Search

Background: This paper explores the heterogeneities in antenatal care (ANC) utilization in India's most populated state, Uttar Pradesh. Taking an intersectionality lens, multiple individual- and district-level factors are used to identify segments of any antenatal care usage in Uttar Pradesh Objective: This paper seeks to understand the multilevel contexts of ANC utilization. The planning and programming challenge is that such knowledge of contextual specificity is rarely known upfront at the initial stages of planning or implementing an intervention. Exploratory data analysis might be needed to identify such contextual specificity. Methods: Tree-structured regression methods are used to identify segments and interactions between factors. The results from the tree-structured regression were complemented with multilevel models that controlled for the clustering of individuals within districts. Results: Heterogeneities in utilization of any ANC were observed. The multiple segments of ANC utilization that were developed went from a low utilization of 23.7% for respondents who were not literate and did not have home ownership to a high of 82.4% for respondents who were literate and at the highest level of wealth. Key variables that helped define the segments of ANC utilization include: woman's literacy, ownership of home, wealth index, and district-level sex ratio. Based on the multilevel model of any ANC utilization, cross-level interactions also were obtained between sex ratio and ownership of home as well as between sex ratio and literacy. Increases in sex ratio increased the influence of ownership of home on any ANC, while increases in sex ratio reduced the impact of woman's literacy on receiving any ANC. Conclusion: We argue that a focus on heterogeneous segments of utilization can help build knowledge of the mechanisms that underlie inequities in maternal health utilization. Such knowledge of heterogeneity needs to be incorporated in contextualizing interventions to meet a variety of recipients' needs. [ABSTRACT FROM AUTHOR]

Public health research has gained increasing importance in India's national health policy as the country seeks to address the high burden of disease and its inequitable distribution, and embarks on an ambitious agenda towards universalising health care. This study aimed at describing the public health research output in India, its focus and distribution, and the actors involved in the research system. It makes recommendations for systematically promoting and strengthening public health research in the country. The study was a bibliometric analysis of PubMed and IndMed databases for years 2000–2010. The bibliometric data were analysed in terms of biomedical focus based on the Global Burden of Disease, location of research, research institutions, and funding agencies. A total of 7,893 eligible articles were identified over the 11-year search period. The annual research output increased by 42% between 2000 and 2010. In total, 60.8% of the articles were related to communicable diseases, newborn, maternal, and nutritional causes, comparing favourably with the burden of these causes (39.1%). While the burdens from non-communicable diseases and injuries were 50.2 and 10.7%, respectively, only 31.9 and 7.5% of articles reported research for these conditions. The north-eastern states and the Empowered-Action-Group states of India were the most under-represented for location of research. In total, 67.2% of papers involved international collaborations and 49.2% of these collaborations were with institutions in the UK or USA; 35.4% of the publications involved international funding and 71.2% of funders were located in the UK or USA. While public health research output in India has increased significantly, there are marked inequities in relation to the burden of disease and the geographic distribution of research. Systematic priority setting, adequate funding, and institutional capacity building are needed to address these inequities. [ABSTRACT FROM AUTHOR]

Background: The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public–private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Methods: Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Results: Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. Conclusions: This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation.

Background: This paper explores the heterogeneities in antenatal care (ANC) utilization in India’s most populated state, Uttar Pradesh. Taking an intersectionality lens, multiple individual- and district-level factors are used to identify segments of any antenatal care usage in Uttar Pradesh Objective: This paper seeks to understand the multilevel contexts of ANC utilization. The planning and programming challenge is that such knowledge of contextual specificity is rarely known upfront at the initial stages of planning or implementing an intervention. Exploratory data analysis might be needed to identify such contextual specificity. Methods: Tree-structured regression methods are used to identify segments and interactions between factors. The results from the tree-structured regression were complemented with multilevel models that controlled for the clustering of individuals within districts. Results: Heterogeneities in utilization of any ANC were observed. The multiple segments of ANC utilization that were developed went from a low utilization of 23.7% for respondents who were not literate and did not have home ownership to a high of 82.4% for respondents who were literate and at the highest level of wealth. Key variables that helped define the segments of ANC utilization include: woman’s literacy, ownership of home, wealth index, and district-level sex ratio. Based on the multilevel model of any ANC utilization, cross-level interactions also were obtained between sex ratio and ownership of home as well as between sex ratio and literacy. Increases in sex ratio increased the influence of ownership of home on any ANC, while increases in sex ratio reduced the impact of woman’s literacy on receiving any ANC. Conclusion: We argue that a focus on heterogeneous segments of utilization can help build knowledge of the mechanisms that underlie inequities in maternal health utilization. Such knowledge of heterogeneity needs to be incorporated in contextualizing interventions to meet a variety of recipients’ needs.

