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Kouanda S, Ouedraogo AM, Sogo AE, Bagaya O, Sorgho TEV, Hien YC, Gbenou DV, Sawadogo Windsouri SR, Zoungrana W, Dadjoari M, Zombré Sanou VM, Usmanova G, Jain Y, Chahar R, Kumar S, Kumar SVV, Srivastava A, Nair TS, Sarkar AH, Bajpai N, Patwardhan V, Joshi CS, Chotiya M, Baswal D, Musange S, Sayinzoga F, Mutabazi V, Murindahabi NK, Nzeyimana D, Rwabufigiri BN, Kabuteni TJ, Mugabo M, Mbizvo M, Chizuni C, Chelwa N, Muliokela R, Phiri C, Kasonda K, Okpara N, Nyirenda M, Malumo SB, Mwiche A, Simushi V, Nsubuga Bakyaita N, Barreix M, Tunçalp Ö, Thwin SS, Bucagu M, Tamrat T, Habib N, Lefevre AE, Lorencatto F. New Antenatal Model in Africa and India (NAMAI) study: implementation research to improve antenatal care using WHO recommendations. Health Res Policy Syst 2023; 21:82. [PMID: 37563619 PMCID: PMC10416399 DOI: 10.1186/s12961-023-01014-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/19/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND In 2020, an estimated 287 000 women died globally from pregnancy-related causes and 2 million babies were stillborn. Many of these outcomes can be prevented by quality healthcare during pregnancy and childbirth. Within the continuum of maternal health, antenatal care (ANC) is a key moment in terms of contact with the health system, yet it remains an underutilized platform. This paper describes the protocol for a study conducted in collaboration with Ministries of Health and country research partners that aims to employ implementation science to systematically introduce and test the applicability of the adapted WHO ANC package in selected sites across four countries. METHODS Study design is a mixed methods stepped-wedge cluster randomized implementation trial with a nested cohort component (in India and Burkina Faso). The intervention is composed of two layers: (i) the country- (or state)-specific ANC package, including evidence-based interventions to improve maternal and newborn health outcomes, and (ii) the co-interventions (or implementation strategies) to help delivery and uptake of the adapted ANC package. Using COM-B model, co-interventions support behaviour change among health workers and pregnant women by (1) training health workers on the adapted ANC package and ultrasound (except in India), (2) providing supplies, (3) conducting mentoring and supervision and (4) implementing community mobilization strategies. In Rwanda and Zambia, a fifth strategy includes a digital health intervention. Qualitative data will be gathered from health workers, women and their families, to gauge acceptability of the adapted ANC package and its components, as well as experience of care. The implementation of the adapted ANC package of interventions, and their related costs, will be documented to understand to what extent the co-interventions were performed as intended, allowing for iteration. DISCUSSION Results from this study aim to build the global evidence base on how to implement quality ANC across different settings and inform pathways to scale, which will ultimately lead to stronger health systems with better maternal and perinatal outcomes. On the basis of the study results, governments will be able to adopt and plan for national scale-up, aiming to improve ANC nationally. This evidence will inform global guidance. TRIAL REGISTRATION NUMBER ISRCTN, ISRCTN16610902. Registered 27 May 2022. https://www.isrctn.com/ISRCTN16610902.
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Jain Y, Chaudhary T, Joshi CS, Chotiya M, Sinha B, Nair TS, Srivastava A, SV VK, Agrawal A, Srivastava V, Baswal D, Lalchandani K, Shah H, Usmanova G, Sood B, Yadav V, Kumar S. Improving quality of intrapartum and immediate postpartum care in public facilities: experiences and lessons learned from Rajasthan state, India. BMC Pregnancy Childbirth 2022; 22:586. [PMID: 35870874 PMCID: PMC9308226 DOI: 10.1186/s12884-022-04888-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background In spite of considerable improvement in maternal and neonatal outcomes over the past decade in India, the current maternal mortality ratio and neonatal mortality rate are far from the Sustainable Development Goal targets due to suboptimal quality of maternity care. A package of interventions for improving quality of intrapartum and immediate postpartum care was co-designed with the Ministry of Health as the Dakshata program and implemented in public sector health facilities in selected districts in the state of Rajasthan of India since June 2015. This article describes the key strategies, interventions, results and challenges from four years of Dakshata program implementation. Methods We have conducted secondary analysis of program data (government data) collected from 202 public facilities across 20 districts of Rajasthan state. The data collected between June–August 2015 (baseline) and the data collected between May-August 2019 (latest) were analyzed. The data sources included: facility assessments, service statistics, monthly progress reports. Results During the period of program implementation, there were 17,94,249 deliveries accounting for 70% of institutional deliveries in intervention districts. As a result of the intervention, there was a notable increase in competency of health care providers, availability of essential resources, achievement of labour room standards and adherence to evidence-based clinical standards. We also observed reductions in the proportion of referrals for pre-eclampsia/eclampsia, postpartum hemorrhage and neonatal asphyxia by 11, 8 and 3 percentage points respectively. Similarly, data revealed a reduction in stillbirth rates in Dakshata intervention facilities (19.3 vs 15.3) compared to non-Dakshata facilities (21.8 vs 18). Conclusions Our experience and findings indicate that the quality of intrapartum and immediate postpartum care can be improved in low- and middle-income countries with the approach presented in this paper. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04888-5.
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Vedam S, Titoria R, Niles P, Stoll K, Kumar V, Baswal D, Mayra K, Kaur I, Hardtman P. Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration. Health Policy Plan 2022; 37:1042-1063. [PMID: 35428886 PMCID: PMC9469892 DOI: 10.1093/heapol/czac032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/30/2022] [Accepted: 04/15/2022] [Indexed: 11/12/2022] Open
Abstract
India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.
