UC San Diego

Background: While the socio-economic determinants of maternal healthcare utilization are well-documented, the influence of climate-related variables, particularly extreme temperatures, remains largely unexplored. This dissertation aims to bridge this knowledge gap by investigating how exposure to extreme temperatures affects maternal healthcare utilization and neonatal survival in India. By examining these climate-sensitive exposures, this study seeks to provide a more comprehensive understanding of the diverse factors influencing maternal and neonatal health outcomes in the region.Methods: I utilized data from the Demographic and Health Survey (DHS) conducted in India from 2019 to 2021 to generate variables for healthcare utilization variables during the antenatal period and identified the place of delivery for women in the age group of 15-49 years. I used the same data source to identify neonatal deaths (i.e. death within 28 days of birth). To assess exposure, I employed a gridded Wet Bulb Globe Temperature (WBGT) dataset. I leveraged geospatial information on the clusters where the survey was conducted along with temporal information such as date of interview, date of birth, and date of death to assign temperature exposures preceding the health outcomes. I used generalized linear mixed effects models, adjusting for confounders, to estimate the association between heat waves and the place of delivery. I then conducted similar models to assess the effect of extreme temperatures on healthcare utilization during pregnancy. Finally, I employed a time-stratified case-crossover design and modeled the non-linear and delayed exposure-response relationship using a distributed lag non-linear model. I tested for effect measure modification for a range of socio-economic variables for all our models. Results: There is a consistent link between extreme heat and the increased likelihood of home births for percentile-based definitions when WBGT is above the threshold for two or more consecutive days. This association is modified by caste, household wealth, access to healthcare, and long-term mean temperatures for some but not all extreme heat definitions (Chapter 2). The likelihood of not receiving any healthcare contact during pregnancy increased with exposure to more extreme hot and cold days. This association was modified by rural/urban place of residence. (Chapter 3). The relationship between mean WBGT percentiles and neonatal mortality risk followed a U-shaped curve, with increased odds of neonatal mortality at both extremely low and high temperatures. The effect of lower temperatures was more pronounced on neonatal mortality than higher temperatures. (Chapter 4). Conclusion: Findings from this dissertation reveal that both extreme heat and cold can significantly compromise the use of maternal healthcare services and threaten neonatal survival. Our findings underscore the urgent need to incorporate climate-sensitive factors into maternal health promotion strategies. To mitigate these effects, we recommend enhancing health system preparedness through the implementation of early warning systems and advanced resource allocation. These measures are crucial for safeguarding maternal and neonatal health in the face of increasingly extreme climate conditions.