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Background: Health care services express social and structural inequalities, especially for Dalits and women, due to the indignity and discrimination experienced in health care facilities. Jagrutha Mahila Sanghatane (JMS), a grass-roots organization led by neo-literate Dalit women in rural Karnataka in India, adopted a human rights-based social accountability (SA) approach to address discrimination and dignity in accessing maternal health services. This approach integrated community-based evidence with multi-pronged and multi-level accountability processes with their goal of socio-political empowerment., Methods: The methodological approach is qualitative and uses document analysis, including thematic and content analysis, in-depth group discussions with the campaign leaders, participant observation and interviews with the community health workers., Results: JMS embedded the practice and processes of SA in the politics of empowerment which was central to addressing the structural issues of discrimination and social exclusion faced by Dalit women. The human rights perspective and the pathway of conscientize-organize-struggle provided by the Dalit liberation leader, Dr B. R. Ambedkar, facilitated the organization to conceptualize SA as a process of claiming dignity and justice for Dalit women. Integrating the evidence generation and its deployment into the community campaign cycles, Dalit women could use the accountability process for intensifying mobilization and empowerment. The cumulative impact of the community enquiry relentlessly pursued through the framework of a campaign brought changes in several aspects of primary health care and specific dimensions of maternal health care. Community ownership of the SA process, participation and empowerment were integral to the generation, synthesis and deploying of evidence. Deploying evidence in multiple forms, both horizontally with the communities and vertically with the authorities deepened communities' mobilization and intensified Dalit women's negotiating power with the authorities. The iterative and persistent process of SA provides insights into re-articulating SA beyond the usual recognition of outputs such as report cards into the politics of meaning-making by the mobilized community of the marginalized. The community-based organization posited the SA itself as the process of resistance to structural injustice and as an avenue or their empowerment., Conclusions: For marginalized communities, the SA process has the potential to be a tool for their empowerment in addressing structural power inequities. For such a repositioning of SA, it is critical to focus not only on the technicality of generating evidence but also on the framework driving such a process, the mode of evidence generation and deployment, and integration into the organizational strategy. Such a process can be equally empowering, efficient in addressing the systemic challenges of increasing marginalized community's access to health care services, and valuable in sustaining those changes. The analysis of the strategies of JMS offers significant insights for researchers and practitioners working on SA and maternal health to re-articulate SA from the point of politics of empowerment of the marginalized communities., (© 2022. The Author(s).)

The maternity benefit scheme piloted as Indira Gandhi Matritva Sahyog Yojana (IGMSY) since 2011 and recently rolled out as Pradhan Mantri Matru Vandana Yojana (PMMVY) incentivizes mothers to participate in infant health-promoting activities. It has become India's largest conditional cash transfer program ever, outrivaling the country's first-generation maternity benefit scheme Janani Suraksha Yojana (JSY), which incentivizes institutional delivery and has been criticized for its unintended side effects on fertility. We approach IGMSY's geographically targeted pilot phase as a natural experiment and use data from a large national health survey to estimate its effects by a matched-pair difference-in-differences approach. Consistent with the program's conditions, we find increases in infant immunization. As side effect, long-term utilization of public health facilities becomes more frequent and intervals between eligible births increase by 17%. Our findings suggest that India'ns second-generation maternity benefit scheme has been more carefully designed than its predecessor, with side effects that support the program's broader objectives. But both direct and indirect effects are small and can make only a small contribution to redressing India's dismal maternal and child health record., (© 2021 The Authors. Health Economics published by John Wiley & Sons Ltd.)

To review the available evidence about the prevalence and determinants of antenatal common mental disorders (antenatal CMDs) among women in India. We searched Ovid Medline, Embase and Psyinfo systematically from date of inception to Oct. 31, 2019 for publications in English language on the prevalence of antenatal CMDs and their determinants among women in India. All study designs were included. Quality was assessed with Standard Quality Assessment Criteria for Evaluating Primary Research Papers. We performed a meta-analysis using a random effects model. Twenty-seven studies involving 7780 women were analysed. There was a high degree of heterogeneity ((I 2  = 97.53%). Publication bias [Egger bias = 0.65 (95% CI: 0.36; .94)] was evident. The overall pooled estimate of the prevalence of antenatal CMDs was 21.87% (95% CI: 17.46; 26.29). Significant risk factors reported in the 18 studies which examined them were negative reaction of husband or in-laws to the dowry, difficult relationship with husband/in-laws, lack of support or experiencing violence perpetrated by an intimate partner and preference for or feeling pressured to have a male child. Protective factors were having more education and being employed, having a supportive husband and opportunities for recreation during pregnancy. Antenatal CMDs are highly prevalent among women in India. There is an urgent need for locally developed policies and programmes for mental health promotion during pregnancy, preventive and early intervention for antenatal CMDs among women to be integrated into maternity care in India.

The present paper explores the cultural context of maternal and child health (MCH) care practices and beliefs of Irula tribes. It identifies the factors and analyses the pattern of their domiciliary deliveries and neonatal care among Irula, which is one of the PVTGs (Particularly Vulnerable Tribal Groups) in Tamil Nadu. The paper adopted a descriptive research design based on the pilot survey and ethnographic fieldwork. It examines the health care beliefs and practices relating to maternal and neonatal care connected with a holistic view of the Irula community's cultural dimensions. The paper also demonstrates the factors for domiciliary deliveries, non-utilization of prevailing state's health interventions, and incentives for maternal and child health care services among the Irulas. Keeping in view the aforementioned argument, an empirical study was carried out in six Irular settlements of Villupuram district in Tamil Nadu. [ABSTRACT FROM AUTHOR]