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Affiliation(s)
- Saraswathi Vedam
- Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC V6T 1Z3, Canada
| | - Reena Titoria
- Population Health Observatory, Fraser Health Authority, Suite 400, Central City Tower 13450 – 102nd Avenue, Surrey, BC V3T 0H1, Canada
| | - Paulomi Niles
- Rory Meyers College of Nursing, New York University, 433 1st Avenue, New York, NY 10010, USA
| | - Kathrin Stoll
- Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC V6T 1Z3, Canada
| | - Vishwajeet Kumar
- Community Empowerment Lab, 26/11 Wazir Hasan Road, Gokhale Marg, Lucknow, UP 226001, India
| | - Dinesh Baswal
- MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave-II, New Delhi 110048, India
| | - Kaveri Mayra
- Global Health Research Institute, Faculty of Social Sciences, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - Inderjeet Kaur
- Fernandez Foundation, Fernandez Hospital, 4-1-120, Bogulkunta, Hyderabad 500001, India
| | - Pandora Hardtman
- Johns Hopkins Program for International Education in Gynecology and Obstetrics, John Hopkins University, 1615 Thames Street, Baltimore, MD 21231, USA
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Choedon T, Sethi V, Chowdhury R, Bhatia N, Dinachandra K, Murira Z, Bhanot A, Baswal D, de Wagt A, Bhargava M, Meshram II, Babu GR, Kulkarni B, Divakar H, Jacob CM, Killeen SL, McAuliffe F, Alambusha R, Joe W, Hanson M. Population estimates and determinants of severe maternal thinness in India. Int J Gynaecol Obstet 2021; 155:380-397. [PMID: 34724208 PMCID: PMC8597590 DOI: 10.1002/ijgo.13940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine prevalence, risk factors, and consequences of maternal severe thinness in India. METHODS This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India. RESULTS Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness. CONCLUSION This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations.
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Affiliation(s)
| | - Vani Sethi
- Nutrition SectionUnited Nations Children’s FundNew DelhiIndia
| | - Ranadip Chowdhury
- Centre for Health Research and DevelopmentSociety for Applied StudiesNew DelhiIndia
| | | | | | - Zivai Murira
- Regional Office for South AsiaUNICEFKathmanduNepal
| | | | - Dinesh Baswal
- ProgrammesMamta Health Institute for Mother and ChildNew DelhiIndia
| | - Arjan de Wagt
- Nutrition SectionUnited Nations Children’s FundNew DelhiIndia
| | - Madhavi Bhargava
- Department of Community MedicineYenepoya Medical CollegeMangaloreIndia
| | | | - Giridhara R. Babu
- Department of EpidemiologyIndian Institute of Public HealthBengaluruIndia
| | - Bharati Kulkarni
- Indian Council of Medical ResearchNational Institute of NutritionHyderabadIndia
| | | | - Chandni Maria Jacob
- NIHR Southampton Biomedical Research CentreUniversity Hospital SouthamptonSouthamptonUK
- Institute of Developmental SciencesUniversity of SouthamptonSouthamptonUK
| | - Sarah Louise Killeen
- UCD Perinatal Research CentreSchool of MedicineUniversity College DublinNational Maternity HospitalDublinIreland
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineUniversity College DublinNational Maternity HospitalDublinIreland
| | | | | | - Mark Hanson
- NIHR Southampton Biomedical Research CentreUniversity Hospital SouthamptonSouthamptonUK
- Institute of Developmental SciencesUniversity of SouthamptonSouthamptonUK
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Sethi V, Choedon T, Chowdhury R, Bhatia N, Dinachandra K, Murira Z, Bhanot A, Baswal D, de Wagt A, Bhargava M, Meshram II, Babu GR, Kulkarni B, Divakar H, Jacob CM, Killeen SL, McAuliffe F, Vergehese M, Ghosh S, Hanson M. Screening and management options for severe thinness during pregnancy in India. Int J Gynaecol Obstet 2021; 155:357-379. [PMID: 34724206 DOI: 10.1002/ijgo.13939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 11/08/2022]
Abstract
This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.
