Efficiency of health care system in India: an inter-state analysis using DEA approach.

Since independence a massive personnel and public health infrastructure has been created in India. However, there is no competition and hardly any choice to the poor patients resulting in poor quality services leading to allocative and technical inefficiencies. This study uses the data envelopment analysis model to assess and compare the efficiency of health system within various states of India. It shows the inadequacy of health infrastructure and manpower in the inefficient states where poor people are concentrated. Among the determinants of efficiency female literacy, poverty level, institutional delivery, and full immunization of children are proved to be important factors in explaining efficiency of health system in India.

Prevalence and causes of chronic energy deficiency and obesity in Indian women.

We investigate the nutritional status of women in India and its relation to the prevalence of chronic energy deficiency (CED) and obesity. To do this, we have used the data from the Indian National Family Health Survey, 1998-1999, on body mass index (BMI) of ever-married women, ages 15-49 years, along with several socioeconomic factors, such as level of education, religion or caste, occupational status, and standard of living index. The study was based on 81,712 women from 26 states and 6 zones, which were grouped according to geographic proximity of the states of India. A multiple linear regression analysis was done to see the relation between nutritional status of women and different socioeconomic factors. The data reveal that the prevalences of CED, overweight, and obesity in India are 31.2%, 9.4%, and 2.6%, respectively. The incidences of CED and obesity are negatively related. The prevalence of CED is the lowest in Arunachal Pradesh and highest in Orissa. Punjab has the highest prevalence of obesity, and Bihar has the lowest. For the zonewise distribution the Northeast zone has the lowest degree of prevalence of CED and the East zone is at the bottom of the list with the highest degree of malnutrition. We also found that the nutritional status of women goes together with the enhancement of their educational status, standard of living, and so on. There are also significant differences between rural and urban sectors and among castes, religions, and occupations. Furthermore, regression analysis shows that all the socioeconomic variables considered here significantly affect BMI in Indian women.

Risk factors for maternal mortality in Delhi slums: a community-based case-control study.

BACKGROUND: In order to develop, implement and evaluate policy for reducing maternal mortality, it is essential to study the risk factors associated with maternal deaths. AIMS: The study aims to determine the epidemiological risk factors and its related causes associated with maternal deaths in Delhi slums. MATERIALS AND METHODS: A community-based case-control study was designed, wherein snowball-sampling method was used to identify the maternal deaths (cases) in the community and circular systematic random sampling procedure was used to select the controls from the same area where a maternal death was found. STATISTICAL ANALYSIS: Data on 70 cases and 384 controls that had live births as the outcome of the pregnancy were analyzed. Logistic regression was applied to identify the risk factors. RESULTS: In the study population, most of the deliveries were conducted at home by untrained 'dais.' Cases were mostly illiterate, young, having high parity and no antenatal care taken during pregnancy (P CONCLUSIONS: The study findings suggest that women should be educated about the importance of antenatal registration and regular checkups. Untrained 'dais' should be trained to recognize the obstetric complications at an early stage and refer high-risk cases for adequate management. These preventive measures could help in reducing maternal mortality at the community level.

Description of breastfeeding practices among poorer sections in Calcutta Metropolitan Area and its impact on postpartum infecundity.

Descriptions of breastfeeding practices among residents in slum areas of Kolkata and the influence of breastfeeding on postpartum amenorrhoea is the focus of this study. Three out of four women initiate breastfeeding after one hour of birth and three out of five women squeeze the first milk from the breast before breastfeeding. Though the median duration of breastfeeding is long, the duration of exclusive breastfeeding is much shorter. Breastfeeding during the first six months has a significant negative influence on the rate of return to menses.

Determinants of child immunization in four less-developed states of north India.

Four northern states of India - Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh - lag far behind the other states of the country regarding demographic transition and socio-economic development. The study described in this article shows the utilization of child immunization services in these states, utilizing data from the National Family Health Survey, India, 1992-3 (IIPS, 1995a, 1995b, 1995c) The study used multivariate logistic regression to correlate the utilization of child immunization. The results showed that children are more likely to receive immunization if their parents are a couple, with the father literate and the mother with at least a middle-school-education level who received antenatal care or delivered in an institutional environment.

Distribution of time of first birth in presence of social customs regulating physical separation and coital frequency.

