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Introduction: Double burden of malnutrition (DBM) has been recognized by the World Health Organisation (WHO) as an emerging Global Syndemic characterized by the simultaneous occurrence of both undernutrition and overnutrition. Women of the reproductive age group (15 to 49 years) are disproportionately affected by DBM and are at high risk of continuing the intergenerational cycle of malnutrition. This study aims to assess the changing trends and determinants of DBM among women of the reproductive age group in India. Materials and methods: We used data from three rounds of National Family Health Surveys (NFHS-3,4,5) conducted in years 2005–06, 2015–16, and 2019–2021. Descriptive statistics and Poisson regression analysis were done using weights with log link function. Results: The prevalence of anaemia, underweight and overweight/obesity was 57.2%, 18.6% and 24% respectively. The combined burden of underweight and anaemia has declined by 46% (21.6% to 11.7%), whereas the combined burden of overweight/obesity and anaemia has increased by 130% (5.4% to 12.4%) in the past 15 years. The prevalence of DBM, which includes both underweight and overweight/obesity with anaemia was 24.1% in 2021, a decline of 11% in 15 years. Women who were younger, rural, less educated, poor and middle class, and women living in the eastern, western and southern regions of India had higher risk for being underweight with anaemia and lower risk for developing overweight/obesity with anaemia. Conclusion: The significant decrease in underweight yet enormous increase in overweight/obesity over the past 15 years with the persistence of anaemia in both ends of the nutritional spectrum is characteristic of the new nutritional reality emphasizing the need to address malnutrition in all its forms. It is critical to consider geography and a population specific, double-duty targeted intervention to holistically address the risk factors associated with DBM and accomplish India's commitment to the global agenda of Sustainable Development Goals-2030. [ABSTRACT FROM AUTHOR]

Background: The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization's Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, "Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?", captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries. Methods and findings: We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15–49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures. Conclusions: Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings. [ABSTRACT FROM AUTHOR]

Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility. [ABSTRACT FROM AUTHOR]

Background: Globally by 2030, 38% of the world's population would be overweight, and another 20% would be obese. This has led to rising concerns regarding how swiftly and substantially the world is moving towards this epidemic of "globesity". India too is facing an increased burden of overweight and obese population. The changing dietary patterns are significantly associated with the increasing prevalence of overweight/obesity and related complications, especially among women. Hence, the present study aims to observe the spatial patterns of overweight or obesity among women in reproductive age group in India and factors associated with it. Methods: The study analyzed data from a cross-sectional nationwide household survey, i.e. National Family Health Survey (NFHS-4), 2015–16. The primary outcome variable of this study was overweight/obesity among reproductive-age women, which was measured through the body mass index (BMI) of the women. Bivariate and multivariate logistic regression analysis was used to analyze the data. Additionally, for spatial analysis in terms of overweight/obesity among women in India, univariate and bivariate Moran's I index measurements were used along with the usage of spatial regression models. Results: The value of spatial-autocorrelation for overweight or obese was 0.64, which depicts the moderately high prevalence of the overweight/obesity coverage over districts of India. The overall prevalence overweight/obesity among women in India is around 25% and higher proportion of women from urban areas (37.8%), and non-poor (33.4%) economic group reported to be overweight or obese. From spatial lag model, the lag coefficient was found to be 0.28, implying that a change in the prevalence of overweight/obesity among women in a certain district may statistically lag the prevalence of overweight/obesity by 28% in the neighbouring districts. There were significantly high clustering of overweight/obese women and non-poor wealth quintiles in 132 districts, mainly from states of Punjab, Haryana, Gujarat, Maharashtra, Kerala, Tamil Nadu, Karnataka and Andhra Pradesh. Additionally, there was high-high clustering of overweight/obese women and those who ever had caesarean in 82 districts, mostly from Kerala, Tamil Nadu, Andhra Pradesh and Karnataka. Conclusion: The spatial patterns on the prevalence of overweight and obesity in India show that the women belonging to the southern states' districts are more overweight or obese in comparison to other states. The determinants like older age, higher education, urban residence, higher economic status are the key factors contributing to the prevalence of overweight or obesity among women in the reproductive age group. The study concludes and recommends an urgent need of interventions catering to urban women belonging to higher socio-economic status, to reduce the risks of health consequences due to overweight and obesity. [ABSTRACT FROM AUTHOR]