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Affiliation(s)
- Vani Sethi
- Nutrition Section, United Nations Children's Fund, New Delhi, India
| | | | - Ranadip Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Neena Bhatia
- NITI Aayog, Government of India, New Delhi, India
| | | | - Zivai Murira
- Regional Office for South Asia, UNICEF, Kathmandu, Nepal
| | | | - Dinesh Baswal
- Programmes, Mamta Health Institute for Mother and Child, New Delhi, India
| | - Arjan de Wagt
- Nutrition Section, United Nations Children's Fund, New Delhi, India
| | - Madhavi Bhargava
- Department of Community Medicine, Yenepoya Medical College, Mangalore, Karnataka, India
| | | | - Giridhara R Babu
- Department of Epidemiology, Indian Institute of Public Health, Bengaluru, India
| | - Bharati Kulkarni
- Indian Council of Medical Research, National Institute of Nutrition, Telangana, India
| | | | - Chandni Maria Jacob
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK.,Institute of Developmental Sciences, University of Southampton, Southampton, UK
| | - Sarah Louise Killeen
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | | | | | - Mark Hanson
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK.,Institute of Developmental Sciences, University of Southampton, Southampton, UK
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Taneja G, Sarin E, Bajpayee D, Chaudhuri S, Verma G, Parashar R, Chaudhry N, Mohanty JS, Bisht N, Gupta A, Tomar SS, Patel R, Sridhar VS, Joshi A, Rathi C, Baswal D, Gupta S, Gera R. Care Around Birth Approach: A Training, Mentoring, and Quality Improvement Model to Optimize Intrapartum and Immediate Postpartum Quality of Care in India. Glob Health Sci Pract 2021; 9:590-610. [PMID: 34593584 PMCID: PMC8514027 DOI: 10.9745/ghsp-d-20-00368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 06/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND With the highest risk of maternal and newborn mortality occurring during the period around birth, quality of care during the intrapartum and immediate postpartum periods is critical for maternal and neonatal survival. METHODS The United States Agency for International Development's Scaling Up Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions project, also known as the Vriddhi project, collaborated with the national and 6 state governments to design and implement the Care Around Birth approach in 141 high caseload facilities across 26 high-priority districts of India from January 2016 to December 2017. The approach aimed to synergize evidence-based technical interventions with quality improvement (QI) processes, respectful maternity care, and health system strengthening efforts. The approach was designed using experiential training, mentoring, and a QI model. A baseline assessment measured the care ecosystem, staff competencies, and labor room practices. At endline, the approach was externally evaluated. RESULTS Availability of logistics, recording and reporting formats, and display of protocols improved across the intervention facilities. At endline (October-December 2017), delivery and newborn trays were available in 98% of facilities compared to 66% and 55% during baseline (October-December 2015), respectively. Competency scores (> 80%) for essential newborn care and newborn resuscitation improved from 7% to 70% and from 5% to 82% among health care providers, respectively. The use of partograph in monitoring labor improved from 29% at the baseline to 61%; administration of oxytocin within 1 minute of delivery from 35% to 93%; newborns successfully resuscitated from 71% to 96%; and postnatal monitoring of mothers from 52% to 94%. CONCLUSION The approach successfully demonstrated an operational design to improve the provision and experience of care during the intrapartum and immediate postpartum periods, thereby augmenting efforts aimed at ending preventable child and maternal deaths.
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Affiliation(s)
- Gunjan Taneja
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Enisha Sarin
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India.
- IPE Global, New Delhi, India
| | - Devina Bajpayee
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Saumyadripta Chaudhuri
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Geeta Verma
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Rakesh Parashar
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Nidhi Chaudhry
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Jaya Swarup Mohanty
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Nitin Bisht
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Anil Gupta
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Shailendra Singh Tomar
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | | | - V S Sridhar
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Anurag Joshi
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Chitra Rathi
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
| | - Dinesh Baswal
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Sachin Gupta
- Maternal and Child Health, United States Agency for International Development-India, New Delhi, India
| | - Rajeev Gera
- United States Agency for International Development-Vriddhi (Scaling up RMNCH+A Interventions) Project, New Delhi, India
- IPE Global, New Delhi, India
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Datta V, Srivastava S, Garde R, Mehta R, Livesley N, Sawleshwarkar K, Pemde H, Patnaik SK, Sooden A, Singh M, John SS, Pradeep J, Vig A, Kumar A, Singh V, Bhatia V, Garg BS, Baswal D. Development of a framework of intervention strategies for point of care quality improvement at different levels of healthcare delivery system in India: initial lessons. BMJ Open Qual 2021; 10:e001449. [PMID: 34344739 PMCID: PMC8336183 DOI: 10.1136/bmjoq-2021-001449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/22/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Inadequate quality of care has been identified as one of the most significant challenges to achieving universal health coverage in low-income and middle-income countries. To address this WHO-SEARO, the point of care quality improvement (POCQI) method has been developed. This paper describes developing a dynamic framework for the implementation of POCQI across India from 2015 to 2020. METHODS A total of 10 intervention strategies were designed as per the needs of the local health settings. These strategies were implemented across 10 states of India, using a modification of the 'translating research in practice' framework. Healthcare professionals and administrators were trained in POCQI using a combination of onsite and online training methods followed by coaching and mentoring support. The implementation strategy changed to a fully digital community of practice platform during the active phase of the COVID-19 pandemic. Dashboard process, outcome indicators and crude cost of implementation were collected and analysed across the implementation sites. RESULTS Three implementation frameworks were evolved over the study period. The combined population benefitting from these interventions was 103 million. A pool of QI teams from 131 facilities successfully undertook 165 QI projects supported by a pool of 240 mentors over the study period. A total of 21 QI resources and 6 publications in peer-reviewed journals were also developed. The average cost of implementing POCQI initiatives for a target population of one million was US$ 3219. A total of 100 online activities were conducted over 6 months by the digital community of practice. The framework has recently extended digitally across the South-East Asian region. CONCLUSION The development of an implementation framework for POCQI is an essential requirement for the initiative's successful country-wide scale. The implementation plan should be flexible to the healthcare system's needs, target population and the implementing agency's capacity and amenable to multiple iterative changes.
