Seasonal and District Level Geo-Spatial Variations in Stillbirth Rates in India: An Analysis of Secondary Data

Stillbirth is a major public health problem across the world as well as in India. The programmatic interventions to tackle stillbirth require granular data upto local levels. The Health Management Information System (HMIS) in India is one of the best sources of granular data on stillbirth. This analysis was conducted using HMIS stillbirth data of three pre-pandemic years 2017-2020 to study the geo-spatial patterns of stillbirth at district level in nine states of India, forming a high burden cluster of four central Indian states and a low burden cluster of five southern states. Geo-spatial variation at sub-district level was studied for Maharashtra given the ready availability of sub-district shapefiles required for such analysis. The analysis also explores the seasonal variations in stillbirths at all-India level. A granular intra-cluster spatial pattern of stillbirth was observed in all states analyzed, with a clear hotspot across a few districts in Odisha and Chhattisgarh (>20 stillbirths/1,000 total births in 2019-20). Even in the southern cluster, the hotspots (8-20 stillbirths/1,000 total births) were found. Availability of sub-district level data in Maharashtra helped to identify intra-state regional variations in stillbirth with high prevalence in certain district clusters. In temporal terms, stillbirths exhibit a regular peak during August-October and a dip during February-April which is inclined with the birth seasonality patterns. This review and analysis underscore the need for more granular data availability, regular analysis of such data by expert and program managers, more decentralized and context specific programme intervention both in locational and seasonal terms.

Effects of timed and targeted counselling by community health workers on maternal and household practices, and pregnancy and newborn outcomes in rural Uganda

INTRODUCTION

Pregnancy and birth-related complications claim the lives of millions of women and newborns every year. Improving their survival chances remains an urgent global challenge, including in Uganda. Community health workers (CHWs) play a crucial role in bridging the gap between the community and the official health system in Uganda. Timed and targeted Counselling (ttC) is an individual-level behavioral change communication method used by CHWs, aimed at pregnant women and caregivers of children under the age of two.

AIM

This study examined whether the implementation of the ttC intervention by the CHWs was associated with improved household practices and outcomes during the pregnancy and newborn period.

METHODS

A multi-stage sampling technique was employed with a total of 749 participants in the intervention group (ttC intervention), and 744 participants in the control group (no ttC). Data on quality of maternal and household antenatal care (ANC) and essential newborn care (ENC) practices, as well as on pregnancy and newborn outcomes were collected through questionnaires from May 2018 to May 2020. McNemar's Chi-square tests were used to compare outcomes before and after implementation, and between the intervention and control group.

RESULTS

Results showed that, compared to baseline, ttC contributed significantly to the demand for quality of service during ANC, ENC and partner involvement in maternal and newborn health. In comparison to the control group, the ttC group showed significantly higher early ANC attendance rates and higher quality of ANC and ENC.

CONCLUSION

ttC is a comprehensive, goal-driven approach that seems to contribute to the improvement of quality of maternal and household practices, and pregnancy and newborn outcomes in Uganda.

TRIAL REGISTRATION

PACTR, PACTR202002812123868, registered on 25 February 2020, http://www.pactr.org/PACTR202002812123868.

An analysis of the impact of newborn survival policies in Pakistan using a policy triangle framework

Introduction

Pakistan has made slow progress towards reducing the newborn mortality burden; as a result, it has the highest burden of newborn mortality worldwide. This article presents an analysis of the current policies, plans, and strategies aimed at reducing the burden of newborn death in Pakistan for the purpose of identifying current policy gaps and contextual barriers towards proposing policy solutions for improved newborn health.

Methods

We begin with a content analysis of federal-level policies that address newborn mortality within the context of health system decentralization over the last 20 years. This is then followed by a case study analysis of policy and programme responses in a predominantly rural province of Pakistan, again within the context of broader health system decentralization. Finally, we review successful policies in comparable countries to identify feasible and effective policy choices that hold promise for implementation in Pakistan, considering the policy constraints we have identified.

Results

The major health policies aimed at reduction of newborn mortality, following Pakistan’s endorsement of global newborn survival goals and targets, lacked time-bound targets. We found confusion around roles and responsibilities of institutions in the implementation process and accountability for the outcomes, which was exacerbated by an incomplete decentralization of healthcare policy-making and health service delivery, particularly for women around birth, and newborns. Such wide gaps in the areas of target-setting, implementation mechanism, and evaluation could be because the policy-making largely ignored international commitments and lessons of successful policy-making in comparable regional counties.

