Non-communicable diseases (NCDs) were previously considered to only affect high-income countries. However, they now account for a very large burden in terms of both mortality and morbidity in low- and middle-income countries (LMICs), although little is known about the impact these diseases have on households in these countries. In this paper, we present a literature review on the costs imposed by NCDs on households in LMICs. We examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. In particular, in the treatment of diabetes, insulin – when required – represents an important source of spending for patients and their families. These financial costs deter many people suffering from NCDs from seeking the care they need. The limited health insurance coverage for NCDs is reflected in the low proportions of patients claiming reimbursement and the low reimbursement rates in existing insurance schemes. The costs associated with lost income-earning opportunities are also significant for many households. Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. In this paper, we identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

The financial burden from non-communicable diseases in low- and middle-income countries: a literature review

Background High maternal mortality is still a significant public health challenge in many countries of the South-Asian region. The majority of maternal deaths occur due to pregnancy and delivery-related complications, which can mostly be prevented by safe facility delivery. Due to the paucity of existing evidence, our study aimed to examine the factors associated with place of delivery, including women’s preferences for such in three selected South-Asian countries. Methods We extracted data from the most recent demographic and health surveys (DHS) conducted in Bangladesh (2014), Nepal (2016), and Pakistan (2017–18) and analyzed to identify the association between the outcome variable and socio-demographic characteristics. A total of 16,429 women from Bangladesh (4278; mean age 24.57 years), Nepal (3962; mean age 26.35 years), and Pakistan (8189; mean age 29.57 years) were included in this study. Following descriptive analyses, bivariate and multivariate logistic regressions were conducted. Results Overall, the prevalence of facility-based delivery was 40%, 62%, and 69% in Bangladesh, Nepal, and Pakistan, respectively. Inequity in utilizing facility-based delivery was observed for women in the highest wealth quintile. Participants from Urban areas, educated, middle and upper household economic status, and with high antenatal care (ANC) visits were significantly associated with facility-based delivery in all three countries. Interestingly, watching TV was also found as a strong determinant for facility-based delivery in Bangladesh (aOR = 1.31, 95% CI:1.09–1.56, P = 0.003), Nepal (aOR = 1.42, 95% CI:1.20–1.67, P<0.001) and Pakistan (aOR = 1.17, 95% CI: 1.03–1.32, P = 0.013). Higher education of husband was a significant predictor for facility delivery in Bangladesh (aOR = 1.73, 95% CI:1.27–2.35, P = 0.001) and Pakistan (aOR = 1.19, 95% CI: 0.99–1.43, P = 0.065); husband’s occupation was also a significant factor in Bangladesh (aOR = 1.30, 95% CI:1.04–1.61, P = 0.020) and Nepal (aOR = 1.26, 95% CI:1.01–1.58, P = 0.041). Conclusion Our findings suggest that the educational status of both women and their husbands, household economic situation, and the number of ANC visits influenced the place of delivery. There is an urgent need to promote facility delivery by building more birthing facilities, training and deployment of skilled birth attendants in rural and hard-to-reach areas, ensuring compulsory female education for all women, encouraging more ANC visits, and providing financial incentives for facility deliveries. There is a need to promote facility delivery by encouraging health facility visits through utilizing social networks and continuing mass media campaigns. Ensuring adequate Government funding for free maternal and newborn health care and local community involvement is crucial for reducing maternal and neonatal mortality and achieving sustainable development goals in this region.

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Factors influencing place of delivery: Evidence from three south-Asian countries.