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Affiliation(s)
- Vikram Datta
- Neonatology, Kalawati Saran Children's Hospital, New Delhi, Delhi, India
- Neonatology, Lady Hardinge Medical College, New Delhi, Delhi, India
| | - Sushil Srivastava
- Pediatrics, University College of Medical Sciences, Delhi, Delhi, India
| | - Rahul Garde
- Quality Improvement, Nationwide Quality of Care Network, New Delhi, Delhi, India
| | - Rajesh Mehta
- Newborn, Child and Adolescent Health, World Health Organization Regional Office for South-East Asia, New Delhi, Delhi, India
| | | | | | - Harish Pemde
- Pediatrics, Lady Hardinge Medical College, New Delhi, Delhi, India
| | - Suprabha K Patnaik
- Neonatology, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharastra, India
| | - Ankur Sooden
- QI, University Research Co LLC, Bethesda, Maryland, USA
- Technical Advisor Health Systems, Nationwide Quality of Care Network, Indora, Himachal Pradesh, India
| | - Mahtab Singh
- QI, Nationwide Quality Of Care Network India, New Delhi, Delhi, India
| | - Susy Sarah John
- College of Nursing, Lady Hardinge Medical College, New Delhi, Delhi, India
| | - Jeena Pradeep
- Department of Nursing, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, New Delhi, Delhi, India
| | - Anupa Vig
- Telemedicine, Piramal Swasthya, Noida, NCR, India
- Obstetrics and Gynaecology, Piramal Swasthya, New Delhi, Delhi, India
| | - Achala Kumar
- Department of Nursing, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, New Delhi, Delhi, India
| | | | | | - Bishan Singh Garg
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Dinesh Baswal
- Maternal Health Division, Ministry of Health and Family Welfare, Government of India, New Delhi, Delhi, India
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Nguyen PH, Avula R, Tran LM, Sethi V, Kumar A, Baswal D, Hajeebhoy N, Ranjan A, Menon P. Missed opportunities for delivering nutrition interventions in first 1000 days of life in India: insights from the National Family Health Survey, 2006 and 2016. BMJ Glob Health 2021; 6:bmjgh-2020-003717. [PMID: 33627359 PMCID: PMC7908280 DOI: 10.1136/bmjgh-2020-003717] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 12/25/2022] Open
Abstract
Objectives Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through the continuum of care in India between 2006 and 2016 and and (2) assessed inequalities in these opportunity gaps. Methods We used two rounds of the National Family Health Survey data from 2005 to 2006 and 2015–2016 (n=36 850 and 190 898 mother–child dyads, respectively). We examine the opportunity gaps over time for seven nutrition interventions and their associated delivery platforms at national and state levels. We assessed equality and changes in equality between 2006 and 2016 for opportunity gaps by education, residence, socioeconomic status (SES), public and private platforms. Results Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms; opportunity gaps ranging from 9 to 32 percentage points (pp) during the pregnancy, 17 pp during delivery and 9–26 pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators, but coverage increases for nutrition interventions was lower than for associated delivery platforms. The opportunity gaps were larger among women with higher education (22–57 pp in 2016), higher SES status and living in urban areas (23–57 pp), despite higher coverage of most interventions and the delivery platforms among these groups. Opportunity gaps vary tremendously by state with the highest gaps observed in Tripura, Andaman and Nicobar islands, and Punjab for different indicators. Conclusions India’s progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equality gaps remained. It is critical to close these gaps by addressing policy and programmatic delivery systems bottlenecks to achieve universal coverage for both health and nutrition within the delivery system.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | | | | | - Alok Kumar
- Department of Health & Family Welfare, Government of Uttar Pradesh, Formerly with NITI Aayog, New Delhi, Delhi, India
| | - Dinesh Baswal
- Formerly with the Maternal Health Division, India Ministry of Health and Family Welfare, New Delhi, Delhi, India
| | | | - Alok Ranjan
- Bill & Melinda Gates Foundation, Delhi, India
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
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9
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Chopra M, Kaur N, Singh KD, Maria Jacob C, Divakar H, Babu GR, Hong Nguyen P, Bhanot A, Sabharwal M, Deb S, Baswal D, Louise Killeen S, McAuliffe FM, Hanson MA, Sethi V. Population estimates, consequences, and risk factors of obesity among pregnant and postpartum women in India: Results from a national survey and policy recommendations. Int J Gynaecol Obstet 2020; 151 Suppl 1:57-67. [PMID: 32894592 PMCID: PMC7590096 DOI: 10.1002/ijgo.13319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine prevalence, risk factors, and consequences of maternal obesity; and provide evidence on current policies and programs to manage maternal obesity in India. METHODS This is a mixed-methods study. We analyzed the National Family Health Survey (NFHS)-4 data (2015-16) to estimate the prevalence and risk factors of obesity, followed by a desk review of literature and stakeholder mapping with interviews to develop policy guidance. RESULTS National prevalence of obesity (defined by WHO as body mass index ≥25) was comparable among pregnant (12%) and postpartum women (13%) ≥20 years of age. A high prevalence of obesity (>40%) was observed in over 30 districts in multiple states. Older maternal age, urban residence, increasing wealth quintile, and secondary education were associated with increased odds of obesity among pregnant and postpartum women; higher education increased odds among postpartum women only (OR 1.90; 95% CI, 1.44-2.52). Dietary variables were not associated with obesity. Several implementation challenges across healthcare system blocks were observed at policy level. CONCLUSION Overall prevalence of obesity in India during and after pregnancy is high, with huge variation across districts. Policy and programs must be state-specific focusing on prevention, screening, and management of obesity among pregnant and postpartum women.