Background: Anaemia is a serious global public health problem that disproportionally affects children, adolescent girls, and women of reproductive age, especially pregnant women. Women of reproductive age are more vulnerable to anaemia, particularly severe and moderate anaemia leads to adverse outcomes among pregnant women. Despite continuous Government efforts, anaemia burden still poses a serious challenge in India. The objective of this study is to assess the trends in prevalence and determinants of severe and moderate anaemia among women of reproductive age between 15 and 49 years. Method: We used three rounds of the large-scale National Family Health Survey (NFHS) India, conducted on a representative sample of households using a cross-sectional design across the country in 2005–06, 2015–16 and 2019–2021. We included all the women aged 15 to 49 years in our analysis. We used the same haemoglobin (Hb) cut-off values for all the three rounds of surveys to ensure comparability. Generalized linear regression analyses with log link were done. Survey weights were incorporated in the analysis. Results: The prevalence of severe or moderate Anaemia (SMA) in non-pregnant women was 14.20%, 12.43% and 13.98%; it was 31.11%, 25.98% and 26.66% for pregnant women in 2006, 2016 and 2021 respectively. The decline in SMA prevalence was 1.54% in non-pregnant women, whereas it was 14.30% in pregnant women in 15 years. Women who were poor, and without any formal education had a higher risk for severe and moderate Anaemia. Conclusion: Despite the intensive anaemia control program in India, SMA has not declined appreciably in non-pregnant women during the last two decades. Despite the decline, the prevalence of SMA was about 26% in pregnant women which calls for a comprehensive review of the existing anaemia control programmes and there must be targeted programmes for the most vulnerable and high-risk women such as rural, poor and illiterate women of reproductive age to reduce the burden of anaemia among them. [ABSTRACT FROM AUTHOR]

Background: A global midwifery shortage hampers the goal of ending preventable maternal/newborn mortality and stillbirths. Whether current measures of midwifery workforce adequacy are valid is unknown. We compare two measures of density and distribution of midwifery professionals to assess their consistency, and explore how incorporating midwifery scope, competency, and the adjusting reference population impacts this critical metric. Methods and findings: We collected a census of midwives employed in eligible facilities in our study settings, (422 in Ghana; 909 in India), assessed the number practicing within the scope of work for midwifery professionals defined in the International Labor Organization International Standard Classification of Occupations, and whether they reported possessing the ICM essential competencies for basic midwifery practice. We altered the numerator, iteratively narrowing it from a simple count to include data on scope of practice and competency and reported changes in value. We altered the denominator by calculating the number of midwives per 10,000 total population, women of reproductive age, pregnancies, and births and explored variation in the indicator. Across four districts in Ghana, density of midwives decreased from 8.59/10,000 total population when counting midwives from facility staffing rosters to 1.30/10,000 total population when including only fully competent midwives by the ICM standard. In India, no midwives met the standard, thus the midwifery density of 1.37/10,000 total population from staffing rosters reduced to 0.00 considering competency. Changing the denominator to births vastly altered subnational measures, ranging from ~1700% change in Tolon to ~8700% in Thiruvallur. Conclusion: Our study shows that varying underlying parameters significantly affects the value of the estimate. Factoring in competency greatly impacts the effective coverage of midwifery professionals. Disproportionate differences were noted when need was estimated based on total population versus births. Future research should compare various estimates of midwifery density to health system process and outcome measures. [ABSTRACT FROM AUTHOR]

Between 1990 and 2016 the number of adolescents with anemia world-wide increased by 20% to almost one in four. Iron deficiency in adolescence results in compromised growth, decreased cognitive function, and depressed immune function, and can increase the risk of negative outcomes in pregnancy, especially in the case of young adolescents. In India, despite several decades of governmental investment in anemia prevention and treatment, more than half of women of reproductive age are anemic, with rates even higher in the adolescent population. Although awareness of adolescence as a nutrition-sensitive developmental stage is increasing, there is a lack of qualitative research on the perspectives of adolescents and families on anemia and related services. In this study, we explored the issues influencing adolescents' awareness of anemia in three rural areas of Karnataka. Sixty-four in-depth interviews and six focus group discussions were conducted with adolescents (those who had never been pregnant, pregnant adolescents, and young mothers), community members, and nutrition-related service providers in the health and education sectors. An inductive analytical approach was used. We found that adolescent girls, particularly those who have not experienced pregnancy or motherhood, had very low awareness of anemia. State programs including school-based distribution of iron and folic acid supplements and nutrition talks were not seen to be resulting in knowledge and acceptance of the importance of preventing anemia. Pregnancy represents a turning point in which adolescents are systematically tested for anemia as part of routine antenatal care, increasing their awareness of, and access to, treatment for the condition. At the same time, pregnancy represents to family and community a period to insist on a nutritious diet. For progress in anemia reduction to be made, improved age-appropriate measures specific for adolescence are required. Improving school-based nutrition outreach is an important opportunity to reach adolescents. [ABSTRACT FROM AUTHOR]