Background The risk of death from complications relating to pregnancy and childbirth for women’s lifetime is higher in developing countries. Improving maternal and child health through a well-organized institutional delivery service is central to achieving reduced maternal and child mortality. Despite the efforts that have been made to improve maternal health outcomes in Ethiopia, institutional delivery is still unacceptably low. Objective This study was conducted to assess institutional delivery service utilization and associated factors in the study area. Methods A Community-based cross-sectional study was conducted. A multi-stage sampling technique was used to employ a total of 546 women. Data were collected using an interviewer-administered questionnaire and entered into EpiData version 3.1 and then exported to SPSS version 23.0. for analysis. Logistic regression models were used to determine factors associated with the outcome variable. Adjusted Odds ratios with 95% CI were computed to measure the strength of association and statistical significance was declared at p-value <0.05. Results The Prevalence of institutional delivery in the study area was 38% (34%-42%). Factors significantly associated with institutional delivery were ANC visit 1.80 (1.12–2.91), knowledge of danger sign during pregnancy 3.60 (2.25–5.76), urban residency 2.09 (1.15–3.81), Parity 0.49 (0.25–0.95) accessibility of health facility 4.60 (2.01–10.89), husbands educational level: primary 2.50 (1.27–4.91), secondary and above 2.36 (1.24–4.48), mothers occupation: governmental employee 2.05 (1.00–4.18), and Private employee 2.42 (1.09–5.35). Conclusions The prevalence of institutional delivery in the District was low. Antenatal visits, residency, knowledge of pregnancy danger signs, parity, and accessibility of health facilities, maternal occupation, and husband education were factors significantly associated with institutional delivery.

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Institutional delivery services utilization and associated factors among mothers who gave birth in the last year in Mandura district, Northwest Ethiopia

Many childbearing women in sub-Saharan African countries like Guinea still face challenges accessing and utilizing health facility delivery services and opt to deliver at home. This study examined the non-utilization of health facility delivery and its associated factors among childbearing women in Guinea. Data from the 2018 Guinea Demographic and Health Survey was used in this study. Data of 5406 childbearing women were analysed using STATA version 14.2 by employing a multilevel logistic regression approach. The results were presented using adjusted odds ratios (aOR) at 95% confidence interval (CI). More than three-quarters (47.6%) of childbearing women in Guinea did not deliver at health facilities. Women who had no formal education (aOR = 1.52, 95% CI = 1.09–2.12), those whose partners had no formal education (aOR = 1.25, 95% CI =1.01–1.56), those whose pregnancies were unintended (aOR = 1.40, 95% CI =1.13–1.74) and those who were Muslims (aOR = 2.87, 95% CI =1.17–7.08) were more likely to deliver at home. Furthermore, women with parity four or more (aOR = 1.78, 95% CI =1.34–2.37), those who listened to radio less than once a week (aOR = 5.05, 95% CI =1.83–13.89), those who never watched television (aOR = 1.46, 95% CI =1.12–1.91), those with poorest wealth quintile (aOR = 4.29, 95% CI =2.79–6.60), women in female-headed households (aOR = 1.38, 95% CI =1.08–1.78) and rural dwellers (aOR = 3.86, 95% CI =2.66–5.60) were more likely to deliver at home. This study has identified low socio-economic status, inadequate exposure to media, having an unplanned pregnancy and religious disparities as key predictors of home delivery among childbearing women in Guinea. The findings call for the need to enhance advocacy and educational strategies like focus group discussions, peer teaching, mentor-mentee programmes at both national and community levels for women to encourage health facility delivery. There is also the need to improve maternal healthcare services utilization policies to promote access to health facility delivery by reducing costs and making health facilities available in communities.

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Non-utilization of health facility delivery and its correlates among childbearing women: a cross-sectional analysis of the 2018 Guinea demographic and health survey data

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Effects of COVID-19 on maternal institutional delivery: Fear of a rise in maternal mortality.

Introduction 
In Nepal, a substantial proportion of women still deliver their child at home. Disparities have been observed in utilisation of institutional delivery and skilled birth attendant services. We performed a disaggregated analysis among marginalised and non-marginalised women to identify if different factors are associated with home delivery among these groups.


Materials and methods 
This study used data from the 2016 Nepal Demographic and Health Survey. It involves the analysis of 3,837 women who had experienced at least one live birth in the five years preceding the survey. Women were categorised as marginalised and non-marginalised based on ethnic group. Bivariate and multivariable logistic regression analysis were performed to identify factors associated with home delivery.