The interval between marriage and the first birth in India, particularly in rural areas, is much longer than what is observed in western countries. In eastern Uttar Pradesh, the mean interval is observed to be even longer, possibly due to traditional customs such as the female partner's visits to her parents in the early years of marriage and the smaller chance of coition because of the observance of rigid intercourse taboos. Thus the models to explain the length of the interval of marriage to first birth proposed by Western demographers, which assume that the period of cohabitation between marriage and first birth is uninterrupted, often do not describe the data satisfactorily when applied to rural India. In this paper a model to describe data on first birth interval is proposed that takes account of the distributions of timing and periods of physical separation and variation in fecundity with effective marriage duration.

PIP: The author refers to literature reviews by Sheps and Menken on studies prior to 1972 and Leridon and Mode for more recent studies of the relationship between first birth and marriage. This study examines the probability distribution of time to first live birth in India and takes into account social customs and taboos that relate to physical separation of spouses and coital regulation. Visits to parents and the period of stay are assumed to interfere with coital frequency in the theoretical model. Data are obtained from the 1987-89 Survey of the Effects of Sociocultural Factors on the Determinants of Fertility in Eastern Uttar Pradesh (rural districts of Varanasi, Ghazipur, and Azamgarh). The sample includes about 350 households and currently married (7 or more years) women aged under 50 years in each religious/caste group for each district. Findings show that the mean duration of cohabitation between return marriage (RM) and the first visit to parents was about 14 months for upper caste Hindus compared to 1-3 months in the other religious/caste groups. The mean duration of stay before the first conception was about 13 months among upper caste Hindus compared to 8-11 months for middle caste Hindus, scheduled castes, and Muslims. Life table estimates are reported for the proportion of women who were still staying with parents during the first visit by months that elapsed since the time of the visit to parents and by age at RM and religion/caste. Life table estimates are given for the proportion of women who had not yet visited parents for the first time by month elapsed since RM and by age of the women. Among upper caste Hindus (Group I), the risk of first conception increased with an increase in age at RM in succeeding years. Among the other religions/castes (Group II), the risk in succeeding years was the same among women aged 14 and 15-16 years. Risk increased among women aged 17-19 years.

Predictors of survival in patients with carcinoma of the gallbladder.

BACKGROUND: The role of resectional surgery in patients with advanced stages of gallbladder carcinoma has not been fully defined. It is generally believed that the survival depends on the stage of the disease, rather than on the treatment option. METHODS: Seventeen selected risk factors were analyzed using univariate and multivariate analyses to predict survival in 87 patients with gallbladder carcinoma who had undergone some form of surgical treatment. Similarly, a subset of 55 patients with American Joint Committee on Cancer Stage IV disease also was analyzed separately. RESULTS: Palpable mass, tumor (T) status, local infiltration, lymph node involvement, distant metastasis, TNM stage, and the type of surgical treatment (laparotomy alone, bypass, or resection) were significant risk factors by univariate analysis. In addition to palpable mass and the type of surgical treatment, age was also a significant predictor of survival by multivariate analysis. Multivariate analysis of patients with Stage IV disease revealed the same three factors to be significant. In this subset of patients, the median survival after resectional surgery was 16.3 months; after biliary and/or gastric bypass, 4.8 months; and after laparotomy alone, 1.6 months. CONCLUSIONS: The type of surgical treatment significantly influenced survival. Resectional surgery was associated with better survival compared with biliary and/or gastric bypass or laparotomy alone for patients with all stages of the disease, including those with advanced carcinoma of the gallbladder.

Breast-feeding in eastern Uttar Pradesh, India: differentials and determinants.

PIP: In India, interviews with currently married women in 4448 households in rural areas of Varanasi, Ghazipur, and Azamgarh districts in Eastern Uttar Pradesh were conducted so researchers could examine differentials in breast feeding among the various socioeconomic groups and the determinants of breast feeding. Around 66% of all women continued to breast feed during the second year of life for the index child. More than 25% continued to breast feed for more than three years. Among Hindus, sons were breast fed three months longer and two months longer than daughters in upper and remaining caste groups, respectively. This difference was significant. Hindu women breast fed their children longer than did Muslim women. Among Hindus, upper caste, high social status, and high educational levels increased the likelihood of early weaning. Among the scheduled castes, mothers aged at least 25, low social status, and husbands working as laborers in the nonagricultural sector, breast fed for shorter duration than their counterparts. As maternal age increased so did the likelihood of breast feeding. For example, mothers aged 35-49 breast fed, on average, 10 months longer than did mothers aged less than 25.^ieng

Does malnutrition predispose to diarrhoea during childhood? Evidence from a longitudinal study in Matlab, Bangladesh.