The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public–private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation. [ABSTRACT FROM AUTHOR]

Background: A large state-wide tobacco survey was conducted using modified version of pretested, globally validated Global Adult Tobacco Survey (GATS) questionnaire in 2015–22016 in Tamil Nadu, India. Due to resource constrains, data collection was carrid out using paper-based questionnaires (unlike the GATS-India, 2009–2010, which used hand-held computer devices) while data entry was done using open access tools. The objective of this paper is to describe the process of data entry and assess its quality assurance and efficiency. Methods: In EpiData language, a variable is referred to as ‘field’ and a questionnaire (set of fields) as ‘record’. EpiData software was used for double data entry with adequate checks followed by validation. Teamviewer was used for remote training and trouble shooting. The EpiData databases (one each for each district and each zone in Chennai city) were housed in shared Dropbox folders, which enabled secure sharing of files and automatic back-up. Each database for a district/zone had separate file for data entry of household level and individual level questionnaire. Results: Of 32,945 households, there were 111,363 individuals aged ≥15 years. The average proportion of records with data entry errors for a district/zone in household level and individual level file was 4% and 24%, respectively. These are the errors that would have gone unnoticed if single entry was used. The median (inter-quartile range) time taken for double data entry for a single household level and individual level questionnaire was 30 (24, 40) s and 86 (64, 126) s, respectively. Conclusion: Efficient and quality-assured near-real-time data entry in a large sub-national tobacco survey was performed using innovative, resource-efficient use of open access tools.

Background: A large state-wide tobacco survey was conducted using modified version of pretested, globally validated Global Adult Tobacco Survey (GATS) questionnaire in 2015–22016 in Tamil Nadu, India. Due to resource constrains, data collection was carrid out using paper-based questionnaires (unlike the GATS-India, 2009–2010, which used hand-held computer devices) while data entry was done using open access tools. The objective of this paper is to describe the process of data entry and assess its quality assurance and efficiency. Methods: In EpiData language, a variable is referred to as ‘field’ and a questionnaire (set of fields) as ‘record’. EpiData software was used for double data entry with adequate checks followed by validation. Teamviewer was used for remote training and trouble shooting. The EpiData databases (one each for each district and each zone in Chennai city) were housed in shared Dropbox folders, which enabled secure sharing of files and automatic back-up. Each database for a district/zone had separate file for data entry of household level and individual level questionnaire. Results: Of 32,945 households, there were 111,363 individuals aged ≥15 years. The average proportion of records with data entry errors for a district/zone in household level and individual level file was 4% and 24%, respectively. These are the errors that would have gone unnoticed if single entry was used.The median (inter-quartile range) time taken for double data entry for a single household level and individual level questionnaire was 30 (24, 40) s and 86 (64, 126) s, respectively. Conclusion: Efficient and quality-assured near-real-time data entry in a large sub-national tobacco survey was performed using innovative, resource-efficient use of open access tools. [ABSTRACT FROM PUBLISHER]

Background: Depending on a country’s diagnostic infrastructure, patients and providers play different roles in ensuring that correct and timely diagnosis is made. However, little is known about the work done by patients in accessing diagnostic services and completing the ‘test and treat’ loop. Objective: To address this knowledge gap, we traced the diagnostic journeys of patients with tuberculosis, diabetes, hypertension and typhoid, and examined the work they had to do to arrive at a diagnosis. Methods: This paper draws on a qualitative study, which included 78 semi-structured interviews and 13 focus group discussions with patients, public and private healthcare providers, community health workers, test manufacturers, laboratory technicians, program managers and policymakers. Data were collected between January and June 2013 in rural and urban Karnataka, South India, as part of a larger project on barriers to point-of-care testing. We reconstructed patient diagnostic processes retrospectively and analyzed emerging themes and patterns. Results: The journey to access diagnostic services requires a high level of involvement and immense work from patients and/or their caretakers. This process entails overcoming cost and distance, negotiating social relations, continuously making sense of their illness and diagnosis, producing and transporting samples, dealing with the social consequences of diagnosis, and returning results to the treating provider. The quality and content of interactions with providers were crucial for completion of test and treat loops. If the tasks became overwhelming, patients opted out, delayed being tested, switched providers and/or reverted to self-testing or self-treatment practices. Conclusion: Our study demonstrated how difficult it can be for patients to complete diagnostic journeys and how the health system works as far as diagnostics are concerned. If new point-of-care tests are to be implemented successfully, policymakers, program officers and test developers need to find ways to ease patient navigation through diagnostic services. [ABSTRACT FROM PUBLISHER]

India has been implementing active case-finding (ACF) for TB among marginalised and vulnerable (high-risk) populations since 2017. The effectiveness of ACF cycle(s) is dependent on the use of appropriate screening and diagnostic tools and meeting quality indicators. To determine the number of ACF cycles implemented in 2021 at national, state (n = 36) and district (n = 768) level and quality indicators for the first ACF cycle. In this descriptive study, aggregate TB program data for each ACF activity that was extracted was further aggregated against each ACF cycle at the district level in 2021. One ACF cycle was the period identified to cover all the high-risk populations in the district. Three TB ACF quality indicators were calculated: percentage population screened (≥10%), percentage tested among screened (≥4.8%) and percentage diagnosed among tested (≥5%). We also calculated the number needed to screen (NNS) for diagnosing one person with TB (≤1538). Of 768 TB districts, ACF data for 111 were not available. Of the remaining 657 districts, 642 (98%) implemented one, and 15 implemented two to three ACF cycles. None of the districts or states met all three TB ACF quality indicators' cut-offs. At the national level, for the first ACF cycle, 9.3% of the population were screened, 1% of the screened were tested and 3.7% of the tested were diagnosed. The NNS was 2824: acceptable (≤1538) in institutional facilities and poor for population-based groups. Data were not consistently available to calculate the percentage of i) high-risk population covered, ii) presumptive TB among screened and iii) tested among presumptive. In 2021, India implemented one ACF cycle with sub-optimal ACF quality indicators. Reducing the losses between screening and testing, improving data quality and sensitising stakeholders regarding the importance of meeting all ACF quality indicators are recommended. [ABSTRACT FROM AUTHOR]

Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates. We aimed to determine caesarean delivery rates at Bihar's first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates. This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018–March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates. Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0–10), 39% had an anaesthetist (range 0–5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0–4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9–55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1–1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3–1.9, p < 0.001) were associated with facility-level CD rates. Only 3.1% of the institutional childbirths in Bihar's FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar. [ABSTRACT FROM AUTHOR]

Background: The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices. Objectives: To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice. Methods: From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project's core activities and outcomes. Results: In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice. Conclusions: OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects. [ABSTRACT FROM AUTHOR]

Background: Schools can play an important role in health promotion by improving students’ health literacy, attitudes, health-related behaviours, social connection and self-efficacy. These interventions can be particularly valuable in low- and middle-income countries with low health literacy and high burden of disease. However, the existing literature provides poor guidance for the implementation of school-based interventions in low-resource settings. This paper describes the development and pilot testing of a multicomponent school-based health promotion intervention for adolescents in 75 government-run secondary schools in Bihar, India. Method: The intervention was developed in three stages: evidence review of the content and delivery of effective school health interventions; formative research to contextualize the proposed content and delivery, involving intervention development workshops with experts, teachers and students and content analysis of intervention manuals; and pilot testingin situto optimize its feasibility and acceptability. Results: The three-stage process defined the intervention elements, refining their content and format of delivery. This intervention focused on promoting social skills among adolescents, engaging adolescents in school decision making, providing factual information, and enhancing their problem-solving skills. Specific intervention strategies were delivered at three levels (whole school, student group, and individual counselling) by either a trained teacher or a lay counsellor. The pilot study, in 50 schools, demonstrated generally good acceptability and feasibility of the intervention, though the coverage of intervention activities was lower in the teacher delivery schools due to competing teaching commitments, the participation of male students was lower than that of females, and one school dropped out because of concerns regarding the reproductive and sexual health content of the intervention. Conclusion: This SEHER approach provides a framework for adolescent health promotion in secondary schools in low-resource settings. We are now using a cluster-randomized trial to evaluate its effectiveness and cost-effectiveness. [ABSTRACT FROM PUBLISHER]

Background: Knowledgeable in child development, primary school teachers in low- and middle-income countries (LMICs) have the potential to identify their students needing mental health care. Objective: We evaluated whether teachers in Darjeeling, India can accurately nominate school-aged children for mental health services after training and aided by a novel tool. Methods: In 2018, 19 primary school teachers from five low-cost private (LCP) schools in rural Darjeeling were trained to nominate children needing care. Teachers evaluated all of their students aided by a novel tool, 'Behavior Type and Severity Tool' (BTST), completed the Achenbach Teacher Report Form (TRF) as a mental health status reference standard, and nominated two students for care. Sensitivity and specificity of being nominated compared to TRF overall and subdomain scores were calculated. BTST performance was determined by comparing BTST and TRF scores and creating Receiver Operating Characteristic curves to determine optimal cutoffs. Multivariable regression models were used to identify demographic predictors of teacher accuracy using the BTST. Results: For students demonstrating a clinical or borderline score in at least one TRF subdomain, the sensitivity (72%) and specificity (62%) of teacher nomination were moderately high. BTST overall scores and TRF Total Problem scores were correlated (Spearman's ρ = 0.34, p < 0.0001), as were all subdomains. For the TRF Total Problem score, a maximum Youden's J of 0.39 occurred at BTST cutoff >4 for borderline struggles and 0.54 at the BTST cutoff >6 for clinical struggles. Younger teacher age, less education, less formal education training, and more years of experience were positively associated with teacher accuracy. Conclusions: With training and a simple decision support tool, primary school teachers in an LMIC nominated students for mental health services with moderate accuracy. With the BTST being weakly accurate, teachers' judgment largely accounted for the moderate accuracy of nominations. [ABSTRACT FROM AUTHOR]