Background: Utilization of maternal healthcare services has a direct bearing on maternal mortality but is contingent on a wide range of socioeconomic factors, including the sex of the household head. This paper studies the role of the sex of the household head in the utilization of maternal healthcare services in India using data from the National Family Health Survey-V (2019-2021)., Methods: The outcome variable of this study is maternal healthcare service utilization. To that end, we consider three types of maternal healthcare services: antenatal care, skilled birth assistance, and postnatal care to measure the utilization of maternal healthcare service utilization. The explanatory variable is the sex of the household head and we control for specific characteristics at the individual level, household-head level, household level and spouse level. We then incorporate a bivariate logistic regression on the variables of interest., Results: 24.25% of women from male-headed households have complete utilization of maternal healthcare services while this proportion for women from female-headed households stands at 22.39%. The results from the bivariate logistic regression confirm the significant impact that the sex of the household head has on the utilization of maternal healthcare services in India. It is observed that women from female-headed households in India are 19% (AOR, 0.81; 95% CI: 0.63,1.03) less likely to utilize these services than those from male-headed households. Moreover with higher levels of education, there is a 25% (AOR, 1.25; 95% CI: 1.08,1.44) greater likelihood of utilizing maternal healthcare services. Residence in urban areas, improved wealth quintiles and access to healthcare facilities significantly increases the chances of maternal healthcare utilization. The interaction term between the sex of the household head and the wealth quintile the household belongs to, (AOR, 1.39; 95% CI: 1.02, 1.89) shows that the utilization of maternal healthcare services improves when the wealth quintile of the household improves., Conclusion: The results throw light on the fact that the added expenditure on maternal healthcare services exacerbates the existing financial burden for the economically vulnerable female-headed households. This necessitates the concentration of research and policy attention to alleviate these households from the sexual and reproductive health distresses., Trial Registration: Not Applicable., Jel Classification: D10, I12, J16., (© 2024. The Author(s).)

Obstetric anaesthesiologists play a pivotal role as peripartum physicians steering the team of obstetric healthcare providers towards a continuum of medical education, enhanced training and safer patient care. However, in resource-limited countries, deficiency of human resources and hence services available poses challenges to those attempting to reduce maternal mortality rates. Measures to fill the gap include creating a cadre of uniformly well-trained and certified non-physician anaesthesia providers (NPAPs) supervised by a physician obstetric anaesthesiologist and well-equipped rural and urban health care facilities. The Association of Obstetric Anaesthesiologists of India needs to upscale their outreach programs with regular knowledge updates and practical skill training to the NPAPs, medical graduates and postgraduate doctors in these regions. A combination of strong local administrative will, legislation for the provision of essential supplies and a global collaborative effort using checklists and protocols may help to stem gaps in the provision of safe maternal care., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Community engagement is gaining prominence in global health research. But communities rarely have a say in the agendas or conduct of the very health research projects that aim to help them. This paper provides new evidence on how to share power in priority-setting in ways that seek to overcome structural constraints created by the funding environment. The five strategies were identified through case study research on the Participation for Local Action project in Karnataka, India. That project was carried out by researchers in partnership with the Zilla Budakattu Girijana Abhivrudhhi Sangha, an indigenous community development organisation representing the Solega people. The paper describes each identified strategy for sharing power in priority-setting, followed by a report of the pitfalls and challenges that arose when implementing it. Thus, the study also demonstrates that even where actions and strategies are used to address power imbalances, pitfalls will arise that need to be navigated. Given those challenges, considerations to reflect upon before employing the identified strategies are suggested. Ultimately, the paper aims to communicate strategies for sharing power during and after priority-setting and lessons on how to implement them effectively that can be used by global health researchers in the current funding environment. [ABSTRACT FROM AUTHOR]

Purpose: This paper aims to understand the maternal health vulnerabilities of migrant women in slums and explore their challenges during and after childbirth. Design/methodology/approach: The study used a qualitative approach, including in-depth interviews through purposive and snowball sampling techniques. Thematic analysis was used for analysing data. The consolidated criteria for reporting qualitative studies (COREQ)-32 items were followed for reporting this study. Findings: The study found that migrant women were highly susceptible to adverse birthing outcomes due to risks involved in birthing, lack of care and hygiene, lack of skilled care in dealing with complicated pregnancies and exposure to domestic and obstetric violence. Originality/value: The study intends to highlight the narratives of female migrants' birthing and maternal health challenges. The entire process of childbirth in slums with consequences can result in maternal and infant morbidities and mortalities. [ABSTRACT FROM AUTHOR]

Background: The importance of reading and comprehending short stories has been focused by many experts, particularly those who work in English as a second or foreign language (ESL) and (EFL). There has been a significant amount of investigation on how effectively employing brief narratives might aid ESL students' instruction. Aim: Many educators and researchers have been looking into more efficient approaches to assisting pupils in realizing their full academic potential as qualified readers. They support the idea that it would be beneficial to add literary works into language education, and they believe this would be beneficial. Suppose students of English as a second language (ESL) are taught literature in general and short stories in particular, effectively by ESL instructors. In that case, ESL and EFL students may get various benefits. Short tales, in particular, may be very beneficial. Method: Several databases have been utilized to search current research. Seventeen relevant papers were selected for evaluation on this topic. They were investigated extensively, and the results were conveyed normatively. Findings: This review paper summarizes the publications' most significant results and explains that short stories may be convincing to enhance vocabulary, self-motivated, and professionalism; this study's goal was to understand better how reading brief stories by students affected their comprehension processes. At the same time, they are correctly chosen and taught. The recommendation is obtained from the review, summarizing the most significant to applying ESL and EFL classes. [ABSTRACT FROM AUTHOR]

Background: The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care., Methods: Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience., Results: The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%)., Conclusion: While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification., (© 2023. The Author(s).)