Background: The common cause of anemia in the general population is iron deficiency. Anemia is adversely affecting women of reproductive age and child health which in turn results in increased morbidity and maternal death, and also hamper social-economic growth. Reproductive women are more prone to anemia due to inadequate dietary intake and iron loss during menstruation and pregnancy. Objectives: This study examined the level and trend of anemia prevalence among the socially disadvantaged group (SC&ST, OBC) of women as compared to the other women (general) and identified the main responsible factors behind this. Data and methods: The data for this analysis has been taken from three rounds of National Family Health Survey (NFHS) conducted during 2005–2006 (NFHS 3), 2015–16 (NFHS 4) and 2019–21 (NFHS 5). Univariate and bivariate analyses were used to assess the level of anemia among reproductive age group women of different social groups. The regression model represents the relative risk of different confounding factors on the occurrence of anemia. GIS technique used for graphical representation of anemia prevalence rate among different social groups of women in different states of India. Result: In India more than 15 states belong to the high prevalence (>%55) of anemia among socially backward groups in 2019–21. The anemia prevalence was high (>55%) in all social groups (SC & ST, OBC, general) observed in 7 states in NFHS-3, 4 in NFHS-4 and 11 states in NFHS-5. The overall result reveals that the SC&ST women were more prone to any anemia than OBC and general women and the prevalence rate slightly increased from 2005–06 to 2019–21. Among all variables, economic status dominantly controls the anemia level in all social groups. Anemia prevalence of the poor and poorest group of general women were much worse than the women of richer and richest groups of SC&ST, OBC. The odds of women having anemia were lower among higher educated and urban women as compared to the non educated and rural women, irrespective of social group. The prevalence of anemia decreases with increased age of women and increases with the number of child bearing. All differences were statistically significant. Conclusions: The problem of iron deficiency remains a major issue in India, where the majority of the states (eastern, north-eastern and central) suffer from high anemia prevalence rate and it increases over time. It is observed that multiple socio-demographic factors ranging from poor economic and educational status, rural residence to higher childbearing of women are responsible for predicting anemia levels among the social groups of women in India. To eradicate this problem India should improve women's overall nutrition status and their income. Meanwhile, GOI should be more focused on the existing policies related to anemia and on their actual implementation on grassroots level. [ABSTRACT FROM AUTHOR]

Background: More than half of women of reproductive age in India have anemia. Over the last decade, India has made some progress towards reducing anemia in pregnant women, but non-pregnant women, who make up the largest sub group of people with anemia, are largely disregarded. Objectives: The objective of this paper is to examine intentions to take iron supplements and factors associated with intentions to inform a social norms-based behavioral intervention to increase uptake of iron supplements and reduce anemia in Odisha, India. Methods: We collected data from 3,914 randomly sampled non-pregnant women of reproductive age in 81 villages. We conducted a survey and took hemocue (anemia level) readings from each participant. We analyzed data using linear regression models beginning with demographics and social norms and adding other factors such as self-efficacy to take iron supplements, anemia risk perception, and knowledge about anemia in a subsequent model. Results: 63% of women in our sample were anemic but less than 5% knew they were anemic. Despite national guidelines that all women of reproductive age should take weekly iron supplements to prevent anemia, less than 3% of women in our sample were currently taking them. While actual use was low, intentions were rather high. On a five point Likert scale where higher numbers meant more intentions to take supplements, average intentions were above the midpoint (M = 3.48, SD = 1.27) and intentions and iron supplement use were significantly correlated (r =.10, p <.001). Both injunctive norms and collective norms were associated with intentions to take iron supplements but descriptive norms were not. Other significant factors included age, breastfeeding, knowledge, self-efficacy, and outcome expectations. The final model accounted for 74% of the variance in iron supplement intentions. Conclusions: In this context, where the actual behavior is low but intentions to enact the behavior are high, starting an intervention with injunctive norms messaging (expectations around the behavior) and self-efficacy to enact the behavior is the step we recommend based on our results. As an intervention unfolds and iron supplement use increases, descriptive norms messaging (that people are indeed taking iron supplements) may add value. [ABSTRACT FROM AUTHOR]