Are cesarean deliveries equitable in India: assessment using benefit incidence analysis

State-wise variation and inequalities in caesarean delivery rates in India: analysis of the National Family Health Survey-5 (2019-2021) data

Background

India's caesarean delivery (CD) rate of 21.5% suggests adequate national access to CD but may mask significant disparities. We examined variation in CD rates across states (geography), wealth, and health care sector (public versus private). We also aimed to determine relative inequality in CD rates across wealth quintiles.

Methods

The current study was a cross-sectional analysis of CD rates from the National Family Health Survey-5 (2019-2021) disaggregated by asset-based household wealth quintiles for each state and by healthcare sector (public versus private). Data from 724,115 women aged 15-49 years across 28 states and eight union territories were analysed. Women who reported their most recent live birth within the past five years were included. Relative inequality was measured by comparing CD rates in the richest versus the poorest quintiles.

Findings

Disaggregating the national CD rate of 21.5% showed substantial variation in CD rate across states, ranging from 5.2% in Nagaland to 60.7% in Telangana and across wealth quintiles, ranging from 0% to 76.7% (Assam). CD facility rates were higher in private than public facilities across all wealth quintiles. Over two-thirds of states (69%) had at least twice the CD rate in the richest wealth quintile versus the poorest quintile. Relative inequality in CD rates between the richest and poorest was 5.3 nationally and was higher in public (4.0) versus private (1.4) facilities.

Interpretation

The national CD rate in India masks complex geographical, wealth, and sector-related inequalities in CD utilisation. Accounting for these variations is imperative when interpreting national-level rates to better assess the equity in the distribution of CD services.

Funding

None.

Socioeconomic gradient of lean diabetes in India: Evidence from National Family Health Survey, 2019-21

Diabetes is a global public health challenge, particularly in India, affecting millions. Among diabetic patients, lean type 2 diabetes is a severe subtype with higher microvascular complication risks. While studies on the prevalence, variations and risk factors of diabetes are increasingly available, there has been limited research on the prevalence, variations, and socioeconomic disparities of lean diabetes in India. This study used NFHS-5 microdata, and lean diabetes is defined as those with a BMI level of under 25 and random blood glucose levels of over 200 or under diabetic medication. Descriptive and multivariate analyses were conducted to understand lean diabetes variations and related factors. Socioeconomic disparities were measured using concentration curves and the concentration index. The study unveiled important insights into lean diabetes in India. 8.2% of men and 6.0% of women had elevated blood glucose levels, indicating a significant diabetes burden. Notably, 2.9% of men and 2.4% of women were diagnosed with lean diabetes. Among type 2 diabetics, 52.56% of males and 43.57% of females had lean type 2 diabetes. Lean diabetes prevalence varied from 11.6% in the poorest quintile to 1.1% in the richest. The odds of lean type 2 diabetes among those in the poorest quintile was 6.7 compared to the richest quintile. The concentration index of lean type 2 diabetes was -0.42 for men and -0.39 for women, suggesting a disproportionate impact on lower socioeconomic groups. This study advances our understanding of the complex interplay between socioeconomic factors and lean type 2 diabetes in India. To address the rising burden of lean diabetes among lower socioeconomic strata, policymakers and healthcare professionals must prioritise initiatives enhancing healthcare access, promoting healthy lifestyles, and ensuring effective diabetes management. By addressing socioeconomic disparities and implementing interventions for vulnerable populations, India can reduce diabetes-related mortality and enhance its citizens' overall health.

Biochemical and immunomodulatory insights of extracellular matrix from decellularized human whole cervix: recellularization andin vivoECM remodeling interplay

Extracellular matrix (ECM) rich whole organ bio-scaffolds, preserving structural integrity and essential growth factors, has potential towards regeneration and reconstruction. Women with cervical anomalies or trauma can benefit from clinical cervicovaginal repair using constructs rich in site specific ECM. In this study, complete human cervix decellularization was achieved using a modified perfusion-based stir bench top decellularization method. This was followed by physico-chemical processes including perfusion of ionic agents, enzymatic treatment and washing using detergent solutions for a duration of 10-12 d. Histopathological analysis, as well as DNA quantification confirmed the efficacy of the decellularization process. Tissue ultrastructure integrity was preserved and the same was validated via scanning electron microscopy and transmission electron microscopy studies. Biochemical analysis and structural characterizations like Fourier transform infrared, Raman spectroscopy of decellularized tissues demonstrated preservation of important proteins, crucial growth factors, collagen, and glycosaminoglycans.In vitrostudies, using THP-1 and human umbilical vein endothelial cell (HUVEC) cells, demonstrated macrophage polarization from M1 to M2 and vascular functional genes enhancement, respectively, when treated with decellularized human cervical matrix (DHCp). Crosslinked DHC scaffolds were recellularized with site specific human cervical epithelial cells and HUVEC, showing non-cytotoxic cell viability and enhanced proliferation. Furthermore, DHC scaffolds showed immunomodulatory effectsin vivoon small rodent model via upregulation of M2 macrophage genes as compared to decellularized rat cervix matrix scaffolds (DRC). DHC scaffolds underwent neo-vascularization followed by ECM remodeling with enhanced tissue integration.