Existing scholarship on the Emergency’s sterilisation programme largely excludes women’s experiences, echoing the Shah Commission of Inquiry’s focus on men’s complaints against the government in its published reports. This paper re-orients historical understandings of this programme to account for female sterilisation during 1975–1977. By reading the Commission’s extensive collection of archived files against the grain, I use the male-dominated archive to illuminate the gendered nature of this policy and its effects on India’s women. Against dominant perceptions that the Emergency’s sterilisation programme focused entirely on vasectomy, this paper discusses instances where women were critical in families’ attempts to negotiate the regime’s coercive measures. It also analyses the negative impacts of coercion on the ‘girl child’ and the consequences of the Emergency’s single minded focus on sterilisation for the Mother and Child Health programme. Through these discussions I argue that such measures exacerbated existing gendered biases. In doing so, this paper challenges dominant understandings of the Emergency’s sterilisation programme and explores women’s experiences. [ABSTRACT FROM AUTHOR]

Background: In spite of considerable improvement in maternal and neonatal outcomes over the past decade in India, the current maternal mortality ratio and neonatal mortality rate are far from the Sustainable Development Goal targets due to suboptimal quality of maternity care. A package of interventions for improving quality of intrapartum and immediate postpartum care was co-designed with the Ministry of Health as the Dakshata program and implemented in public sector health facilities in selected districts in the state of Rajasthan of India since June 2015. This article describes the key strategies, interventions, results and challenges from four years of Dakshata program implementation., Methods: We have conducted secondary analysis of program data (government data) collected from 202 public facilities across 20 districts of Rajasthan state. The data collected between June-August 2015 (baseline) and the data collected between May-August 2019 (latest) were analyzed. The data sources included: facility assessments, service statistics, monthly progress reports., Results: During the period of program implementation, there were 17,94,249 deliveries accounting for 70% of institutional deliveries in intervention districts. As a result of the intervention, there was a notable increase in competency of health care providers, availability of essential resources, achievement of labour room standards and adherence to evidence-based clinical standards. We also observed reductions in the proportion of referrals for pre-eclampsia/eclampsia, postpartum hemorrhage and neonatal asphyxia by 11, 8 and 3 percentage points respectively. Similarly, data revealed a reduction in stillbirth rates in Dakshata intervention facilities (19.3 vs 15.3) compared to non-Dakshata facilities (21.8 vs 18)., Conclusions: Our experience and findings indicate that the quality of intrapartum and immediate postpartum care can be improved in low- and middle-income countries with the approach presented in this paper., (© 2022. The Author(s).)

Background: Utilisation of continuum of maternal health care services is crucial for a healthy pregnancy and childbirth and plays an important role in attaining Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) related to maternal and child health. This paper aims to assess the percentage of dropouts across various stages of utilization of continuum of maternal health services (CMHS) in India and also investigates the factors hindering the utilization of these services., Methods: We used recent data from National Family Health Survey(NFHS) encompassing a total sample of 1,70,937 pregnant women for the period 2015-16. The percentage of women dropping out while seeking maternal health care is measured using descriptive statistics. While, the factors impeding the utilization of maternal health services is estimated using a Multinomial Logistic Regression Model, where dependent variable (CMHS) is defined as complete care, incomplete care and no care., Results: Only17% of pregnant women availed the utilisation of complete care and 83% either did not seek any care or dropped after seeking one or two services. For instance, it is found that 79% of women who registered for antenatal care services (ANC) did not avail the same adequately. An empirical investigation of determinants of inadequate utilization of CMHS revealed that factors like individual characteristics, for instance- access to media (RRR: 2.06) and mother's education play (RRR: 3.61) a vital role in the uptake of CMHS. It is also found that the interaction between wealth index and place of residence plays a pivotal role in seeking complete care. Lastly, the results revealed that male participation (RRR: 2.69) and contacting multi-purpose worker (MPW) (RRR: 2.33) are also at play., Conclusion: The study suggests that the major determinants of utilisation of CMHS are access to media, mother's education, affordability barriers and male participation. Hence, policy recommendations should be oriented towards strengthening these dimensions and the utilisation of adequate ANC has to be considered as the need of the hour., (© 2022. The Author(s).)

Background: Maternal healthcare service utilization is a pivotal indicator of a nation's progress in safeguarding the health and well-being of its women and children. In this context, women's empowerment emerges as a critical determinant influencing the utilization of maternal healthcare services. The study aims to assess the relationship between women's level of empowerment and utilization of maternal healthcare services among currently married women in India. Data and Methods: The study uses data from the fifth round of the National Family Health Survey conducted in 2019–2021 and analyzed 26,552 (15–49 aged) currently married women who had a live birth in the last 5 years preceding the survey. Additionally, univariate and bivariate analyses, multivariate logistic regression, and the SWPER index were used for the analysis. Results: Over the years, utilization of antenatal care, skilled birth attainment, and postnatal care has increased extensively in India. However, the study found that utilization of services was higher among empowered women, and it varies across the state with the extent of empowerment. State-level analysis shows that the extent of women empowerment was higher in Goa, followed by Tamil Nadu and Kerala, and lower in Jharkhand, followed by Tripura, so as the utilization of maternal and health care services. The extent of empowerment and utilization of services also varies by level of educational attainment, employment, and socio-economic status. Conclusion: There is a need for comprehensive strategies to enhance women's empowerment through education, employment, political participation, self-awareness, and reduction in gender-based violence and child marriages, which may improve awareness demand for better public health structure, and may ensure higher utilization of maternal healthcare services. Ultimately, these strategies may converse the higher maternal death and child mortality. Significance: What is already known about this subject? Existing literature in India mostly highlights a clear connection between women's autonomy and maternal healthcare services utilization. Women with higher autonomy, decision-making power, and mobility are more likely to use these services. However, in exploring the link between women's empowerment and maternal healthcare, some studies focus on education, employment, and media access among Indian mothers, sidelining broader empowerment dimensions. What this study adds? This study is likely the first to investigate the relationship between women's empowerment and the level of maternal healthcare service utilization in India. It covers key dimensions of women's empowerment, including Attitude to Violence, Social Independence, and Decision-making Power. Moreover, it is possibly the first Indian research paper to employ a survey-based women's empowerment index in this context. Notably, the assessment highlights Social Independence as a significant dimension. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase). Methods: In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness. Discussion: Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally. Trial registration: CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022). Plain language summary: The new WHO Labour Care Guide (LCG) is an innovative partograph that emphasises women-centred, evidence-based care during labour and childbirth. Together with clinicians working at four hospitals in India, we will develop and test a strategy to implement the LCG into routine care in labour wards of these hospitals. We will use a randomised trial design where this LCG strategy is introduced sequentially in each of the four hospitals, in a random order. We will collect data on all women giving birth and their newborns during this period and analyse whether the LCG strategy has any effects on the use of Caesarean section, women's and newborn's health outcomes, and women's experiences during labour and childbirth. While the trial is being conducted, we will also collect qualitative and quantitative data from doctors, nurses and midwives working in these hospitals, to understand their perspectives and experiences of using the LCG in their day-to-day work. In addition, we will collect economic data to understand how much the LCG strategy costs, and how much money it might save if it is effective. Through this study, our international collaboration will generate critical evidence and innovative tools to support implementation of the LCG in other countries. [ABSTRACT FROM AUTHOR]

Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country‐specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community‐level activities were essential for complementing facility‐based services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts. Key messages: Integrating evidence‐based nutrition interventions into ANC to reach PW at scale is urgently needed for improving maternal and newborn health and nutrition.The Theory of Change and steps for strengthening nutrition interventions based on four‐country experiences provide practical guidance on addressing missed opportunities for nutrition in ANC.Strategic use of data can contextualize global maternal nutrition guidelines, protocols, capacity building and supervision approaches, and improve micronutrient supply chains and record‐keeping as part of health services strengthening.Engaging family and community members to support PW and improving the knowledge and self‐confidence of PW are important elements of all country programme models. [ABSTRACT FROM AUTHOR]

This paper examines the effect of maternal healthcare utilization on early neonatal, neonatal and post-neonatal mortality in India using the recent round of National Family Health Survey (NFHS-4) data. At the national level, for the last live birth of women during the five year preceding the survey, the early neonatal mortality rate was about 16, neonatal mortality rate was 19 and post-neonatal mortality was 7 per thousand live births. Also, only one-fifth of women who had a birth in the past five years received full antenatal care (ANC), 83 percent women received safe delivery and 65 percent women received post-natal care. Findings of the study indicate that full ANC and postnatal care were significantly associated with early neonatal and neonatal mortality. However, no significant association between safe delivery and newborn mortality were found after adjusting the socio-economic and demographic characteristics. Therefore, for a policy point of view, there is a dire need to strengthen supply dependent factors regarding public awareness, accessibility, and affordability of maternal and child healthcare services. It is also necessary to focus on increasing utilization along with continuum of care of maternal and child healthcare services to sustain the reduction in mortality during infancy. [ABSTRACT FROM AUTHOR]

Background: In 2001, India prioritized eight most socioeconomically disadvantaged states known as Empowered Action Group (EAG) states and in 2013, it prioritized 190 of the 718 as high priority districts (HPDs) to accelerate the decline in maternal and newborn mortality. This paper assesses whether the HPDs achieved a greater coverage of maternal and newborn health interventions than the non-HPDs and HPDs in EAG states achieved greater coverage than those in non-EAG states.Methods: We used data from the Sample Registration System to assess rural neonatal mortality trends in EAG states and all India. We computed a co-coverage index based on seven maternal and newborn health interventions from the 2015/16 National Family Health Survey. Difference in differences (DID) analyses were used to examine the contribution of district prioritization, considering the HPDs and the illiterate as treatment groups and 2013 as the time cut-off for the pre- and post-treatment.Results: Neonatal mortality declined in rural India from 36 to 27 per 1000 live births during 2010-2016 at 4.5% per year. Four EAG states experienced faster rates of decline than the national rate. From 2013, the co-coverage index increased significantly more in the HPDs compared to non-HPDs (DID = 0.11, P ≤ 0.005). The district prioritization effect on co-coverage was statistically significant in only EAG states (DID = 0.13, P ≤ 0.05). The coverage gains for illiterate mothers were greater than for literate mothers, especially in the HPDs.Conclusions: The district prioritization in India is associated with greater improvements in the coverage of maternal and newborn health services in EAG states and the HPDs, including reductions in inequalities within those states and districts. There are however still large gaps between states and districts and within districts by the mother's literacy status that need further prioritization to make progress towards the SDG targets by 2030. [ABSTRACT FROM AUTHOR]

Unsafe Abortion is prevalent practice and a major challenge to maternal health in India. The process of termination of unintended pregnancy by unauthorized and unskilled people in an environment which does not comply with the minimal medical and hygienic standards is defined as 'Unsafe abortion' by the World Health Organization. With more than 5.6 million abortion instances being reported worldwide and around 15.6 million in India, unsafe abortion is resulting in approximately 830 women death every day globally and 13 women death in India. On the contrary. India is one among the very few countries to have passed the Medical Termination of Pregnancy (MTP) Act in 1971 which empowers women to legally seek abortion to preserve her physical and mental health, for economic or social reasons, and in cases of rape, foetal impairment, or when pregnancy results from contraceptive failure. Further amendments in 2002 and 2003 aimed at extending abortion service regulations applicable to districts, changing physical requirements for facilities providing first trimester abortions in India. My research paper is an attempt to establish the prevalent ignorance in relation to maternal health and how women can be educated and grown aware in regard to safe abortion practices using participatory theatres. Participatory theatres are a theatrical form which promotes audience interaction with performers through interactive dialogues and Q&A sessions in local dialect. The present paper is an attempt to understand the potentialities of participatory theatres in communicating safe, scientific abortion techniques performed by a qualified abortion providers for maternal wellbeing and preventing almost all abortion-related deaths. Keeping unsafe abortion practices and poor MTP Act awareness as the backdrop of the research work, the researcher will use descriptive qualitative research methodology using case study approach undertaken by Ipas, an NGO in collaboration Banglanatak.com and district health intermediaries using participatory theatres in West Bengal. Participatory theatres are offering a sustainable alternative approach to communication bridging all communication barriers existent in various societal strata's and educating rural people advocating attitudinal and behavioral changes. [ABSTRACT FROM AUTHOR]

