This Lancet Series paper, one of three on the high rate of Caesarean Section (CS), describes the global, regional and selected country levels, trends, determinants and inequalities in CS. Based on data from 169 countries representing 98.4% of the world's births, we estimate that 21.1% (95% uncertainty range 19.9-22.4%) or 29.7 million births occurred through CS in 2015, representing almost a doubling since 2000 (12.1%; 10.9-13.3%). The differences in CS rates between regions in 2015 were tenfold, with a high of 44.3% (41.3-47.4%) in the Latin America and the Caribbean region and a low of 4.1% (3.6-4.6%) in the West and Central African region. The global and regional increases were driven both by increasing coverage of births by health facilities (66.5% of the global increase) and higher CS rates within health facilities (33.5%), with considerable variation between regions. Based on the most recent data, population-based CS rates exceeded 15% of births in 63% of 169 countries, while 28% countries had CS rates below 10%. National CS rates varied from 0.6% in South Sudan to 58.1% in the Dominican Republic. Within-country disparities in CS rates were also very large, with a sixfold difference in CS rates between births in the richest and poorest quintiles in low-and middle-income countries, markedly high CS rates among low obstetric risk births among especially more educated women in Brazil and China and 1.6 times higher CS rates in private facilities compared to public facilities.
This Lancet Series paper, one of three on the high rate of Caesarean Section (CS), describes the global, regional and selected country levels, trends, determinants and inequalities in CS. Based on data from 169 countries representing 98.4% of the world's births, we estimate that 21.1% (95% uncertainty range 19.9-22.4%) or 29.7 million births occurred through CS in 2015, representing almost a doubling since 2000 (12.1%; 10.9-13.3%). The differences in CS rates between regions in 2015 were tenfold, with a high of 44. 3% (41.3-47.4%) in the Latin America and the Caribbean region and a low of 4.1% (3.6-4.6%) in the West and Central African region. The global and regional increases were driven both by increasing coverage of births by health facilities (66.5% of the global increase) and higher CS rates within health facilities (33.5%), with considerable variation between regions.Based on the most recent data, population-based CS rates exceeded 15% of births in 63% of 169 countries, while 28% countries had CS rates below 10%. National CS rates varied from 0.6% in South Sudan to 58.1% in the Dominican Republic. Within-country disparities in CS rates were also very large, with a sixfold difference in CS rates between births in the richest and poorest quintiles in low-and middle-income countries, markedly high CS rates among low obstetric risk births among especially more educated women in Brazil and China and 1.6 times higher CS rates in private facilities compared to public facilities. Manuscript Key messages Global CS rates are high and increasing. In 2015, an estimated 21.1% or 29.7 million births occurred through CS, which represented almost a doubling since 2000. The differences in population CS rates between regions were very large, with a high of 44.3% in the Latin America and the Caribbean region and a low of 4.1% in West and Central African region. There are large persistent disparities in the CS rate between and within countries. Population CS rates are increasing in all regions but are still well below 10% in sub-Saharan Africa. Many poor women in low-and middle-income countries still do not have adequate access to CS. In several countries, poor women have CS rates close to 0%, implying that women and babies die because they cannot access life-saving surgery during labour. At the other end, there is strong evidence of massive over-use of CS in many countries. CS rates are still increasing in most regions with rates well over 15% by 2015, driven by extremely high CS rates among wealthier women, high rates in private facilities and by high proportions of women at low risk of obstetric complications giving birth by CS. AbstractThis Lancet Series paper, one of three on the high rate of Caesarean Section (CS), describes the global, regional and selected country levels, trends, determinants and inequalities in CS. Based on data from 169 countries representing 98.4% of the world's births, we estimate that 21.1% (95% uncertainty range 19.9-22.4%) or 29.7 million births occurred through CS in 2015, representing almos...
Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban–rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban–rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.
Health facility data are a critical source of local and continuous health statistics. Countries have introduced web-based information systems that facilitate data management, analysis, use and visualisation of health facility data. Working with teams of Ministry of Health and country public health institutions analysts from 14 countries in Eastern and Southern Africa, we explored data quality using national-level and subnational-level (mostly district) data for the period 2013–2017. The focus was on endline analysis where reported health facility and other data are compiled, assessed and adjusted for data quality, primarily to inform planning and assessments of progress and performance. The analyses showed that although completeness of reporting was generally high, there were persistent data quality issues that were common across the 14 countries, especially at the subnational level. These included the presence of extreme outliers, lack of consistency of the reported data over time and between indicators (such as vaccination and antenatal care), and challenges related to projected target populations, which are used as denominators in the computation of coverage statistics. Continuous efforts to improve recording and reporting of events by health facilities, systematic examination and reporting of data quality issues, feedback and communication mechanisms between programme managers, care providers and data officers, and transparent corrections and adjustments will be critical to improve the quality of health statistics generated from health facility data.
IntroductionThere are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation.MethodsMonthly routine health facility data by district for the period 2017–2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020.ResultsThe completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few. The country median reduction in utilisation of nine health services for the whole period March–December 2020 was 3.9% (range: −8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=−17.0%) and outpatient admissions (median=−7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from −2% to −6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March–June 2020 for general services, when the response was strongest as measured by a stringency index.ConclusionThe district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.
We observed adherence that is higher than what has been reported for other chronic diseases, and other non-population-based MS cohorts. Closer examination as to why adherence appears to be relatively better in MS and how adherence influences disease outcomes could contribute to our understanding of MS, and prove useful in the management of other chronic diseases.
Summary Background The proportion of heterosexual HIV transmission in Sub-Saharan Africa that occurs within cohabiting partnerships, as opposed to among single people, or in extra-couple relationships, is a subject of active debate. This question is of immediate importance. As plans to use antiretroviral drugs as a strategy for population-level prevention progress, understanding the importance of different transmission routes is critical to targeting intervention efforts. Methods We built a mechanistic HIV transmission model using data from Demographic and Health Surveys covering 27,201 cohabiting couples from 18 sub-Saharan African countries with information on couple duration, age at sexual debut, and HIV serostatus. We combined this model with estimates of HIV survival times and country-specific estimates of HIV prevalence and ART coverage. We then estimated the proportion of observed infections in surveyed cohabiting couples that occurred prior to couple formation, between couple members, and through extra-couple intercourse. Findings We estimate that extra-couple transmission accounts for between 27-61% and 21-51% of all infected males and females, respectively, in surveyed couples, with the ranges given reflecting inter-country variation. We project that over the next year extra-couple transmission will account for 30-65% and 10-47% of new incident HIV infections in males and females, respectively, in cohabiting couples. Our results also suggest that the directionality of transmission within couples is largely from males to females; however, females experience a very high-risk period prior to couple formation. Interpretation Due to the large contribution of extra-couple transmission, HIV prevention interventions should target the general sexually active population, and not just serodiscordant couples.
Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women’s, Children’s and Adolescent’s Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.
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