A multiple-strategy community intervention, known as National Rural Health Mission (NRHM), launched in India to improve the availability of and access to better-quality healthcare, especially for rural, poor mothers and children. The final goal of the intervention is to reduce maternal and child health inequalities across geographical areas, socioeconomic status groups, and sex of the child. Extensive, in-depth research is necessary to assess the effectiveness of NRHM, on multiple outcome dimensions. This paper presents the design of a new study, able to overcome the shortcomings of previous research. To propose a comprehensive, methodologically sound protocol to assess the extent of implementation and the effectiveness of NRHM measures to improve maternal and child health outcomes and reduce maternal and child health inequalities. A mixed-methods approach (quantitative and qualitative) is proposed for this study in Haryana, a state in North India. NRHM's health sector plans included health system strengthening, specific maternal and child healthcare strategies, and communitization. Mission documents and reports on progress, financial monitoring, and common and joint review will be reviewed in-depth to assess the extent of the implementation of plans. Data on maternal and child health indicators will be obtained from demographic health surveys held before, during, and after the implementation of the first phase of the NRHM (2005–2012) and compared over time. Differences in maternal and child health indicators will be used to measure maternal and child health inequalities; these will be compared pre- and post-NRHM. Focus group discussions (FGDs) with service providers and in-depth interviews with program managers, community representatives, and mothers will be conducted until data saturation is achieved, in two districts of Haryana. Using Nvivo software, an inductive qualitative content analysis will be performed to search for the broader themes across the interviews and FGDs. Ethical approval was obtained from the Ethics Committee of the Post Graduate Institute of Medical Education and Research. [ABSTRACT FROM AUTHOR]

The graduates of the diploma and degree programmes of nursing and midwifery in India are considered skilled birth attendants (SBAs). This paper aimed to assess the confidence of final-year students from pre-service education programmes (diploma and bachelor's) in selected midwifery skills from the list of midwifery competencies of the International Confederation of Midwives (ICM). A cross-sectional survey was conducted in Gujarat, India, involving 633 final-year students from 25 educational institutions (private or government), randomly selected, stratified by the type of programme (diploma and bachelor's). Students assessed their confidence on a four-point scale, in four midwifery competency domains – antepartum, intrapartum, postpartum, and newborn care. Explorative factor analysis was used to reduce skill statements into separate subscales for each domain. Overall, 25–40% of students scored above the 75th percentile and 38–50% below the 50th percentile of confidence in all subscales for antepartum, intrapartum, postpartum, and newborn care. The majority had not attended the required number of births prescribed by the Indian Nursing Council. The pre-service education offered in the diploma and bachelor's programmes in Gujarat does not prepare confident SBAs, as measured on selected midwifery competencies of the ICM. One of the underlying reasons was less clinical experience during their education. The duration, content, and pedagogy of midwifery education within the integrated programmes need to be reviewed. [ABSTRACT FROM AUTHOR]

In-service nurse mentoring is increasingly seen as a way to strengthen the quality of health care in rural areas, where healthworkers are scarce. Despite this, the evidence base for designing large-scale programs remains relatively thin. In this capacity-building article, we reflect on the limited evidence that exists and introduce features of the world’s largest program, run by CARE-India since 2015. Detail on the mechanics of large-scale programs is often missing from empirical research studies, but is a crucial aspect of organizational learning and development. Moreover, by focusing on the complex ways in which capacity-building is being institutionalized through an embedded model of in-service mentorship, this article bridges research and practice. We point to a number of areas that require further research as well as considerations for program managers designing comparable workforce strengthening programs. With careful planning and cross-national policy learning, we propose that in-service nurse mentoring may offer a cost-effective and appropriate workforce development approach in a variety of settings. [ABSTRACT FROM AUTHOR]

Background: Delayed introduction of solid, semi-solid or soft foods (complementary feeding) and associated factors are related to stunting and severe stunting among children in many low- and middle-income countries. In India, however, there is limited evidence on the relationship between delayed complementary feeding and associated factors with stunting and severe stunting to advocate for policy interventions. Objectives: The present study investigated the relationship between delayed complementary feeding and associated factors with stunting and severe stunting among infants aged 6–8 months in India. Methods: Survey data on 13,548 infants aged 6–8 months were obtained from the 2015–16 National Family Health Survey in India. Logistic regression (Generalized Linear Latent and Mixed Models [GLLAMM] with a logit link and binomial family) models that adjusted for clustering and sampling weights were used to investigate the relationship between delayed complementary feeding and associated factors (community, household, maternal, child and health service factors) with stunting and severe stunting among infants aged 6–8 months in India. Results: The prevalence of stunting and severe stunting was 22.0% (95% CI: 21.0–23.7%) and 10.0% (95% CI: 9.0–11.0%) among infants aged 6–8 months who received no complementary foods, respectively. Delayed introduction of solid, semi-solid or soft foods was associated with stunting (adjusted Odd ratios [aOR] = 1.24, 95% CI: 1.09–1.41) and severe stunting (aOR = 1.21, 95% CI: 1.01–1.45) among infants aged 6–8 months. High maternal education (secondary or higher education) and household wealth (middle, richer and richest) were protective against stunting and severe stunting. Conclusion: Delayed introduction of complementary foods and associated factors were related to stunting and severe stunting among infants aged 6–8 months in India. Reducing the proportion of infants who are stunted in India would require comprehensive national nutrition policy actions that target the sub-population of mothers with no schooling and limited resources. [ABSTRACT FROM AUTHOR]