It is posited that diarrhoeal illness during one period has influence on diarrhoeal illness in a subsequent period. This relationship may potentially mask the association between malnutrition and subsequent diarrhoea. To test this, we analysed data on cross-sectional anthropometry in combination with data on diarrhoeal morbidity collected longitudinally in a community-based study of 1262 children (aged 6-60 months) during March-December, 1976, in Matlab, Bangladesh. The results confirmed the posited relationship between diarrhoeal morbidities in two consecutive periods and showed that the risks of diarrhoeal attack and longer diarrhoeal illness increased more than threefold during the 2 months following diarrhoeal illness during the preceding 2 months (previous diarrhoea). Children with no previous diarrhoea indicated a positive association between malnutrition and subsequent diarrhoea, but the pattern found among children with previous diarrhoea was not understandable. Logistic regression analyses performed separately for younger and older children showed that controlling for effects of previous diarrhoea, maternal illiteracy and household poverty, severe malnutrition as assessed by weight-for-age was found to be strongly associated with the risk of longer diarrhoeal illness in a 2-month interval in the age group 24-60 months; in the same age group the association with the risk of diarrhoeal attack was significant at the 10 per cent level. No such association for malnutrition, however, was found in the age group 6-23 months.

An extension of a model for first birth interval and some social factors.

"A model for the time of first birth is presented under certain assumptions, which involve biological and socio-cultural factors." The model is illustrated using data from Rural Development and Population Growth--A Sample Survey, 1978, conducted in Varanasi, India, and involving some 3,514 households.

Model for interlive birth interval and some social factors.

PIP: The authors develop a probability model to describe the length of intervals between successive live-births. Duration of post-partum abstinence and variation in coital pattern during the early part of the interval as a result of sociocultural practices are incorporated in the model's formulation. The model is applied to observed data.^ieng

A note on Brass's model for the distribution of births in human populations.

PIP: Brass's model for the distribution of births considered only births to fertile women, making it inapplicable for countries with low fertility or samples of women who differ markedly in terms of fecundability. The authors show that a simple extension of a modified Poisson distribution, considering females to comprise 2 groups with respect to fecundability (high versus low ability to conceive), describes satisfactorily the data provided by Brass. Brass had noted that the major discrepancies between the observed and expected distribution of births in low-fertility countries reflect the practice of contraception and variations in the rate of childbearing during the reproductive period. The analysis indicated that the proportion of subfecund females is 70-90% in developed countries, reflecting high contraceptive usage. In contrast, in India, the data show that only 14% of fertile females belong to the low-risk group and about 4% remain sterile throughout the reproductive period. The revised model was applied to data from a Rural Development and Population Growth survey conducted in Varanasi, India, in 1978. Only women who were married when under 20 years of age and did not practice contraception were included in the test of the model. The observed (expected) number of females in each number of births category was as follows: 0, 41 (41); 1, 25 (24.3); 2, 50 (51.8); 3, 96 (93.5); 4, 182 (183.8); 5, 261 (272.3); 2, 221 (221.1); 7, 86 (79.6); 8, 13 (9.4); and 9 and over, 2 (0.2).^ieng

Probability distributions of number of births and their applications.

This paper develops probability distributions to describe the variations in the number of live birth-conceptions to a female during a given time interval (0, To) of length To. In the derivation, the interval (0, To) is divided into 2 consecutive segments, and fertility parameters within each segment are assumed to be constant but may differ between the segments. A method of obtaining maximum likelihood estimates of the parameters is outlined. The models are applied to an observed set of data. An application of the models in the evaluation of family planning programs is illustrated.

Probability distributions of number of births and their implications.

