India at the crossroads of millennium development goals 4 and 5

Effects of health behaviour change intervention through women's self-help groups on maternal and newborn health practices and related inequalities in rural india: A quasi-experimental study

BACKGROUND

Despite the health system efforts, health disparities exist across sub-populations in India. We assessed the effects of health behaviour change interventions through women's self-help groups (SHGs) on maternal and newborn health (MNH) behaviours and socio-economic inequalities.

METHODS

We did a quasi-experimental study of a large-scale SHG program in Uttar Pradesh, India, where 120 geographic blocks received, and 83 blocks did not receive health intervention. Data comes from two cross-sectional surveys with 4,615 recently delivered women in 2015, and 4,250 women in 2017. The intervention included MNH discussions in SHG meetings and community outreach activities. The outcomes included antenatal, natal and postnatal care, contraceptive use, cord care, skin-to-skin care, and breastfeeding practices. Effects were assessed using multilevel mixed-effects regression adjusted difference-in-differences (DID) analysis adjusting for geographic clustering and potential covariates, for all, most-marginalised and least-marginalised women. Concentration indices examined the socio-economic inequality in health practices over time.

FINDINGS

The net improvements (5-11 percentage points [pp]) in correct MNH practices were significant in the intervention areas. The improvements over time were higher among the most-marginalised than least-marginalised for antenatal check-ups (DID: 20pp, p<0•001 versus DID: 6pp, p = 0•093), consumption of iron folic acid tablets for 100 days (DID: 7pp, p = 0•036 versus DID: -1pp, p = 0•671), current use of contraception (DID: 12pp, p = 0•046 versus DID: 10pp, p = 0•021), cord care (DID: 12pp, p = 0•051 versus DID: 7pp, p = 0•210), and timely initiation of breastfeeding (DID: 29pp, p = 0•001 versus DID: 1pp, p = 0•933). Lorenz curves and concentration indices indicated reduction in rich-poor gap in health practices over time in the intervention areas.

INTERPRETATION

Disparities in MNH behaviours declined with the efforts by SHGs through behaviour change communication intervention.

Changes in Under-5 Mortality Rate and Major Childhood Diseases: A Country-Level Analysis

Under-5 child mortality decreased throughout the world by 49% from 1990 to 2013. However, it is unknown if this reduction was more effectively achieved in countries with a higher child mortality burden. We investigated the reduction of cause-specific global child mortality burden in 2000-2010. A total of 195 countries were selected for this analysis. A random-effect or fixed-effect model was chosen based on the Hausman test. Countries with a higher child mortality rate performed better with regard to the prevention of child deaths from major infectious diseases, but cause-specific progress was highly variable by disease within each country. Pneumonia-specific progress was much slower than that for diarrhea, and neonatal-specific child mortality increased in some countries. With a few exceptions, the overall performance in the countries with the largest share of child deaths was not good. This study identified priority interventions for child survival in the post-2015 period.

Social capital and the utilization of maternal and child health services in India: a multilevel analysis

This study examines the association between social capital and the utilization of antenatal care, professional delivery care, and childhood immunizations using a multilevel analytic sample of 10,739 women who recently gave birth and 7403 children between one and five years of age in 2293 communities and 22 state-groups from the 2005 India Human Development Survey. Exploratory factor analysis was used to create and validate six social capital measures that were used in multilevel logistic regression models to examine whether each form of social capital had an independent, contextual effect on health care use. Results revealed that social capital operated at the community level in association with all three care-seeking behaviors; however, the results differed based on the type of health care utilized. Specifically, components of social capital that led to heterogeneous bridging ties were positively associated with all three types of health care use, whereas components of social capital that led to strong bonding ties were negatively associated with the use of preventive care, but positively associated with professional delivery care.

Trends in child immunization across geographical regions in India: focus on urban-rural and gender differentials

BACKGROUND

Although child immunization is regarded as a highly cost-effective lifesaver, about fifty percent of the eligible children aged 12-23 months in India are without essential immunization coverage. Despite several programmatic initiatives, urban-rural and gender difference in child immunization pose an intimidating challenge to India's public health agenda. This study assesses the urban-rural and gender difference in child immunization coverage during 1992-2006 across six major geographical regions in India.

DATA AND METHODS

Three rounds of the National Family Health Survey (NFHS) conducted during 1992-93, 1998-99 and 2005-06 were analyzed. Bivariate analyses, urban-rural and gender inequality ratios, and the multivariate-pooled logistic regression model were applied to examine the trends and patterns of inequalities over time.

KEY FINDINGS

The analysis of change over one and half decades (1992-2006) shows considerable variations in child immunization coverage across six geographical regions in India. Despite a decline in urban-rural and gender differences over time, children residing in rural areas and girls remained disadvantaged. Moreover, northeast, west and south regions, which had the lowest gender inequality in 1992 observed an increase in gender difference over time. Similarly, urban-rural inequality increased in the west region during 1992-2006.

CONCLUSION

This study suggests periodic evaluation of the health care system is vital to assess the between and within group difference beyond average improvement. It is essential to integrate strong immunization systems with broad health systems and coordinate with other primary health care delivery programs to augment immunization coverage.