Background: Globally, opportunities to validate government reports through external audits are rare, notably in India. A cross-sectional maternal health study in Uttar Pradesh, India's most populous state, compares government administrative data and externally collected data on maternal health service indicators. Objectives: Our study aims to determine the level of concordance between government-reported health facility data compared to externally collected health facility data on the same maternal healthcare quality indicators. Second, our study aims to explore whether the level of agreement between government administrative data versus the externally collected data differs by level of facility or by type of maternal health service. Methods: Facility assessment surveys were administered to key health staff by government-hired enumerators from January 2017 to March 2017 at nearly 750 government health facilities across UP. The same survey was re-conducted by external data collectors from August 2017 to October 2017 at 40 of the same facilities. We conduct comparative analyses of the two datasets for agreement among the same measures of maternal healthcare quality. Results: The findings indicate concordance between most indicators across government administrative data and externally collected health facility data. However, when stratified by facility-level or service type, results suggest significant over-reporting in the government administrative data on indicators that are incentivized. This finding is consistent across all levels of facilities; however, the most significant disparities appear at higher-level facilities, namely District Hospitals. Conclusion: This study has a number of important programmatic and policy implications. Government administrative health data have the potential to be highly critical in informing large-scale quality improvements in maternal healthcare quality, but its credibility must be readily verifiable and accessible to politicians, researchers, funders, and most importantly, the public, to improve the overall health, patient experience, and well-being of women and newborns. [ABSTRACT FROM AUTHOR]

Background: Limited access to safe, timely banked blood is a critical barrier to providing basic surgical care in resource-limited settings globally. Contextual, locally driven data are required to elucidate country needs, develop effective interventions, and guide policy decisions. Objective: We employ qualitative methodology to describe barriers faced and solutions proposed by front-line obstetric providers in Bihar – a poor, populous Indian state where maternal mortality exceeds the national average. We aim to make locally driven recommendations for ongoing policy work in India to strengthen the country's blood transfusion system. Methods: From February to May 2016, two researchers conducted semi-structured interviews with 19 obstetric providers across Bihar. Snowball sampling was employed until thematic saturation was reached. Following immersion into de-identified texts and dual codebook development, a primary analyst completed topical coding, and a secondary analyst confirmed reproducibility. Results: Providers report that pervasive banked blood shortages force hospitals to require replacement donation, but patients' families often cannot or will not donate. Providers wait one to six hours for blood, depending on availability of staff and supplies, blood bank proximity, and the ability of the patient being treated to navigate the system. Providers feel forced to refer their patients, often to distant, poorly equipped centers. Providers identify donor education, improved infrastructure, and improved local coordination as focus areas for intervention. Conclusions: A multi-stakeholder approach that aims to increase blood donation through community education, mitigate limited infrastructure through short-term workarounds, and improve local-level coordination through state support and policy change is required in Bihar. This study generates data to guide policy and future research aimed at generating affordable, contextually appropriate interventions to the blood drought. [ABSTRACT FROM AUTHOR]

Background: The collaborative quality improvement approach proposed by the Institute for Healthcare Improvement has the potential to improve coverage of evidence-based maternal and newborn health practices. The Safe Care, Saving Lives initiative supported the implementation of 20 evidence-based maternal and newborn care practices, targeting labour wards and neonatal care units in 85 public and private hospitals in Telangana and Andhra Pradesh, India. Objective: We present a protocol for the evaluation of this programme which aims to (a) estimate the effect of the initiative on evidence-based care practices and mortality; (b) evaluate the mechanisms leading to changes in adherence to evidence-based practices, and their relationship with contextual factors; (c) explore the feasibility of scaling-up the approach. Methods: The mixed-method evaluation is based on a plausibility design nested within a phased implementation. The 29 non-randomly selected hospitals comprising wave II of the programme were compared to the 31 remaining hospitals where the quality improvement approach started later. We assessed mortality and adherence to evidence-based practices at baseline and endline using abstraction of registers, checklists, observations and interviews in intervention and comparison hospitals. We also explored the mechanisms and drivers of change in adherence to evidence-based practices. Qualitative methods investigated the mechanisms of change in purposefully selected case study hospitals. A readiness assessment complemented the analysis of what works and why. We used a difference-in-difference approach to estimate the effects of the intervention on mortality and coverage. Thematic analysis was used for the qualitative data. Discussion: This is the first quality improvement collaborative targeting neonatal health in secondary and tertiary hospitals in a middle-income country linked to a government health insurance scheme. Our process evaluation is theory driven and will refine hypotheses about how this quality improvement approach contributes to institutionalization of evidence-based practices. [ABSTRACT FROM AUTHOR]

Background: The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices. Objectives: To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice. Methods: From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project’s core activities and outcomes. Results: In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice. Conclusions: OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects.

Background: Public health research has gained increasing importance in India's national health policy as the country seeks to address the high burden of disease and its inequitable distribution, and embarks on an ambitious agenda towards universalising health care. Objective: This study aimed at describing the public health research output in India, its focus and distribution, and the actors involved in the research system. It makes recommendations for systematically promoting and strengthening public health research in the country. Design: The study was a bibliometric analysis of PubMed and IndMed databases for years 2000–2010. The bibliometric data were analysed in terms of biomedical focus based on the Global Burden of Disease, location of research, research institutions, and funding agencies. Results: A total of 7,893 eligible articles were identified over the 11-year search period. The annual research output increased by 42% between 2000 and 2010. In total, 60.8% of the articles were related to communicable diseases, newborn, maternal, and nutritional causes, comparing favourably with the burden of these causes (39.1%). While the burdens from non-communicable diseases and injuries were 50.2 and 10.7%, respectively, only 31.9 and 7.5% of articles reported research for these conditions. The north-eastern states and the Empowered-Action-Group states of India were the most under-represented for location of research. In total, 67.2% of papers involved international collaborations and 49.2% of these collaborations were with institutions in the UK or USA; 35.4% of the publications involved international funding and 71.2% of funders were located in the UK or USA. Conclusions: While public health research output in India has increased significantly, there are marked inequities in relation to the burden of disease and the geographic distribution of research. Systematic priority setting, adequate funding, and institutional capacity building are needed to address these inequities.