This paper examines the sequential impact of components of maternal and child health care on the continuum of care in India using data from the Indian National Family Health Surveys conducted in 2005–06 and 2015–16. Continuum of care (CoC) for maternal and child health is defined in this paper as the sequential uptake of three key maternal services (antenatal care, institutional delivery and postnatal care for the mother). Women who received all three services were classified as full CoC recipients. Characteristics odd ratios for achieving CoC were estimated by mother's place of residence, household wealth status, mother's education, birth order and child full vaccination. Odds ratios were computed to understand the relative impact of each preceding service utilization on the odds of subsequent service uptake. At national level, 30.5% and 55.5% of women achieved full CoC in 2005–06 and 2015–16, respectively, and the overall progress of CoC over the 10-year period was 25.5 percentage points, with significant variation across states and socioeconomic groups. Full CoC improved from 7.5% to 32.4% among the poorest women, whereas among the richest women it improved from 70.5% to 75.1%. Similarly, among uneducated women full CoC improved from 11.7% to 35.9% as against 75.1% to 80.5% among educated mothers over the same period. Furthermore, greater CoC was observed among parity one women. The conditionality between various components of CoC indicated that at national level the odds of having an institutional delivery with antenatal care were 9 times higher in the earlier period as against 4.5 times higher in the more recent period. Furthermore, women who had institutional deliveries complied more with mother's postnatal care compared with women who did not have institutional deliveries. This again helps increase the likelihood of a child receiving full vaccination. [ABSTRACT FROM AUTHOR]

Introduction: Improving quality of care (QoC) for childbirth and sick newborns is critical for maternal and neonatal mortality reduction. Information on the process and impact of quality improvement at district and sub-district hospitals in India is limited. This implementation research was prioritized by the Haryana State (India) to improve the QoC for maternal and newborn care at the busy hospitals in districts., Methods: This study at nine district and sub-district referral hospitals in three districts (Faridabad, Rewari and Jhajjar) during April 2017-March 2019 adopted pre-post, quasi-experimental study design and plan-do-study-act quality improvement method. During the six quarterly plan-do-study-act cycles, the facility and district quality improvement teams led the gap identification, solution planning and implementation with external facilitation. The external facilitators monitored and collected data on indicators related to maternal and newborn service availability, patient satisfaction, case record quality, provider's knowledge and skills during the cycles. These indicators were compared between baseline (pre-intervention) and endline (post-intervention) cycles for documenting impact., Results: The interventions closed 50% of gaps identified, increased the number of deliveries (1562 to 1631 monthly), improved care of pregnant women in labour with hypertension (1.2% to 3.9%, p<0.01) and essential newborn care services at birth (achieved ≥90% at most facilities). Antenatal identification of high-risk pregnancies increased from 4.1% to 8.8% (p<0.01). Hand hygiene practices improved from 35.7% to 58.7% (p<0.01). The case record completeness improved from 66% to 87% (p<0.01). The time spent in antenatal clinics declined by 19-42 minutes (p<0.01). The pooled patient satisfaction scores improved from 82.5% to 95.5% (p<0.01). Key challenges included manpower shortage, staff transfers, leadership change and limited orientation for QoC., Conclusion: This multipronged quality improvement strategy improved the maternal and newborn services, case documentation and patient satisfaction at district and sub-district hospitals. The processes and lessons learned shall be useful for replicating and scaling up., Competing Interests: There is no competing interest for the authors. The authors, SD, SK, APK, GKA, RKD, KK, RC, and BS are the officials of Department of Health and Family Welfare, Government of Haryana and were implementing and/or supervising the implementation of the quality improvement interventions in the districts. The authors, RB, YBN and SAQ are staff members/technical advisors of the World Health Organization and were not involved in the implementation or interpretation of the results. The expressed views and opinions in this paper do not necessarily express the policies of the Government of Haryana and World Health Organization.

The key recommendation of the Child Survival and Safe Motherhood programme was the provision of Emergency Obstetric Care (EmOC) for the prevention of maternal mortality, especially in developing countries like India. The objectives of this paper were three-fold: to examine the socioeconomic differentials in mean out-of-pocket expenditure on EmOC in public and private health care facilities in India; to evaluate the catastrophic health expenditure of households at the threshold levels of 5% and 10%; and finally, to assess the effects of various socioeconomic and demographic covariates on the levels of catastrophic health expenditure on EmOC. Data were extracted from the 71st round of the National Sample Survey Office (NSSO) survey conducted in India between January and June 2014. A stratified multi-stage sampling design was followed to conduct the survey. The information was collected from 65,932 households (rural: 36,480; urban: 29,452) and 33,104 individuals across various states and union territories in India. However, the present study had taken only 1653 sample women who availed EmOC care during the last one year preceding the survey date. Binary logistic regression was applied. Large differences in out-of-pocket expenditure on EmOC were found between private and public health care facilities. Mean annual out-of-pocket expenditure by women in private hospitals was INR 23,309 (US$367), which was about 6 times higher than in public hospitals, where mean spending was INR 3651 (US$58). Furthermore, logistic regression analysis showed a significant association between household socioeconomic status and level of catastrophic health expenditure on EmOC. The odds of catastrophic health expenditure in public health facilities among women from the North region were higher than among those from the Central, South and West regions. Age and level of education significantly influenced the mean level of catastrophic health expenditure. Access to good-quality obstetric care is key to reducing the maternal mortality rate and child deaths, and thus achieving Sustainable Development Goal 3. There is an urgent need for policy interventions to reduce the financial burden of households in accessing obstetric care in India.