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Affiliation(s)
- Mansi Chopra
- National Centre of Excellence and Advanced Research on Diets, Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| | - Naman Kaur
- National Centre of Excellence and Advanced Research on Diets, Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| | - Konsam Dinachandra Singh
- National Centre of Excellence and Advanced Research on Diets, Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| | - Chandni Maria Jacob
- Institute of Developmental Sciences, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | | | - Giridhara R Babu
- Department of Epidemiology, Indian Institute of Public Health, Public Health Foundation of India, Bengaluru, India
| | | | - Arti Bhanot
- National Centre of Excellence and Advanced Research on Diets, Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| | - Manisha Sabharwal
- National Centre of Excellence and Advanced Research on Diets, Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| | - Sila Deb
- Ministry of Health and Family Welfare, New Delhi, India
| | - Dinesh Baswal
- Ministry of Health and Family Welfare, New Delhi, India
| | - Sarah Louise Killeen
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Mark A Hanson
- Institute of Developmental Sciences, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Vani Sethi
- Nutrition Section, United Nations Children's Fund, New Delhi, India
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10
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Nguyen P, Menon P, Avula R, Tran LM, Kumar A, Baswal D, Sethi V, Hajeebhoy N, Ranjan A. Can Health Systems Platforms Do More for Nutrition in India? Insights on Missed Opportunities from India's National Family Health Survey, 2015–2016. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa053_079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Most nutrition interventions can be delivered through health systems. However, the progress to scale up effective nutrition interventions and achieve universal health coverage has not been uniform. We aimed to 1) examine the opportunity gaps (OGs) between delivery platforms and corresponding nutrition interventions through the continuum of care (from pregnancy up to early childhood) in India between 2006 and 2016; and 2) assess inequalities in these OGs.
Methods
We used two rounds of National Family Health Survey data collected in 2005–06 and 2015–16 (n = 36,850 and 190,898 mother-child dyads with the last child aged of 0–5 years, respectively). We examine the OGs over time for a set of seven nutrition interventions and their associated delivery platforms during antenatal, delivery, postnatal and early childhood care at the national, state and district levels. We then assessed equality and changes in equality between 2006–2016 for the OGs by education, residence, socioeconomic status, public and private platforms.
Results
Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms, with the OGs ranging from 9–32 percentage points (pp) during pregnancy, 17pp during delivery, and 9–26pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators but the OGs became wider. The OGs were larger among women with higher education, higher SES status and living in urban areas, despite higher coverage of most interventions and the delivery platforms among these groups. Compared to private facilities, public facilities performed better in counseling/support for breastfeeding but were poorer in iron and folic acid supplementation. OGs vary tremendously by state and district, highlighting governance and implementation successes and challenges.
Conclusions
India's progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equity gaps must be closed by addressing policy and programmatic health systems bottlenecks to achieve universal coverage for both health and nutrition. We recommend this analytic approach to track and assess OGs in scaling up nutrition through health systems in India and worldwide.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by IFPRI.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
| | | | | | - Dinesh Baswal
- National Health Systems Resource Centre, New Delhi, India
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11
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Singh KD, Choedon T, Bhanot A, Kaur N, Chopra M, Sabharwal M, Sethi V, Baswal D, Scott S, Menon P, Nguyen P. Tipping the Scales: Population Estimates and Risk Factors for Severe Thinness, Thinness, Overweight and Obesity Among Pregnant Women and Mothers in India. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa054_047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Thinness and overweight/obesity are prevalent among women of reproductive age in India but there is limited evidence on the burden and predictors of this during pregnancy and post-partum. We estimated prevalence and risk factors for thinness and overweight among pregnant and recently delivered women (RDW).
Methods
We used India's National Family Health Survey (2015–2016), including 16,153 pregnant women <20 weeks of gestation and 19,430 RDW of 2–6-month-old infants. All women were classified as severe thin (ST), thin (TH), overweight (OV) or obese (OB) (body mass index, BMI <16, <18.5, ≥23 and ≥25 kg/m2, respectively), using cutoffs for Asian populations. Logistic regression was used to examine associated factors (including socio-demography, hygiene and sanitation, antenatal health services and diet) with those outcomes.
Results
Barely 40% of women were of normal BMI. ST, TH, OV/OB and OB were seen in 2%, 20%, 25% and 13% respectively among pregnant women, and for RDW, they were 2%, 21%, 24% and 13%. Factors associated with a lower odds of ST and TH among pregnant women and RDW included higher wealth quintile (adjusted odds ratios, AORs ranging from 0.58–0.63 for highest quintile), higher education (AORs: 0.64–0.81), age group ≥25 y (AORs: 0.58–0.83), and improved toilet facility (AOR 0.81). Multiparous pregnant women had higher odds of TH compared to primiparas (AORs: 1.24–1.31). Factors associated with OV and OB among pregnant women and RDW were belonging in higher socio-economic group (AORs: 1.34–1.53), higher wealth quintile (AORs: 1.56–8.49), age group ≥25 y (AORs: 2.73–5.09), urban residence (AOR 1.16–1.36), and having higher education (AORs: 1.44–1.60). Among RDW, receiving supplementary food and health and nutrition education increased odds of TH (AORs: 1.15) and reduced odds of OV and OB (AORs: 0.83–0.87), but this is likely attributable to selection bias in program use.
Conclusions
TN and OV/OB affect 1 in 5 pregnant women and 1 in 4 RDW in India. Socio-economic factors, sanitation, parity, education and age influence TN and OV/OB. Better diet and physical activity estimates are needed to understand OV and OB in this population. Given the high burden of both forms of malnutrition, a policy focus on healthy weight gain is essential.
Funding Sources
UNICEF; Bill & Melinda Gates Foundation (via POSHAN).
