like strengthening the functionality of referral networks, expand coverage of healthcare and raising awareness regarding maternal complications and danger signs.

Analyzing the etiology behind mortality associated with antepartum, intrapartum, and post-partum cases in a tertiary care teaching hospital of West Bengal

OBJECTIVE: The study was undertaken to understand the causes and circumstances of maternal deaths in West Bengal. MATERIAL AND METHODS: One hundred ten maternal deaths were reported during the period December 2010 through June 2012 in the Maternity Ward of Medical College and Hospitals, West Bengal. These deaths were reviewed using a facility-based Maternal Death Review protocol. The number and percentages were calculated and binary logistic regression analysis was performed. RESULTS: The majority of the deaths occurred in the 20-24 years' age group, those with Hindu religion, in the first and second gravida, and the postpartum period. One third of mothers had cesarean sections. The majority (78.2%) of deaths were among referred cases. Eclampsia was the leading cause of maternal death (29.1%). Approximately half of the deceased women sought care after 10 hours of developing complications. More than one-third of maternal deaths were registered with type 1 delays. CONCLUSION: Our study demonstrates that maternal deaths occurred among young women, referred cases, with cesarean sections and type 1 delays. We recommend that imparting basic skills and improving awareness to the community about the danger signs of pregnancy could be an effective measure to detect maternal complications at an earlier stage.

The Risk of Hypertension and Other Chronic Diseases: Comparing Smokeless Tobacco with Smoking.

BACKGROUND: In the past, studies have compared smokeless tobacco and non-tobacco users for the risk of various chronic diseases. The differences in the risk of chronic diseases between smokeless tobacco user and smokers have not been explored. The objective of this study is to estimate the risk of chronic diseases among smokeless tobacco users compared to smokers. METHODS: The data were used from the Study on Global Ageing and Adult Health (SAGE) Wave-1, conducted in 2007-2008 in India. The study sample is the respondents who reported consuming any form of tobacco in last 1 month. The total sample size was 4,038 respondents. The odds ratio of chronic morbidities was estimated taking smokers as the reference category. RESULTS: The odds ratios for (self-reported) diabetes, asthma, and hypertension were not significant for smokeless tobacco user compared to smoked tobacco users. The odds ratio of chronic lung diseases (CLDs) was significantly lower among smokeless tobacco users compared to smoked tobacco users. The odds ratio of hypertension (measured) combined with low education and belonging to lowest wealth quintiles were not significant for smokeless tobacco users compared to smoked tobacco users. Duration of the use of smokeless tobacco and quantity of use was found to have no significant relation with risk of chronic diseases as compared to smoking. CONCLUSION: This study did not find the significantly higher risk of chronic morbidities except for CLD for smokeless tobacco users compared to smoked tobacco users. The study suggests that the use of any form of tobacco may have a similar risk of chronic diseases.