Dataset Information

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.

ABSTRACT:

Objectives

To describe the prevalence and determinants of births by caesarean section in private and public health facilities in underserved communities in South Asia.

Design

Cross-sectional study.

Setting

81 community-based geographical clusters in four locations in Bangladesh, India and Nepal (three rural, one urban).

Participants

45,327 births occurring in the study areas between 2005 and 2012.

Outcome measures

Proportion of caesarean section deliveries by location and type of facility; determinants of caesarean section delivery by location.

Results

Institutional delivery rates varied widely between settings, from 21% in rural India to 90% in urban India. The proportion of private and charitable facility births delivered by caesarean section was 73% in Bangladesh, 30% in rural Nepal, 18% in urban India and 5% in rural India. The odds of caesarean section were greater in private and charitable health facilities than in public facilities in three of four study locations, even when adjusted for pregnancy and delivery characteristics, maternal characteristics and year of delivery (Bangladesh: adjusted OR (AOR) 5.91, 95% CI 5.15 to 6.78; Nepal: AOR 2.37, 95% CI 1.62 to 3.44; urban India: AOR 1.22, 95% CI 1.09 to 1.38). We found that highly educated women were particularly likely to deliver by caesarean in private facilities in urban India (AOR 2.10; 95% CI 1.61 to 2.75) and also in rural Bangladesh (AOR 11.09, 95% CI 6.28 to 19.57).

Conclusions

Our results lend support to the hypothesis that increased caesarean section rates in these South Asian countries may be driven in part by the private sector. They also suggest that preferences for caesarean delivery may be higher among highly educated women, and that individual-level and provider-level factors interact in driving caesarean rates higher. Rates of caesarean section in the private sector, and their maternal and neonatal health outcomes, require close monitoring.

SUBMITTER: Neuman M

PROVIDER: S-EPMC4283435 | biostudies-literature | 2014 Dec

REPOSITORIES: biostudies-literature

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Publications

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.

Neuman Melissa M Alcock Glyn G Azad Kishwar K Kuddus Abdul A Osrin David D More Neena Shah NS Nair Nirmala N Tripathy Prasanta P Sikorski Catherine C Saville Naomi N Sen Aman A Colbourn Tim T Houweling Tanja A J TA Seward Nadine N Manandhar Dharma S DS Shrestha Bhim P BP Costello Anthony A Prost Audrey A

BMJ open 20141230 12

<h4>Objectives</h4>To describe the prevalence and determinants of births by caesarean section in private and public health facilities in underserved communities in South Asia.<h4>Design</h4>Cross-sectional study.<h4>Setting</h4>81 community-based geographical clusters in four locations in Bangladesh, India and Nepal (three rural, one urban).<h4>Participants</h4>45,327 births occurring in the study areas between 2005 and 2012.<h4>Outcome measures</h4>Proportion of caesarean section deliveries by ...[more]

PMID: 25550293

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Project description:BackgroundSignal functions for emergency obstetric and newborn care (EmONC) are the major interventions for averting maternal and neonatal mortalities. Readiness of the facilities is essential to provide all the basic and comprehensive signal functions for EmONC to ensure emergency services from the designated facilities. The study assessed population coverage and availability of EmONC services in public and private facilities in Bangladesh.MethodsAn assessment was conducted in all the public and private facilities providing obstetric care in to in-patients 24 districts. Data were collected on the performance of signal functions for EmONC from the study facilities in the last three months prior to the date of assessment. Trained data-collectors interviewed the facility managers and key service providers, along with review of records, using contextualized tools. Population coverage of signal functions was assessed by estimating the number of facilities providing the signal functions for EmONC compared to the United Nations requirements. Availability was assessed in terms of the proportion of facilities providing the services by type of facilities and by district.ResultsCaesarean section (CS) delivery and blood transfusion (BT) services (the two major components of comprehensive EmONC) were respectively available in 6.4 (0.9 public and 5.5 private) and 5.6 (1.3 public and 4.3 private) facilities per 500,000 population. The signal functions for basic EmONC, except two (parental anticonvulsants and assisted vaginal delivery), were available in a minimum of 5 facilities (public and private sectors combined) per 500,000 population. A major inter-district variation in the availability of signal functions was observed in each public- and private-sector facility. Among the various types of facilities, only the public medical college hospitals had all the signal functions. The situation was poor in other public facilities at the district and sub-district levels as well as in private facilities.ConclusionsIn the public sector, CS delivery and BT services were available in the minimum required number of facilities. However, to ensure basic EmONC services, participation of the private sector is necessary. Public-private partnership should be promoted for nationwide coverage of signal functions for EmONC in Bangladesh.

Project description:BackgroundAlthough safe motherhood strategies recommend that women seek timely care from health facilities for obstetric complications, few studies have described facility availability of emergency obstetric care (EmOC). We sought to describe and compare availability and readiness to provide EmOC among public and private health facilities commonly visited for pregnancy-related complications in two districts of northwest Bangladesh. We also described aspects of financial and geographic access to healthcare and key constraints to EmOC provision.MethodsUsing data from a large population-based community trial, we identified and surveyed the 14 health facilities (7 public, 7 private) most frequently visited for obstetric complications and near misses as reported by women. Availability of EmOC was based on provision of medical services, assessed through clinician interviews and record review. Levels of EmOC availability were defined as basic or comprehensive. Readiness for EmOC provision was based on scores in four categories: staffing, equipment, laboratory capacity, and medicines. Readiness scores were calculated using unweighted averages. Costs of C-section procedures and geographic locations of facilities were described. Textual analysis was used to identify key constraints.ResultsThe seven surveyed private facilities offered comprehensive EmOC compared to four of the seven public facilities. With 100% representing full readiness, mean EmOC readiness was 81% (range: 63%-91%) among surveyed private facilities compared to 67% (range: 48%-91%) in public facilities (p = 0.040). Surveyed public clinics had low scores on staffing and laboratory capacity (69%; 50%). The mean cost of the C-section procedure in private clinics was $77 (standard deviation: $16) and free in public facilities. The public sub-district facilities were the only facilities located in rural areas, with none providing comprehensive EmOC. Shortages in specialized staff were listed as the main barrier to EmOC provision in public facilities.ConclusionsAlthough EmOC availability and readiness was higher among the surveyed seven most commonly visited private clinics, public facilities appeared to be more affordable for C-section and more geographically accessible. Strategies to retain anesthesiologists and surgeons, such as non-financial incentives, are needed to improve EmOC provision in the public sector. Centralized blood banks are recommended to streamline safe blood acquisition for obstetric surgeries.

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Project description:OBJECTIVES:To explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile. DESIGN:Qualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic. SETTING:Santiago, Chile. PARTICIPANTS:Qualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women. MAIN OUTCOME MEASURES:Rates of caesarean section in different types of institutions; consultants' views on private practice; work patterns in private practice; women's reasons for choosing private care; women's preferences on method of delivery. RESULTS:Private health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the "programming" (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians. CONCLUSIONS:Policies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.

Dataset Information

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.

Objectives

Design

Setting

Participants

Outcome measures

Results

Conclusions

Publications

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.

Similar Datasets

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