PIP: To apply models of the variation in the number if births to a couple throughout the reproductive period, it is necessary to account for variations that are dependent on age and parity. This paper presents time-dependent models for the number of live births/conceptions to a woman during given time intervals and applies these models to data derived from the Rural Development and Population Growth survey conducted in India in 1978. The reproductive span was segmented into 20-30 years and 30-35 years. Within each segment, fecundability was assumed to be constant but to vary between segments. The model assuming variability in fecundability provided a better fit to the data than the model assuming homogeneity. The data analysis suggests that about 4% of women are sterile at ages 20-35 years. The female population appears to consist of 2 groups with respect to fecundability: 1) a high-risk group (82.5%) with an average risk of conception of 0.7555 and 2) a low-risk group (17.5%) with an average conception rate of 0.2611. The average rate of conception for the 2 groups in the 20-39-year age period is 0.6607. These models can be used to demonstrate expected changes in fertility when contraceptives of varying degrees of effectiveness are used. If contraceptive effectiveness is increased 4 times, the expected number of births is decreased by 2.8 times/year.^ieng

Analytical models for number of births--a review.

PIP: This review describes analytical probability models for number of births in human populations. First the biological variables are defined: effective reproductive period; fecundability; fetal loss; non-susceptible period. The models are classified into 2 groups, depending on whether they are designed to conform to a Markov renewal process or not. Equations in each group are presented with increasing complexity, involving heterogeneity and taking into account dependence of factors on each other, such as fecundability on parity. Recently, statisticians have introduced into their models the use of contraceptive techniques and the possibility of switching between methods.^ieng

On some bivariate distributions of number of births.

PIP: This paper presents probability models to describe the variation in number of live birth-conceptions to a group of females in two consecutive segments of the reproductive period. In derivation of the models, it is assumed that the parameters considered in the models remain constant in each segment but may differ between the segments. The models utilize the observed distribution of women according to the number of births given in two consecutive segments arranged in a bivariate table, providing more cells with significant number of observations for estimating the fertility parameters. A procedure to obtain the maximum likelihood estimates of some of the parameters is given. The models are applied to data for 977 Indian women surveyed in the 1978 Rural Developments and Population Growth Sample Survey.^ieng

Desired family size--a parity dependent model and its application.

PIP: This paper proposes a model for number of births that considers the following factors: contraceptive practice and its effectiveness, the chance of undergoing induced abortion, the chance of undergoing sterilization following spontaneous induced abortion or live birth, and the length of time involved in deciding to undergo sterilization following a live birth. These variables are assumed to be dependent on parity as well as family size. The model is used to measure the percentage reduction in total fertility when several vertical family planning programs are in operation. Under the various program combinations, the proportions of females according to number of births during the 1st 30 years of marriage, average family size, and percentage reduction in number of births are calculated. The fertility reduction is higher among women with smaller family size desires, regardless of family planning program effort. The data further indicate that a higher reduction in total fertility can be attained through sterilization than through the use of highly effective contraception.^ieng

Births averted under family planning programme: a mathematical approach.

"In this paper a probability model is proposed to describe the distribution of births to couples in first T years of marriage, when T is large and/or when couples use various methods of family planning. This model is derived on the assumption that conditional instantaneous risk of a conception, the incidence of foetal loss and the chance of attaining [sterility] following a child birth are functions of parity....The application of the model in evaluation of family planning programme changes in the child bearing pattern is illustrated."

A modification of a model for number of births and estimation of age specific fecundability and sterility.

"This paper deals with derivation of models to describe the number of births to women during interval (O,T) of length T, when the start of the observation is marriage as well as when it is a distant point after marriage. These models are extensions of the models of Singh, et al., (1973) and of Sheps and Menken (1973) and can suitably be applied to data for short periods of observation as the parameters are assumed to be homogeneous in time. The methods to obtain maximum likelihood estimates of the parameters are outlined." The models are applied to data from a sample survey on rural development and population growth carried out by the Demographic Research Centre of Banaras Hindu University in 1978 in order to examine trends in fecundability and sterility by age of women.

A probability model for number of births and its application in estimation of fecundability for a heterogeneous population.

"Under some simple assumptions relating to the human reproduction process, an extension of a probability model describing the variations in the number of births to a female during a specified period of time (O, T) of length T, is proposed. The model is extended to a situation when the female population consists of two distinct groups with respect to fecundability. A procedure of estimation of some of the underlying parameters is given. The applicability of the model is illustrated with an observed distribution." Data for the illustration are from a population survey undertaken in Varanasi, India, in 1978.