India's nationwide lockdown to curtail the transmission of Covid-19 has given rise to concerns over the health system's response to maternal and child health (MCH) services. This paper aims to understand the challenges faced by pregnant women seeking institutional care during the lockdown. We conducted a qualitative content analysis of 54 online news reports, published in English and Hindi, between 25 March 2020 and 31 May 2020. They covered cases across 17 states in India and 16 maternal deaths. Three broad thematic categories of challenges for pregnant women emerged from the analysis: 1) physical access to health facilities, 2) admission to health facilities, and 3) lack of respectful maternity care during the lockdown. In conclusion, strengthening health systems and incorporating MCH into the Covid-19 response is imperative. Failure to provide quality MCH services during the lockdown has implications for the continuum of women's care, maternal mortality, and human rights.

Objective(s): Obstetric Violence refers to professional deficiencies in maternity care, which can occur in both low and high resource settings. Examples include non-dignified care, lack of respect when giving care, discrimination and abandonment of care. The objective of this study was to assess knowledge and attitudes towards obstetric violence in a cohort of medical students in India and the UK., Study Design: An online survey was sent to 240 UK and 280 Indian medical students. This incorporated a video showing a dramatized scenario of obstetric violence. The survey assessed participant's demographics and prior knowledge of obstetric violence. Participants scored their perceptions of eight behaviours in the video on visual analogue scales. Participants were asked to reflect on their own practice and score this. Comparisons of survey responses between UK and Indian participants were made using chi squared/Student's t-test., Results: 62 Indian medical students and 58 UK medical students completed the survey. Indian medical students were significantly more likely to be male (p < 0.001). 26 % of UK participants had previously heard the term obstetric violence, compared to 34 % of Indian participants (p = 0.15). Both were able to correctly define obstetric violence at similar rates (32 % versus 34 %). Indian medical students were significantly less critical (p < 0.001) of all eight scored behaviours in the video of obstetric violence compared to their UK counterparts. UK medical students were significantly less likely to agree that the video had changed their perception on how teams should behave and act in this context (p < 0.001). 90 % of UK participants and 38 % of Indian participants had received training in professional behaviours. 14 % of UK participants had seen examples of obstetric violence in clinical practice compared to 49 % of Indian participants., Conclusions: UK and Indian medical students were able to identify behaviours associated with obstetric violence, although the majority were previously unaware of the term. Indian medical students in this study were less critical of obstetric violence in the video, which may be because of cultural reasons, greater numbers of male students, greater exposure to obstetric violence or less training on professional behaviours. Standardised training to prevent obstetric violence should be part of undergraduate medical training internationally., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier B.V.)

The COVID‐19 crisis has translated into an unprecedented humanitarian crisis for the poor and marginalized groups in society. The countrywide lockdowns, quarantine measures, and mobility restrictions across 200 countries of the world have resulted in a host of negative manifestations for women. There have been unprecedented losses in the informal economy, which is dominated by women. Some scholars also contend that the pandemic will translate into heightened burden of unpaid domestic work, loss of economic autonomy and disruption to maternal health services. Despite these factors a gendered perspective is absent in the policy response to this crisis. It is against this background that the present paper employed a feminist intersectionality lens to conduct participatory field based research on the lived experiences of women in informal employment in Indian Punjab during the COVID‐19 crisis. The research unearthed the specific pathways through which existing socio‐economic inequities rooted in caste, class and occupational entities magnify the vulnerabilities experienced by women during such a health crisis. The research offers a contextualized framework for understanding the gendered impacts of the crisis. It also highlights the urgency of taking account of gender specific constraints during the health crisis so as to institute robust, effective and equitable policy interventions. [ABSTRACT FROM AUTHOR]

Purpose - Huge gap exists between demand and supply of seeking health care leads to remain high maternal mortality in rural areas of Uttar Pradesh, India. The purpose of this paper is to make an effort in this direction. Design/methodology/approach - This paper draws on Three Delays Model to understand the reasons behind poor maternal health outcomes among 964 currently married women aged 15-34, given birth in last two years preceding the survey including six case studies in poor settings of Northern India. Findings - Receiving minimum four antenatal care and identifying the severity of obstetric complications during pregnancy was quite low (7 and 34 per cent, respectively). Major delay in seeking care in district was decision delay (average four days) followed by arranging transportation (average 4 hours) and start treatment within an hour after reaching health facility. Health services and trained human resources are mainly concentrated at towns and poor supply of drugs and equipment in labour room is always in demand at primary level in the district in area. Delays in decision making, travel and treatment compounded by ignorance of obstetric complications and poor healthcare infrastructure are the major contributing factors of maternal deaths in the district in area. Originality/value - Interventions to improve timely seeking of medical care for obstetric complications may need to more effectively target husbands and family members rather than women. Strengthening of primary and secondary level facilities and timely referral to tertiary level care can play a crucial role in improving obstetric care in the district in rural areas. [ABSTRACT FROM AUTHOR]

Background: Poor Maternal and Child Health (MCH) outcomes pose challenges to India's ability to attain Goal-3 of the Sustainable Development Goals (SDGs). The government of India strengthened the existing network of frontline health workers (FHWs), under its National Rural Health Mission in 2005 and subsequent National Urban Health Mission in 2013 as a strategy to mitigate the shortage of skilled health workers and to provide affordable healthcare services. However, there is a lack of robust national-level empirical analysis on the role of maternal engagement with FHWs in influencing the level of maternal and child health care utilisation and child health outcomes in India., Methods: Using data from the nationally representative Indian National Family Health Survey (NFHS) 2015-2016, this paper aims to investigate the intensity of engagement of FHWs with married women of child-bearing age (15-49 years), its influence on utilisation of maternal and child healthcare services, and child health outcomes. Our empirical analyses use multivariate regression analyses, focusing on five maternal and child health indicators: antenatal care visits (ANC) (4 or > 4 times), institutional delivery, full-immunisation of children, postnatal care (PNC) (within 2 days of delivery), and child survival., Results: Our analysis finds that maternal engagement with FHWs is statistically significant and a positive predictor of maternal and child health care utilisation, and child survival. Further, the level of engagement with FHWs is particularly important for women from economically poor households. Our robustness checks across sub-samples of women who delivered only in public health institutions and those from rural areas provides an additional confidence in our main results., Conclusions: From a policy perspective, our findings highlight that strengthening the network of FHWs in the areas where they are in shortage which can help in further improving the utilisation of maternal and child healthcare services, and health outcomes. Also, the role of FHWs in the government health system needs to be enhanced by improving skills, working environment, and greater financial incentives.