Background: A multiple-strategy community intervention, known as National Rural Health Mission (NRHM), launched in India to improve the availability of and access to better-quality healthcare, especially for rural, poor mothers and children. The final goal of the intervention is to reduce maternal and child health inequalities across geographical areas, socioeconomic status groups, and sex of the child. Extensive, in-depth research is necessary to assess the effectiveness of NRHM, on multiple outcome dimensions. This paper presents the design of a new study, able to overcome the shortcomings of previous research. Objective: To propose a comprehensive, methodologically sound protocol to assess the extent of implementation and the effectiveness of NRHM measures to improve maternal and child health outcomes and reduce maternal and child health inequalities. Design: A mixed-methods approach (quantitative and qualitative) is proposed for this study in Haryana, a state in North India. NRHM's health sector plans included health system strengthening, specific maternal and child healthcare strategies, and communitization. Mission documents and reports on progress, financial monitoring, and common and joint review will be reviewed in-depth to assess the extent of the implementation of plans. Data on maternal and child health indicators will be obtained from demographic health surveys held before, during, and after the implementation of the first phase of the NRHM (2005–2012) and compared over time. Differences in maternal and child health indicators will be used to measure maternal and child health inequalities; these will be compared pre- and post-NRHM. Focus group discussions (FGDs) with service providers and in-depth interviews with program managers, community representatives, and mothers will be conducted until data saturation is achieved, in two districts of Haryana. Using Nvivo software, an inductive qualitative content analysis will be performed to search for the broader themes across the interviews and FGDs. Ethical approval was obtained from the Ethics Committee of the Post Graduate Institute of Medical Education and Research.

Background: Heat stress is a major occupational problem in India that can cause adverse health effects and reduce work productivity. This paper explores this problem and its impacts in selected workplaces, including industrial, service, and agricultural sectors in Chennai, India. Design: Quantitative measurements of heat stress, workload estimations, and clothing testing, and qualitative information on health impacts, productivity loss, etc., were collected. Heat strain and associated impacts on labour productivity between the seasons were assessed using the International Standard ISO 7933:2004, which applies the Predicted Heat Strain (PHS) model. Results and conclusions: All workplaces surveyed had very high heat exposure in the hot season (Wet Bulb Globe Temperature x¯ =29.7), often reaching the international standard safe work values (ISO 7243:1989). Most workers had moderate to high workloads (170–220 W/m2), with some exposed to direct sun. Clothing was found to be problematic, with high insulation values in relation to the heat exposure. Females were found to be more vulnerable because of the extra insulation added from wearing a protective shirt on top of traditional clothing (0.96 clo) while working. When analysing heat strain – in terms of core temperature and dehydration – and associated productivity loss in the PHS model, the parameters showed significant impacts that affected productivity in all workplaces, apart from the laundry facility, especially during the hot season. For example, in the canteen, the core temperature limit of 38°C predicted by the model was reached in only 64 min for women. With the expected increases in temperature due to climate change, additional preventive actions have to be implemented to prevent further productivity losses and adverse health impacts. Overall, this study presented insight into using a thermo-physiological model to estimate productivity loss due to heat exposure in workplaces. This is the first time the PHS model has been used for this purpose. An exploratory approach was taken for further development of the model.

Background: Depending on a country’s diagnostic infrastructure, patients and providers play different roles in ensuring that correct and timely diagnosis is made. However, little is known about the work done by patients in accessing diagnostic services and completing the ‘test and treat’ loop. Objective: To address this knowledge gap, we traced the diagnostic journeys of patients with tuberculosis, diabetes, hypertension and typhoid, and examined the work they had to do to arrive at a diagnosis. Methods: This paper draws on a qualitative study, which included 78 semi-structured interviews and 13 focus group discussions with patients, public and private healthcare providers, community health workers, test manufacturers, laboratory technicians, program managers and policymakers. Data were collected between January and June 2013 in rural and urban Karnataka, South India, as part of a larger project on barriers to point-of-care testing. We reconstructed patient diagnostic processes retrospectively and analyzed emerging themes and patterns. Results: The journey to access diagnostic services requires a high level of involvement and immense work from patients and/or their caretakers. This process entails overcoming cost and distance, negotiating social relations, continuously making sense of their illness and diagnosis, producing and transporting samples, dealing with the social consequences of diagnosis, and returning results to the treating provider. The quality and content of interactions with providers were crucial for completion of test and treat loops. If the tasks became overwhelming, patients opted out, delayed being tested, switched providers and/or reverted to self-testing or self-treatment practices. Conclusion: Our study demonstrated how difficult it can be for patients to complete diagnostic journeys and how the health system works as far as diagnostics are concerned. If new point-of-care tests are to be implemented successfully, policymakers, program officers and test developers need to find ways to ease patient navigation through diagnostic services.