Results 
A higher proportion of marginalised women delivered at home (47%) than non-marginalised women (26%). Compared to non-marginalised women (35%), a larger proportion of marginalised women (64%) felt that it was not necessary to give birth at health facility. The multivariable analysis indicated an independent association of having no or basic education, belonging to middle, poorer and the poorest wealth quintile, residing in Province 2 and not having completed of four antenatal care visits per protocol with home delivery among both marginalised and non-marginalised women. Whereas residing in a rural area, residing in Province 7, and at a distance of >30 minutes to a health facility were factors independently associated with home delivery only among marginalised women.


Conclusion 
We conclude that poor education, poor economic status, non-completion of four ANC visits and belonging to Province 2 particularly determined either group of women to deliver at home, whereas residing in rural areas, living far from health facility, and belonging to Province 7 determined marginalised women to deliver at home. Preventing mothers from delivering at home would thus require focusing on specific geographical areas besides considering wider socio-economic determinants.

Determinants of home delivery in Nepal - A disaggregated analysis of marginalised and non-marginalised women from the 2016 Nepal Demographic and Health Survey.

Background Between 1990 and 2017, Nepal experienced a shift in the burden of disease from communicable, maternal, neonatal and nutritional (CMNN) diseases to non-communicable diseases (NCDs). With an increasing ageing population and life-style changes including tobacco use, harmful alcohol consumption, unhealthy diets, and insufficient physical activity, the proportion of total deaths from NCDs will continue to increase. An analysis of current diseases pattern and projections of the trends informs planning of health interventions. This analysis aims to project the mortality and risk factor of disease until 2040, based on past trends. Methods This study uses secondary data from the Global Burden of Disease (GBD) Study which analyses historic data from 1990 to 2016 to predict key variables such as, the mortality rates, life expectancy and Years of Life Lost for different causes of death from 2017 to 2040. ‘GBD Foresight Visualization’, a visualisation tool publicly available in the webpage of Institute for Health Metrics and Evaluation was the source of data for this analysis. GBD forecasting uses three-component modelling process: the first component captures variations due to risk factors and interventions, the second takes into consideration the variation due to measures of development quantified as social development index and the third uses an autoregressive integrated moving average model to capture the unexplained component correlated over time. We extracted Nepal specific data from it and reported number of deaths, mortality rates (per 100,000 population) as well as causes of death for the period 1990 to 2040. Results In 1990, CMNN diseases were responsible for approximately two-thirds (63.6%) of total deaths in Nepal. The proportion of the deaths from the CMNN diseases has reduced to 26.8% in 2015 and is estimated to be about a fifth of the 1990 figure (12.47%) in 2040. Conversely, deaths from NCDs reflect an upward trend. NCDs claimed a third of total deaths (29.91%) in the country in 1990, while in 2015, were responsible for about two-thirds of the total deaths (63.31%). In 2040, it is predicted that NCDs will contribute to over two-thirds (78.64%) of total deaths in the country. Less than a tenth (6.49%) of the total deaths in Nepal in 1990 were associated with injuries which increased to 13.04% in 2015 but is projected to decrease to 8.89% in 2040. In 1990, metabolic risk factors including high systolic blood pressure, high total cholesterol, high fasting plasma glucose, high body mass index and impaired kidney functions collectively contributed to a tenth of the total deaths (10.38%) in Nepal, whereas, in 2040 more than a third (37.31%) of the total deaths in the country could be attributed to it. Conclusion A reverse of the situation in 1990, NCDs are predicted to be the leading cause of deaths and metabolic risk factors are predicted to contribute to the highest proportion of deaths in 2040. NCDs could demand a major share of resources within the health sector requiring extensive multi-sectoral prevention measures, re-allocation of resources and re-organisation of the health system to cater for long-term care.

Peter Godwin

Papers

Determinants of home delivery in Nepal - A disaggregated analysis of marginalised and non-marginalised women from the 2016 Nepal Demographic and Health Survey.

Mortality and risk factors of disease in Nepal: Trend and projections from 1990 to 2040.