Trends in child immunization across geographical regions in India: focus on urban-rural and gender differentials

BACKGROUND

Although child immunization is regarded as a highly cost-effective lifesaver, about fifty percent of the eligible children aged 12-23 months in India are without essential immunization coverage. Despite several programmatic initiatives, urban-rural and gender difference in child immunization pose an intimidating challenge to India's public health agenda. This study assesses the urban-rural and gender difference in child immunization coverage during 1992-2006 across six major geographical regions in India.

DATA AND METHODS

Three rounds of the National Family Health Survey (NFHS) conducted during 1992-93, 1998-99 and 2005-06 were analyzed. Bivariate analyses, urban-rural and gender inequality ratios, and the multivariate-pooled logistic regression model were applied to examine the trends and patterns of inequalities over time.

KEY FINDINGS

The analysis of change over one and half decades (1992-2006) shows considerable variations in child immunization coverage across six geographical regions in India. Despite a decline in urban-rural and gender differences over time, children residing in rural areas and girls remained disadvantaged. Moreover, northeast, west and south regions, which had the lowest gender inequality in 1992 observed an increase in gender difference over time. Similarly, urban-rural inequality increased in the west region during 1992-2006.

CONCLUSION

This study suggests periodic evaluation of the health care system is vital to assess the between and within group difference beyond average improvement. It is essential to integrate strong immunization systems with broad health systems and coordinate with other primary health care delivery programs to augment immunization coverage.

Maternal autonomy and child health care utilization in India: results from the National Family Health Survey

The objective of this study was to examine the association of maternal autonomy with preventive and curative child health care utilization in India. Data from the National Family Health Survey 2005-2006 were used to ascertain association of maternal autonomy (in 3 dimensions: decision making, access to financial resources, freedom of movement) with child's primary immunization status (indicative of preventive health care use) and treatment seeking for child's acute respiratory infection (indicative of curative health care use). Low maternal freedom of movement was associated with higher odds of incomplete primary immunization of the child and for not seeking treatment for the child's acute respiratory infection. Low maternal financial access was associated with increased odds for incomplete primary immunization of the child. The findings show that improvement in autonomy of Indian mothers, especially their freedom of movement, may help improve utilization of health care for their children.

Addressing the sluggish progress in reducing maternal mortality in India

Although some progress has been made in India, achievement of the Fifth Millennium Development Goal (MDG5; ie, 75% reduction in maternal mortality ratio [MMR] from 1990 by 2015) target seems to be unattainable by 2015. Failure of the National Population Policy, 2000, and the National Health Policy, 2002, to reduce the MMR demanded a new direction, leading to the establishment of a National Rural Health Mission in 2005. This commentary addresses both the real achievements and the hurdles faced in India's stagnating progress in maternal health. Promotion of maternal nutrition and health education, with greater attention to emergency obstetrical care at the district subcenter and primary health care center levels, must be prioritized. These changes of focus are vital to make prenatal, delivery, and postnatal care safer with increased resources allotted to adolescents, the poor, and women living in rural areas in order to enhance maternal health and achieve the MDG target.

Performance of cause-specific childhood mortality surveillance by health workers using a short verbal autopsy tool

BACKGROUND

The routine use of verbal autopsy in health-care delivery settings has been limited. Hence, the performance of neonatal and postneonatal verbal autopsy (VA) tools developed at the Comprehensive Rural Health Services Project (CRHSP), Ballabgarh (India), were assessed.

METHODS

Short VA tools developed by CRHSP were filled by health workers during their routine house visits while standard VA tools of the International Network of Field Sites with continuous Demographic Evaluation (INDEPTH) were filled by trained research workers for all 143 under-five-children deaths that occurred in 2008. The level of agreement in the cause of death assigned by the two VA tools was assessed by kappa and by comparison of the cause-specific mortality fractions.

RESULTS

Among 65 neonatal deaths, the cause specific mortality fraction (CSMF) was 43.1% and 40% for low birthweight, 15.4% and 26.2% for birth asphyxia, and 7.7% and 10.8% for pneumonia by INDEPTH and CRHSP VA tools respectively. In 78 deaths among 29-days to <5-year olds, the CSMF was 29.4% and 26.9% for diarrhoea, and 16.6% each for pneumonia using the INDEPTH and CRHSP VA tools respectively. Kappa for most causes of death was more than 0.8, except for birth asphyxia, which had a kappa of 0.678.

CONCLUSIONS

Short VA tools have a satisfactory performance in field settings, which can be used routinely by health workers for filling the gaps in the cause-of-death information in places where medical certification of cause of death is deficient.

Measuring subnational under-5 mortality: lessons from a survey in the eastern Indonesian district of Ende

There is an urgent need for measurements of the magnitude and determinants of under-5 mortality at the district level in Indonesia. This article describes a sample household survey conducted in Ende District, East Nusa Tenggara province. Complete birth histories were recorded from all women residing in a sample of 32 villages (7454 households) of Ende. The survey was conducted in early 2010, deriving measures for the period 2000-2009. The survey instrument also included key variables required to measure determinants of under-5 mortality. The results showed that there are significant differentials in under-5 mortality risk within Ende, ranging from 27 to 85 per 1000. This information will assist the district health office to implement maternal and child health programs to meet national targets for United Nations Millennium Development Goal 4. The findings provide robust mortality measures at the district level and demonstrate the feasibility of conducting such a study using local resources, in a short time, and with low costs.