Background: Schools can play an important role in health promotion by improving students’ health literacy, attitudes, health-related behaviours, social connection and self-efficacy. These interventions can be particularly valuable in low- and middle-income countries with low health literacy and high burden of disease. However, the existing literature provides poor guidance for the implementation of school-based interventions in low-resource settings. This paper describes the development and pilot testing of a multicomponent school-based health promotion intervention for adolescents in 75 government-run secondary schools in Bihar, India. Method: The intervention was developed in three stages: evidence review of the content and delivery of effective school health interventions; formative research to contextualize the proposed content and delivery, involving intervention development workshops with experts, teachers and students and content analysis of intervention manuals; and pilot testing in situ to optimize its feasibility and acceptability. Results: The three-stage process defined the intervention elements, refining their content and format of delivery. This intervention focused on promoting social skills among adolescents, engaging adolescents in school decision making, providing factual information, and enhancing their problem-solving skills. Specific intervention strategies were delivered at three levels (whole school, student group, and individual counselling) by either a trained teacher or a lay counsellor. The pilot study, in 50 schools, demonstrated generally good acceptability and feasibility of the intervention, though the coverage of intervention activities was lower in the teacher delivery schools due to competing teaching commitments, the participation of male students was lower than that of females, and one school dropped out because of concerns regarding the reproductive and sexual health content of the intervention. Conclusion: This SEHER approach provides a framework for adolescent health promotion in secondary schools in low-resource settings. We are now using a cluster-randomized trial to evaluate its effectiveness and cost-effectiveness.

To fulfil its commitment to universal health coverage, it will be necessary for the Indian government to expand access to appropriate and affordable health services. Through the mechanism of microfinance-based self-help groups (SHGs), poor women and their families are provided not only with access to finance to improve their livelihoods but also, in many cases, with a range of basic health services. Governments and non-governmental organisations in India have implemented large-scale programmes for the promotion of SHGs. With 93 million people organised nationally, the SHGs provide an established population base that can potentially be used to extend health coverage. However, the potential for working with SHGs to improve people’s access to health services has not been an active part of the national policy discourse.​ [ABSTRACT FROM PUBLISHER]

Background: Persistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions. Objective: This study aimed to examine pregnant women's expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider's perceptions of the same, as well as the barriers that limit their ability to provide high-quality care. Methods: A qualitative descriptive analysis was conducted on data from two studies - focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women's experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016-17) to understand provision of person-centred care. Provider perspectives were matched with themes of women's perspectives on quality of childbirth care in facilities. Results: Major themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries. Conclusions: This study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers' perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes. [ABSTRACT FROM AUTHOR]

Background: In India, 50-65% of the population face difficulties in accessing medicines. The Health Impact Fund (HIF) is a novel proposal whereby pharmaceutical companies would be paid based on the measured global health impact of their drugs. We conducted a key stakeholder analysis to explore access to medicines in India, acceptability of the HIF and potential barriers and facilitators at policy level. Objectives: To conduct a stakeholder analysis of the HIF in India: to determine key stakeholder views regarding access to medicines in India; to evaluate acceptability of the HIF; and to assess potential barriers and facilitators to the HIF as a policy. Methods: In New Delhi, we conducted semi-structured interviews. There was purposive recruitment of participants with snowball sampling. Transcribed data were analysed using stakeholder analysis frameworks and directed content analysis. Results: Participation rate was 29% (14/49). 14 semi-structured interviews were conducted among stakeholders in New Delhi. All participants highlighted access to medicines as a problem in India. There were mixed views about the HIF in terms of relevance and scaleability. Stakeholders felt it should focus on diseases with limited or no market and potentially incorporate direct investment in research. Conclusions: First, access to medicines is perceived to be a major problem in India by all stakeholders, but affordability is just one factor. Second, stakeholders despite considerable support for the idea of the HIF, there are major concerns about scaleability, generalisability and impact on access to medicines. Third, the HIF and other novel drug-related health policies can afford to be more radical, e.g. working outside the existing intellectual property rights regime, targeting generic as well as branded drugs, or extending to research and development. Further innovations in access to medicines must involve country-specific key stakeholders in order to increase the likelihood of their success. [ABSTRACT FROM AUTHOR]

Access to facility delivery in India has significantly increased with the Janani Suraksha Yojana (JSY) cash transfer programme to promote facility births. However, a decline in maternal mortality has only followed secular trends as seen from the beginning of the decade well before the programme began. We, therefore, examined the quality of intrapartum care provided in facilities under the JSY programme to study whether it ensures skilled attendance at birth. 1) Non-participant observations (n=18) of intrapartum care during vaginal deliveries at a representative sample of 11 facilities in Madhya Pradesh to document what happens during intrapartum care. 2) Interviews (n=10) with providers to explore reasons for this care. Thematic framework analysis was used. Three themes emerged from the data: 1) delivery environment is chaotic: delivery rooms were not conducive to safe, women-friendly care provision, and coordination between providers was poor. 2) Staff do not provide skilled care routinely: this emerged from observations that monitoring was limited to assessment of cervical dilatation, lack of readiness to provide key elements of care, and the execution of harmful/unnecessary practices coupled with poor techniques. 3) Dominant staff, passive recipients: staff sometimes threatened, abused, or ignored women during delivery; women were passive and accepted dominance and disrespect. Attendants served as 'go-betweens' patients and providers. The interviews with providers revealed their awareness of the compromised quality of care, but they were constrained by structural problems. Positive practices were also observed, including companionship during childbirth and women mobilising in the early stages of labour. Our observational study did not suggest an adequate level of skilled birth attendance (SBA). The findings reveal insufficiencies in the health system and organisational structures to provide an 'enabling environment' for SBA. We highlight the need to ensure quality obstetric care prior to increasing coverage of facility births if cash transfer programmes like the JSY are to improve health outcomes. [ABSTRACT FROM AUTHOR]