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Affiliation(s)
| | - Tashi Choedon
- National Centre of Excellence and Advanced Research on Diets
| | - Arti Bhanot
- National Centre of Excellence and Advanced Research on Diets
| | - Naman Kaur
- National Centre of Excellence and Advanced Research on Diets
| | - Mansi Chopra
- National Centre of Excellence and Advanced Research on Diets
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12
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Neogi SB, Devasenapathy N, Singh R, Bhushan H, Shah D, Divakar H, Zodpey S, Malik S, Nanda S, Mittal P, Batra A, Chauhan MB, Yadav S, Dongre H, Saluja S, Malhotra V, Gupta A, Sangwan R, Radhika AG, Singh A, Bhaskaran S, Kotru M, Sikka M, Agarwal S, Francis P, Mwinga K, Baswal D. Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, controlled trial. Lancet Glob Health 2020; 7:e1706-e1716. [PMID: 31708151 DOI: 10.1016/s2214-109x(19)30427-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/27/2019] [Accepted: 09/17/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Intravenous iron sucrose is a promising therapy for increasing haemoglobin concentration; however, its effect on clinical outcomes in pregnancy is not yet established. We aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy. METHODS We did a multicentre, open-label, phase 3, randomised, controlled trial at four government medical colleges in India. Pregnant women, aged 18 years or older, at 20-28 weeks of gestation with a haemoglobin concentration of 5-8 g/dL, or at 29-32 weeks of gestation with a haemoglobin concentration of 5-9 g/dL, were randomly assigned (1:1) to receive intravenous iron sucrose (dose was calculated using a formula based on bodyweight and haemoglobin deficit) or standard oral iron therapy (100 mg elemental iron twice daily). Logistic regression was used to compare the primary maternal composite outcome consisting of potentially life-threatening conditions during peripartum and postpartum periods (postpartum haemorrhage, the need for blood transfusion during and after delivery, puerperal sepsis, shock, prolonged hospital stay [>3 days following vaginal delivery and >7 days after lower segment caesarean section], and intensive care unit admission or referral to higher centres) adjusted for site and severity of anaemia. The primary outcome was analysed in a modified intention-to-treat population, which excluded participants who refused to participate after randomisation, those who were lost to follow-up, and those whose outcome data were missing. Safety was assessed in both modified intention-to-treat and as-treated populations. The data safety monitoring board recommended stopping the trial after the first interim analysis because of futility (conditional power 1·14% under the null effects, 3·0% under the continued effects, and 44·83% under hypothesised effects). This trial is registered with the Clinical Trial Registry of India, CTRI/2012/05/002626. FINDINGS Between Jan 31, 2014, and July 31, 2017, 2018 women were enrolled, and 999 were randomly assigned to the intravenous iron sucrose group and 1019 to the standard therapy group. The primary maternal composite outcome was reported in 89 (9%) of 958 patients in the intravenous iron sucrose group and in 95 (10%) of 976 patients in the standard therapy group (adjusted odds ratio 0·95, 95% CI 0·70-1·29). 16 (2%) of 958 women in the intravenous iron sucrose group and 13 (1%) of 976 women in the standard therapy group had serious maternal adverse events. Serious fetal and neonatal adverse events were reported by 39 (4%) of 961 women in the intravenous iron sucrose group and 45 (5%) of 982 women in the standard therapy group. At 6 weeks post-randomisation, minor side-effects were reported by 117 (16%) of 737 women in the intravenous iron sucrose group versus 155 (21%) of 721 women in the standard therapy group. None of the serious adverse events was found to be related to the trial procedures or the interventions as per the causality assessment made by the trial investigators, ethics committees, and regulatory body. INTERPRETATION The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia. FUNDING WHO, India.
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Affiliation(s)
- Sutapa B Neogi
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India.
| | | | - Ranjana Singh
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India
| | | | - Duru Shah
- Breach Candy Hospital, Mumbai, India; Indian College of Obstetricians and Gynaecologists, Federation of Obstetrics and Gynaecology Society of India, Mumbai, India
| | | | - Sanjay Zodpey
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India
| | - Sunita Malik
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Smiti Nanda
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Pratima Mittal
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Achla Batra
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Meenakshi B Chauhan
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Sunita Yadav
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Harsha Dongre
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sumita Saluja
- Department of Hematology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Vani Malhotra
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Anjali Gupta
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Roopa Sangwan
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - A G Radhika
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Alpana Singh
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Sruti Bhaskaran
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Mrinalini Kotru
- Department of Pathology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Meera Sikka
- Department of Pathology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Sonika Agarwal
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | | | | | - Dinesh Baswal
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
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13
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Sethi V, de Wagt A, Bhanot A, Singh KD, Agarwal P, Murira Z, Bhatia S, Baswal D, Unisa S, Subramanian SV. Levels and determinants of malnutrition among India's urban poor women: An analysis of Demographic Health Surveys 2006 and 2016. Matern Child Nutr 2020; 16:e12978. [PMID: 32141172 PMCID: PMC7296805 DOI: 10.1111/mcn.12978] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 01/16/2020] [Accepted: 01/28/2020] [Indexed: 12/13/2022]
Abstract
A quarter of 400 million urban Indian residents are poor. Urban poor women are as undernourished as or worse than rural women but urban averages mask this disparity. We present the spectrum of malnutrition and their determinants for more than 26,000 urban women who gave birth within 5 years from the last two rounds of Demographic Health Survey 2006 and 2016. Among urban mothers in the lowest quartile by wealth index (urban poor), 12.8% (95% CI [11.3%, 14.5%]) were short or with height < 145 cm; 20.6% (95% CI [19%, 22.3%]) were thin or with body mass index < 18.5 kg/m2 ; 57.4% (95% CI [55.5%, 59.3%]) had any anaemia (haemoglobin < 12 g/dL), whereas 32.4% (95% CI [30.5%, 34.3%]) had moderate to severe anaemia; and 21.1% (95% CI [19.3%, 23%]) were obese (body mass index ≥ 25 kg/m2 ). Decadal gains were significant for thinness reduction (17p.p.) but obesity increased by 12 p.p. Belonging to a tribal household increased odds of thinness by 1.5 (95% CI [1.06, 2.18]) times among urban poor mothers compared with other socially vulnerable groups. Secondary education reduced odds of thinness (0.61; 95% CI [0.48, 0.77]) and higher education of short stature (0.41; 95% CI [0.18, 0.940]). Consuming milk/milk products, pulses/beans/eggs/meats, and dark green leafy vegetables daily reduced the odds of short stature (0.52; 95% CI [0.35, 0.78]) and thinness (0.72; 95% CI [0.54, 0.98]). Urban poor mothers should be screened for nutritional risks due to the high prevalence of all forms of malnutrition and counselled or treated as per risk.