Background: In the last two decades, India's central and many state governments launched several public health programs with the goal of improving maternal and child health outcomes. Many individual studies assessed the impact of these programs; however, they focused on select health programs and few specific outcomes., Objectives and Methods: This paper summarizes the literature, published during 2000-2019, investigating the impacts of public health programs on both the uptake of maternal and child health services and the related-health outcomes in India. We followed PRISMA guidelines of systematic review, and carried out a narrative synthesis of the study findings., Findings and Conclusion: We found 66 relevant studies covering 11 health programs across India. Most studies had applied non-experimental study designs (n = 50), with few applying experimental (n = 1) and quasi-experimental (n = 15) designs. Most studies (n = 64) assessed the impact on the intermediate outcomes of the uptake of various health services rather on the long-term outcomes of improvement in health. Overall we found studies reporting positive impacts, however, we could not find any strong consensus emerging from these studies about the impact, partly due to differences in: outcome indicators; study designs; study population; data sets. Several studies also reported considerable beneficial impacts among low socioeconomic population groups. However, given that the outreach of the public health programs have been low across the country and population groups, we found that broader objectives of health programs remained unassessed: most studies assessed the impact on who actually participated in the program (average treatment effect on-the-treated) rather on the target population (intent-to-treat effect). Furthermore, there was dearth of research on the impacts of the state-level programs. Future research need to assess the impact of the programs on health outcomes, and on quality adjusted measures of maternal and child health services and its continuum of care., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Caste plays a significant role in Indian society and it influences women to health care access in the community. The implementation of the maternal health benefits scheme in India is biased due to caste identity. In this context, the paper investigates access to Janani Suraksha Yojana (JSY) among social groups to establish that caste still plays a pivotal role in Indian society. Also, this paper aims to quantify the discrimination against Scheduled Castes/Scheduled Tribes (SCs/STs) in accessing JSY., Methods: This paper uses a national-level data set of both NFHS-3 (2005-06) and NFHS-4 (2015-16). Both descriptive statistics and the Fairlie decomposition econometric model have been used to measure the explained and unexplained differences in access to JSY between SCs/STs and non-SCs/STs groups., Results: Overall, the total coverage of JSY in India is still, 36.4%. Further, it is found that 72% of access to JSY is explained by endowment variables. The remaining unexplained percentage (28%) indicates that there is caste discrimination (inequity associated social-discrimination) against SCs/STs in access to JSY. The highest difference (54%) between SCs/STs and non-SCs/STs in access to JSY comes from the wealth quintile, with the positive sign indicating that the gap between the two social groups is widening., Discussion and Conclusion: It is necessary for the government to implement a better way to counter the caste-based discrimination in access to maternal health benefits scheme. In this regard, ASHA and Anganwadi workers must be trained to reduce the influence of dominant caste groups as well as they must be recruited from the same community to identify the right beneficiaries of JSY and in order to reduce inequity associated with social-discrimination., Competing Interests: The authors have declared that no competing interests exist.

Background: Maternal deaths among young women (15-24 years) shares 38% of total maternal mortality in India. Utilizing maternal health care services can reduce a substantial proportion of maternal mortality. However, there is a paucity of studies focusing on young women in this context. This paper, therefore, aimed to examine the trends and determinants of full antenatal care (ANC) and skilled birth attendance (SBA) utilization among young married women in India., Methods: The study analysed data from the four rounds of National Family Health Surveys conducted in India during the years 1992-93, 1998-99, 2005-06 and 2015-16. Young married women aged 15-24 years with at least one live birth in the 3 years preceding the survey were considered for analysis in each survey round. We used descriptive statistics to assess the prevalence and trends in full ANC and SBA use. Pooled multivariate logistic regression was conducted to identify the demographic and socioeconomic determinants of the selected maternity care services. The significance level for all analyses was set at p ≤ 0.05., Results: The use of full ANC among young mothers increased from 27 to 46% in India, and from 9 to 28% in EAG (Empowered Action Group) states during 1992-2016. SBA utilization was 88 and 83% during 2015-16 by showing an increment of 20 and 50% since 1992 in India and EAG states, respectively. Findings from multivariate analysis revealed a significant difference in the use of selected maternal health care services by maternal age, residence, education, birth order and wealth quintile. Additionally, Muslim women, women belonging to scheduled caste (SC)/ scheduled tribe (ST) social group, and women unexposed to mass media were less likely to utilize both the maternal health care services. Concerning the time effect, the odds of the utilization of full ANC and SBA among young women was found to increase over time., Conclusions: In India coverage of full ANC among young mothers remained unacceptably low, with a wide and persistent gap in utilization between EAG and non-EAG states since 1992. Targeted health policies should be designed to address low coverage of ANC and SBA among underprivileged young mothers and increased efforts should be made to ensure effective implementation of ongoing programs, especially in EAG states.