Infections acquired during childbirth are a common cause of maternal and perinatal mortality and morbidity. Changing provider behaviour and organisational settings within the health system is key to reducing the spread of infection. To explore the opinions of health personnel on health system factors related to infection control and their perceptions of change in a sample of hospital maternity units. An organisational change process called 'appreciative inquiry' (AI) was introduced in three maternity units of hospitals in Gujarat, India. AI is a change process that builds on recognition of positive actions, behaviours, and attitudes. In-depth interviews were conducted with health personnel to elicit information on the environment within which they work, including physical and organisational factors, motivation, awareness, practices, perceptions of their role, and other health system factors related to infection control activities. Data were obtained from three hospitals which implemented AI and another three not involved in the intervention. Challenges which emerged included management processes (e.g. decision-making and problem-solving modalities), human resource shortages, and physical infrastructure (e.g. space, water, and electricity supplies). AI was perceived as having a positive influence on infection control practices. Respondents also said that management processes improved although some hospitals had already undergone an accreditation process which could have influenced the changes described. Participants reported that team relationships had been strengthened due to AI. Technical knowledge is often emphasised in health care settings and less attention is paid to factors such as team relationships, leadership, and problem solving. AI can contribute to improving infection control by catalysing and creating forums for team building, shared decision making and problem solving in an enabling environment. [ABSTRACT FROM AUTHOR]

Infectious disease surveillance has long been a challenge for countries like India, where 75% of the health care services are private and consist of both formal and informal health care providers. Infectious disease surveillance data are regularly collected from governmental and qualified private facilities, but not from the informal sector. This study describes a mobile-based syndromic surveillance system and its application in a resource-limited setting, collecting data on patients' symptoms from formal and informal health care providers. The study includes three formal and six informal health care providers from two districts of Madhya Pradesh, India. Data collectors were posted in the clinics during the providers' working hours and entered patient information and infectious disease symptoms on the mobile-based syndromic surveillance system. Information on 20,424 patients was collected in the mobile-based surveillance system. The five most common (overlapping) symptoms were fever (48%), cough (38%), body ache (38%), headache (37%), and runny nose (22%). During the same time period, the government's disease surveillance program reported around 22,000 fever cases in one district as a whole. Our data – from a very small fraction of all health care providers – thus highlight an enormous underreporting in the official surveillance data, which we estimate here to capture less than 1% of the fever cases. Additionally, we found that patients from more than 600 villages visited the nine providers included in our study. The study demonstrated that a mobile-based system can be used for disease surveillance from formal and informal providers in resource-limited settings. People who have not used smartphones or even computers previously can, in a short timeframe, be trained to fill out surveillance forms and submit them from the device. Technology, including network connections, works sufficiently for disease surveillance applications in rural parts of India. The data collected may be used to better understand the health-seeking behaviour of those visiting informal providers, as they do not report through any official channels. We also show that the underreporting to the government can be enormous. [ABSTRACT FROM AUTHOR]

Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens. Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the 'three delays' framework and were examined by using a human rights lens. All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility. The study highlighted various socio-cultural and service delivery–related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality. [ABSTRACT FROM AUTHOR]

Unsafe abortion contributes to a significant portion of maternal mortality in India. Access to safe abortion care is known to reduce maternal mortality. Availability and distribution of abortion care facilities can influence women's access to these services, especially in rural areas. To assess the availability and distribution of abortion care at facilities providing childbirth care in three districts of Madhya Pradesh (MP) province of India. Three socio demographically heterogeneous districts of MP were selected for this study. Facilities conducting at least 10 deliveries a month were surveyed to assess availability and provision of abortion services using UN signal functions for emergency obstetric care. Geographical Information System was used for visualisation of the distribution of facilities. The three districts had 99 facilities that conducted >10 deliveries a month: 74 in public and 25 in private sector. Overall, 48% of facilities reported an ability to provide safe surgical abortion service. Of public centres, 32% reported the ability compared to 100% among private centres while 18% of public centres and 77% of private centres had performed an abortion in the last 3 months. The availability of abortion services was higher at higher facility levels with better equipped and skilled personnel availability, in urban areas and in private sector facilities. Findings showed that availability of safe abortion care is limited especially in rural areas. More emphasis on providing safe abortion services, particularly at primary care level, is important to more significantly dent maternal mortality in India. [ABSTRACT FROM AUTHOR]