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Affiliation(s)
- Vani Sethi
- Nutrition Section, UNICEF India, Country Office, New Delhi, India
| | - Arjan de Wagt
- Nutrition Section, UNICEF India, Country Office, New Delhi, India
| | | | | | - Praween Agarwal
- Nutrition Section, UNICEF India, Country Office, New Delhi, India
| | - Zivai Murira
- Regional Office for South Asia, UNICEF, Kathmandu, Nepal
| | - Salima Bhatia
- Ministry of Health and Family Welfare, Government of India, India
| | - Dinesh Baswal
- Ministry of Health and Family Welfare, Government of India, India
| | - Sayeed Unisa
- International Institute for Population Sciences, Mumbai, India
| | - S V Subramanian
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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14
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Sethi V, Dinachandra K, Murira Z, Gausman J, Bhanot A, de Wagt A, Unisa S, Bhatia S, Baswal D, Subramanian SV. Nutrition status of nulliparous married Indian women 15-24 years: Decadal trends, predictors and program implications. PLoS One 2019; 14:e0221125. [PMID: 31454363 PMCID: PMC6711595 DOI: 10.1371/journal.pone.0221125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/12/2019] [Indexed: 01/15/2023] Open
Abstract
In India, 66% of 8 million married adolescents (~5.3 million) are nulliparous and likely to conceive soon. Among married young women aged 20–24 years about 9.1 million are nulliparous. This group remains relatively less reached in maternal nutrition programs. Current estimates of their nutritional status and predictors of body mass index (BMI) are unavailable. Thinness (BMI <18.5 kg/m2), severe thinness (BMI <16 kg/m2), overweight or obesity (BMI ≥ 23kg/m2) prevalence estimates are presented based on a sample of 11,265 married nulliparous adolescents (15–19 years, married, no parity) and 15,358 young women (20–24 years, married, no parity) drawn from the National Family Health Surveys 2005–06 and 2015–16. Trends by age, time and state were analysed. Predictors of BMI were investigated using linear regression. Using BMI for age z score (BAZ) as standard reference, BMI cut-off was calculated for thinness (-2SD) and overweight or obesity (+1SD) among married nulliparous adolescents as recommended for population under 19 years. 35% sampled adolescents and 26% young women were thin; 4%-5% severely thin. Overweight or obesity was higher among married nulliparous young women than married nulliparous adolescents (21% versus 11%). Eight in 1000 were short, thin and young and six in 1000 were short, thin, anemic and young. At 15 years of age, prevalence of thinness based on BMI was 46.5% while based on BAZ, 7.6%. At 24 years of age thinness was 22.5%. Decadal reduction in thinness was half among married nulliparous adolescents (4% points) compared with married nulliparous young women (8% points). Decadal increase in overweight/ obesity ranged from 4% to 5% in both age groups. Western states had high prevalence of thinness; Tamil Nadu had highest prevalence of overweight or obesity. Incremental increase in age and wealth increased BMI among young women more than adolescents. BMI was lower among adolescents and young women wanting a child later than soon [β -0.28 (CI -0.49- -0.07), β -0.33(CI -0.56- -0.093), respectively]. BMI cut-off 16.49 kg/m2 and 24.12 kg/m2 had a high sensitivity (100%, 99.7%) and specificity (98.9%, 98.5%) to screen thin and overweight or obese adolescents, respectively. Owing to the high prevalence of both thinness and overweight/obesity among nulliparous married adolescents and women, nutritional anthropometry based screening should be initiated for this target group, along with a treatment package in states with high and persistent malnutrition. Family planning services should be integrated in nutrition programs for this target group to achieve normal nutritional status before conception.