Conclusions

Inclusion of clear goals and targets in newborn survival policies and plans, completion of the decentralization process of maternal and child healthcare service delivery, and policy-making and implementation by translating complex evidence and using regional but locally applicable case studies will be essential to any effective policy-making on newborn survival in Pakistan.

Cortisol fetal fluid concentrations in term pregnancy of small-sized purebred dogs and its preliminary relation to first 24 hours survival of newborns

Along the perinatal period, in mammals, cortisol (C) plays a pivotal role in the final intrauterine fetal maturation and in the early neonatal adaptation. Because of the scarce knowledge about canine perinatology, the present study was aimed to assess the C concentrations in amniotic and allantoic fluids collected, without invasiveness, from small-sized, purebred newborn puppies born by elective cesarean section, at term of pregnancy. Possible correlations between fetal fluid C concentrations and maternal parity, litter size, birth weight, Apgar score, were evaluated. In addition, the possible effect of fetal fluid C concentrations on newborn survival at 24 hours of age, and the effect of the litter or the newborn gender on fetal fluid C concentrations were also assessed. The results, obtained from 50 born alive, normal-weight puppies, without gross physical malformation, showed that C concentration was higher in allantoic than in amniotic fluid (P < 0.01), even if a strong positive correlation between the two fluids C concentration was found (P < 0.0001; R = 0.83). Neither amniotic nor allantoic C concentrations were correlated to maternal parity, litter size, birth weight, and Apgar score. Interestingly, higher amniotic (P < 0.05), but not allantoic, C concentrations were found in puppies not surviving at 24 hours after birth. Therefore, it could be suggested that this parameter may be useful for the recognition, at birth, of puppies needing special surveillance during the first day of age. A significant (P < 0.001) effect of the litter in both amniotic and allantoic C concentrations was found. In conclusion, the present results showed that in small-sized purebred puppies, born at term by elective cesarean section, the exact fetal, maternal, or placental source contributing to fetal fluid C concentrations remains to be clarified. From a clinical perspective, however, the evaluation of amniotic C concentration at birth seems useful for the detection of puppies that need special surveillance during the first 24 hours of age, and should be coupled to the early newborn evaluation by Apgar score. However, the small total number of newborns, and especially of the dead puppies enrolled in the present study, suggests that further, more-focused investigations on a large number of subjects are needed before the method could be considered for application in the clinical practices.

Enculturating science: Community-centric design of behavior change interactions for accelerating health impact

Despite significant advancements in the scientific evidence base of interventions to improve newborn survival, we have not yet been able to "bend the curve" to markedly accelerate global rates of reduction in newborn mortality. The ever-widening gap between discovery of scientific best practices and their mass adoption by families (the evidence-practice gap) is not just a matter of improving the coverage of health worker-community interactions. The design of the interactions themselves must be guided by sound behavioral science approaches such that they lead to mass adoption and impact at a large scale. The main barrier to the application of scientific approaches to behavior change is our inability to "unbox" the "black box" of family health behaviors in community settings. The authors argue that these are not black boxes, but in fact thoughtfully designed community systems that have been designed and upheld, and have evolved over many years keeping in mind a certain worldview and a common social purpose. An empathetic understanding of these community systems allows us to deconstruct the causal pathways of existing behaviors, and re-engineer them to achieve desired outcomes. One of the key reasons for the failure of interactions to translate into behavior change is our failure to recognize that the content, context, and process of interactions need to be designed keeping in mind an organized community system with a very different worldview and beliefs. In order to improve the adoption of scientific best practices by communities, we need to adapt them to their culture by leveraging existing beliefs, practices, people, context, and skills. The authors present a systems approach for community-centric design of interactions, highlighting key principles for achieving intrinsically motivated, sustained change in social norms and family health behaviors, elucidated with progressive theories from systems thinking, management sciences, cross-cultural psychology, learning and social cognition, and the behavioral sciences. These are illustrated through a case study of designing effective interactions in Shivgarh, India, that led to rapid and substantial changes in newborn health behaviors and reduction in NMR by half over a span of 16 months.