Are institutional deliveries equitable in the southern states of India? A benefit incidence analysis

BACKGROUND

Despite a commendable rise in the number of women seeking delivery care at public health institutions in South India, it is unclear if the benefit accrues to wealthier or poorer socio-economic groups. The study's aim was to investigate at how the public subsidy is distributed among Indian women who give birth in public hospitals in the southern regions.

METHODS

Data from the Indian Demographic Health Survey's fifth wave (NFHS-5, 2019-21) was used in this study. A total of 22, 403 were institutional deliveries across all the southern states of India were included. Out-of-pocket expenditure (OOPE) on childbirth in health institutions was the outcome variable. We used summary statistics, Benefits Incidence Analysis (BIA), concentration index (CI), and concentration curve (CC) were used.

RESULTS

Most women in the lowest, poorest, and medium quintiles of wealth opted to give birth in public facilities. In contrast, about 69% of mothers belonging to highest quintile gave birth in private health institutions. The magnitude of CI and CC of institutional delivery indicates that public sector usage was concentrated among poorer quintiles [CIX: - 0.178; SE: 0.005; p < 0.001] and private sector usage was concentrated among wealthier quintiles [CIX: 0.239; SE: 0.006; p < 0.001]. Benefit incidence analyses suggest that middle quintile of women received the maximum public subsidy in primary health centres (33.23%), followed by richer quintile (25.62%), and poorer wealth quintiles (24.84%). These pattern in the secondary health centres was similar.

CONCLUSION

Poorer groups utilize the public sector for institutional delivery in greater proportions than the private sector. Middle quintiles seem to benefit the most from public subsidy in terms of the median cost of service and non-payment. Greater efforts must be made to understand how and why these groups are being left behind and what policy measures can enhance their inclusion and financial risk protection.

Clinical Equivalence of Polyglycolic Acid Suture and Polyglactin 910 Suture for Subcutaneous Tissue Closure After Cesarean Delivery: A Single-Blind Randomized Study

Purpose

The global rise in frequency of cesarean delivery raises the concern to minimize the post-operative complications, in order to improve the maternal and neonatal health. Closure of subcutaneous tissue following cesarean section closes dead space, hence reduces the wound complications. No previous study has compared the clinical equivalence of polyglycolic acid suture with polyglactin 910 suture for subcutaneous tissue closure following cesarean section. Therefore, this study compared the incidence of subcutaneous abdominal wound disruptions within the first 6 weeks of subcutaneous tissue closure with either of the sutures.

Patients and Methods

A single-blind, prospective, randomized study was conducted in two centres between February and November, 2021. Primiparous or multiparous women (18-40 years) with a singleton pregnancy requiring cesarean section were randomized to polyglycolic acid suture (Truglyde^®) (n=54) and polyglactin 910 suture (Vicryl^®) (n=54) group. The primary endpoint, incidence of subcutaneous abdominal wound disruptions within 6 weeks of cesarean delivery was evaluated. In addition, the secondary endpoints, incidence of post-operative subcutaneous abdominal wound disruptions for the study period, skin disruption, surgical site infection (SSI), seroma, hematoma, intraoperative handling, operative time, hospital stay, suture removal, microbial deposits on sutures, pain, time taken to resume normal activities, and adverse events were recorded.

Results

Non-significant difference in the incidence of subcutaneous abdominal wound disruptions, skin disruption, SSI, seroma, hematoma, intraoperative handling characteristics, operative time, pain, duration of hospital stay, suture removal, microbial deposits, time taken to return to day-to-day activities, and adverse events were observed between the two treatment groups.

Conclusion

Following cesarean section, subcutaneous tissue closure using polyglycolic acid suture or polyglactin 910 suture was not associated with incidence of subcutaneous abdominal wound disruptions. Additionally, non-significant differences regarding secondary endpoints between the groups suggested the clinical equivalence of the sutures.

CTRI Registration Number

CTRI/2020/12/029737; Registration date: 11/12/2020.

Does Obesity Influence Women's Decision Making about the Mode of Delivery?

Introduction: The ratio of cesarean deliveries (CDs) has been increasing worldwide, with a growing problem of cesarean delivery on maternal request (CDMR) and an alarmingly increasing rate of CD in the private sector. There are numerous factors influencing women’s preferences for the mode of delivery and their opinion about shared decision making (SDM). Material and method: The study was designed as an online survey, filled in by 1040 women. The questionnaire included questions about women’s preferences for the mode of delivery, their opinions about CDMR and the process of decision making regarding the mode of delivery. Results: There were no statistically significant differences found between women with a BMI ≤ 25 kg/m2 and >25 kg/m2, nor with a BMI ≤ 30 kg/m2 and >30 kg/m2, on the subject of the preferred method of delivery, and the opinion regarding SDM and CDMR without medical indications. More than 85% of women in all groups, who preferred CD as the mode of delivery, wanted to have CDMR. Conclusion: We have not found obesity and overweight to be a factor influencing women’s preferred mode of delivery, their opinion about SDM and their preference for CDMR without medical indications. However, the sample size of women with morbid obesity with a BMI ≥ 35 kg/m2 was too small for the results to be considered significant in this group, and it will therefore be subject to further studies.