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Affiliation(s)
- Vani Sethi
- Nutrition Section, UNICEF India, Country Office, New Delhi, India
- * E-mail:
| | | | - Zivai Murira
- Regional Office for South Asia, UNICEF, Kathmandu, Nepal
| | - Jewel Gausman
- Women & Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | | | - Arjan de Wagt
- Nutrition Section, UNICEF India, Country Office, New Delhi, India
| | - Sayeed Unisa
- International Institute for Population Sciences, Mumbai, India
| | - Salima Bhatia
- Ministry of Health and Family Welfare, Government of India, Guwahati, Assam, India
| | - Dinesh Baswal
- Ministry of Health and Family Welfare, Government of India, Guwahati, Assam, India
| | - S. V. Subramanian
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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15
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Kumar S, Dave P, Srivastava A, Stekelenburg J, Baswal D, Singh D, Sood B, Yadav V. Harmonizing scientific rigor with political urgency: policy learnings for identifying accelerators for scale-up from the safe childbirth checklist programme in Rajasthan, India. BMC Health Serv Res 2019; 19:273. [PMID: 31046754 PMCID: PMC6498660 DOI: 10.1186/s12913-019-4093-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quick scaling-up of innovative and promising interventions in health systems of low and middle-income countries to rapidly achieve population level benefits is a key challenge. While there is consensus on the need for rigorous scientific evidence on effectiveness of interventions before considering scale-up, there can be significant time lag for the want of gold-standard evidence. The Safe Childbirth Checklist (SCC) programme in India, demonstrated how an innovation was robustly evaluated and scaled up nationally, within a short span of time. In this narrative review, we describe the strategies discussed in various published scale-up frameworks and map them against the strategies adopted by the SCC programme to identify accelerators which facilitated its rapid scale up. METHODS The narrative review - done from May to June 2017 - involved keyword searches of electronic databases of PubMed, Ovid Medline and Google Scholar. It included the key words 'pilot', 'health innovations', 'scale-up', 'replication', 'expansion', 'increased coverage', 'conceptual models for scale-up', 'frame-works for scale-up', 'evidence for scale-up' in the title of publications,. This search was limited to publications in English after the year 1995. We used snowball sampling approach (by referring to bibliographies of shortlisted publications) to identify additional publications related to scale-up. We then screened the identified publications independently and relevant publications that discussed attributes for a conceptual model for scale-up of public health interventions in low and middle-income countries were shortlisted. We then mapped the strategies we used in SCC program scale up against those described in the shortlisted frameworks to identify seven accelerators which facilitated rapid scale up. RESULTS The identified accelerators were: testing the intervention in real world, resource constrained settings; using an appropriate and time sensitive research design; testing the intervention at substantial scale and in diverse settings; using an adaptive and iterative prototyping approach for implementation; sharing data and evidence with key stakeholders on an ongoing basis; targeting bridge resources through strategic engagement of stakeholders and timely integration of scale-up plans with annual planning and budgeting cycles and systems. CONCLUSION These accelerators will complement current frameworks and provide guidance to future scale-up initiatives in India and elsewhere.
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Affiliation(s)
- Somesh Kumar
- Jhpiego-an affiliate of Johns Hopkins University, 29, Okhla Phase -3, New Delhi, 110019, India.,Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Priti Dave
- Children's Investment Fund Foundation (CIFF), London, United Kingdom
| | - Ashish Srivastava
- Jhpiego-an affiliate of Johns Hopkins University, 29, Okhla Phase -3, New Delhi, 110019, India.
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.,Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - Dinesh Baswal
- Maternal Health Division, Ministry of Health & Family Welfare, Government of India, New Delhi, India
| | - Deepti Singh
- Jhpiego-an affiliate of Johns Hopkins University, 29, Okhla Phase -3, New Delhi, 110019, India
| | - Bulbul Sood
- Jhpiego-an affiliate of Johns Hopkins University, 29, Okhla Phase -3, New Delhi, 110019, India
| | - Vikas Yadav
- Jhpiego-an affiliate of Johns Hopkins University, 29, Okhla Phase -3, New Delhi, 110019, India
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Parashar R, Gupt A, Bajpayee D, Gupta A, Thakur R, Sangwan A, Sharma A, Sharma D, Gupta S, Baswal D, Taneja G, Gera R. Implementation of community based advance distribution of misoprostol in Himachal Pradesh (India): lessons and way forward. BMC Pregnancy Childbirth 2018; 18:428. [PMID: 30373537 PMCID: PMC6206722 DOI: 10.1186/s12884-018-2036-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/28/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Postpartum Hemorrhage remains the leading cause of maternal mortality. To prevent PPH, Misoprostol tablet in a dose of 600 micrograms is recommended for use immediately after childbirth in home deliveries wherein the use of oxytocin is difficult. The current article describes an implementation of "community based advance distribution of Misoprostol program" in India which aimed to design an operational framework for implementing this program. METHODS The intervention was carried out in Janjheli block in Mandi district of the state of Himachal Pradesh which is a mountainous terrain with limited geographical access and reported 90% home deliveries in the year 2014-15. An operational framework to implement program activities was designed which was based on WHO HSS building blocks. Key implementing steps included- Ensuring local ownership through program leadership, forecasting and procurement of 600 mcg misoprostol tablets, training, branding and communication, community engagement and counselling, recording and reporting, monitoring, supportive supervision and feedback mechanisms. RESULTS Over the one year of implementation, 512 home deliveries were reported, out of which 89% received the tablets and 84% consumed the tablet within one minute of delivery. No incidence of PPH in tablet consuming mothers was reported. On account of periodic counselling and effective community engagement the intervention also contributed to better tracking of pregnancies till delivery and institutional delivery rates which increased to 93% from 45% and 57% from 11% respectively as compared to the preceding year. CONCLUSIONS The model has successfully shown the use of single misoprostol tablets of 600 mcg, first time in this program. We also demonstrated a HSS based operational framework, based on which the program is being scaled to additional blocks in Himachal Pradesh as well as to other states of India.
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Affiliation(s)
| | - Anadi Gupt
- Maternal Health, Department of Health and Family Welfare, Government of Himachal Pradesh, Shimla, India
| | - Devina Bajpayee
- Maternal and Newborn Health, USAID-VRIDDHI/IPE Global, New Delhi, India
| | - Anil Gupta
- USAID-VRIDDHI/IPE Global, Shimla, Himachal Pradesh India
| | - Rohan Thakur
- USAID-VRIDDHI/IPE Global, Mandi, Himachal Pradesh India
| | - Ankur Sangwan
- USAID-VRIDDHI/IPE Global, Kinnaur, Himachal Pradesh India
| | - Anuradha Sharma
- Department of Health and Family Welfare, Government of Himachal Pradesh, Mandi, Himachal Pradesh India
| | - Deshraj Sharma
- Department of Health and Family Welfare, Government of Himachal Pradesh, Mandi, Himachal Pradesh India
| | - Sachin Gupta
- Maternal and Child Health, USAID-India, New Delhi, India
| | - Dinesh Baswal
- Maternal Health, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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