Aim: This study aimed to understand the complex relationship between maternal complications and women's characteristics in India., Methods: The present study builds structural equation modeling (SEM) using the data from the National Family Health Survey round 4 (2015-16) and includes 190, 898 women who had given their last birth during 5 years preceding the survey. Based on eight questions related to maternal complications, the SEM constructed two latent variables - complications during pregnancy (PREGCOMP) and delivery (DELCOMP)., Results: Result shows that prolonged labor was highly prevalent (42%) among women, followed by vaginal bleeding (34%) and swelling in legs, body or face (32%). Women from affluent households (β = -0.02 for each-middle, richer and richest quantile), with higher education (β = -0.02), timing when they received first ANC (β = -0.003) and women who received full ANC (β = -0.01) had a lower risk of PREGCOMP. However, consanguineous marriage (β = 0.01) was positively related to PREGCOMP. Further, women with PREGCOMP (β = 0.20), rural residents (β = 0.02), having exposure to mass media (β = 0.01), and who had facility delivery (β = 0.04) were at high risk of DELCOMP. Women with pregnancy complications are more likely to have delivery complications. [Correction added on 27 November, after first online publication: The statement "who received full antenatal care (ANC) (β = -0.05)" has been removed.] CONCLUSION: Socioeconomic and demographic factors significantly affect both the latent variables. This study concludes that the use of intensive healthcare services reduces health complications. The paper recommends early visits and full ANC checkups to reduce pregnancy complications., (© 2020 Japan Society of Obstetrics and Gynecology.)

Background: This paper examines two state-led public-private demand-side financial support programs aiming to raise hospital delivery rates in two neighbouring Indian states-Gujarat and Madhya Pradesh. The national Janani Suraksha Yojana (JSY) was complemented with a public-private partnership program Janani Sahayogi Yojana (JSaY) in Madhya Pradesh in which private obstetricians were paid to deliver poor women. A higher amount was paid for caesarean sections (CS) than for vaginal deliveries (VD). In Gujarat state, the state program Chiranjeevi Yojana (CY) paid private obstetricians a fixed amount for a block 100 deliveries irrespective of delivery mode. The two systems thus offered an opportunity to observe the influence of supplier-induced demand (SID) from opposite incentives related to delivery mode. Methods: The data from the two programs was sourced from the Departments of Health and Family Welfare, Governments of Gujarat and Madhya Pradesh, India. Results: In JSaY program the CS rate increased from 26.6 % (2007-2008) to 40.7 % (2010-2011), against the background rate for CS in Madhya Pradesh, of only 4.9 % (2004-2006). Meanwhile in CY program in Gujarat, the CS rate decreased to 4.3 % (2010-2011) against a background CS rate of 8.1 % (2004-2006). Conclusions: The findings from India are unique in that they not only point to a significant impact from the introduction of the financial incentives but also how disincentives have an inverse impact on the choice of delivery method. [ABSTRACT FROM AUTHOR]

Introduction: Although India has made significant progress in institutional delivery after the implementation of the National Rural Health Mission under which the Janani Suraksha Yojana (JSY) is a sub-programme which played a vital role in the increase of institutional delivery in public facilities. Therefore, this paper aims to provide an understanding of the JSY coverage at the district level in India. Further, it tries to carve out the factors responsible for the regional disparity of JSY coverage at district levels., Methods: The study used the National Family Health Survey data, which is a cross-sectional survey conducted in 2015-16, India. The sample size of this study was 148,145 women aged 15-49 years who gave last birth in the institution during 5 years preceding the survey. Bivariate and multivariate regression analysis was used to fulfill the study objectives. Additionally, Moran's I statistics and bivariate Local Indicator for Spatial Association (LISA) maps were used to understand spatial dependence and clustering of JSY coverage. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of JSY utilization., Results: The value of spatial-autocorrelation for JSY was 0.71 which depicts the high dependence of the JSY coverage over districts of India. The overall coverage of JSY in India is 36.4% and it highly varied across different regions, districts, and even socioeconomic groups. The spatial error model depicts that if in a district the women with no schooling status increase by 10% then the benefits of JSY get increased by 2.3%. Similarly, if in a district the women from poor wealth quintile, it increases by 10% the benefits of JSY also increased by 4.6%. However, the coverage of JSY made greater imperative to understand it due to its clustering among districts of specific states only., Conclusion: It is well reflected in the EAGs states in terms of spatial-inequality in service coverage. There is a need to universalize the JSY programme at a very individual level. And, it is required to revisit the policy strategy and the implementation plans at regional or district levels.

Objective: Maternal healthcare coverage is the outcome of health service availability and utilization, and includes antenatal care (ANC), care at delivery, and postnatal care. This study examines the contribution of India's National Health Mission (NHM) to maternal health through a pre-post comparison of rates of delivery at a healthcare institution and use of ANC along with inequalities in the determinants of one of the major maternal health outcomes-at least four ANC visits., Methods: Data came from the Indian National Family Health Surveys conducted between 1992-93 and 2015-16. A multivariate logistic regression model was used to estimate the odds ratios (ORs) associated with the predictors of at least four ANC visits., Results: Institutional delivery increased by 12.6 percentage points between 1992-93 and 2005-06 (the pre-NRHM era), and thereafter interventions through the National Rural Health Mission/NHM contributed to a significant increase of 40.2 percentage points from 2005-06 to 2015-16. However, both inter- and intra-state disparities persist even now. Overall, the proportion of pregnant women who have at least four ANC visits is as low as 51.2 percent. The likelihood of having at least four ANC visits is almost four times higher for women in the richest households compared with those in the poorest (OR: 3.59; 95% CI: 3.44-3.75) CONCLUSION: Future public health efforts should focus on removing inter- and intra-state disparities in institutional delivery and ensuring at least four ANC visits for pregnant women, to meet the infant and maternal mortality targets set out in the Sustainable Development Goals (SDG)., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Despite decent progress in Children Full Immunisation (CFI) in India during the last decade, surprisingly, Gujarat, an economically more developed state, had the second-lowest coverage of CFI (50%) in the country, lower than economically less developed states such as Bihar (62%). Further, the proportion of children with no immunisation in Gujarat has risen from 5% in 2005 to 9% in 2016. This paper investigated factors associated with the low level of CFI coverage in Gujarat., Methods: The study used two types of datasets: (1) the information on immunisation from 7730 children aged 12-23 months and their mothers from the fourth round of the Gujarat chapter of National Family Health Survey (NFHS 2015-16). (2) A macro (district) level data on both supply and demand-side factors of CFI are compiled from multiple sources. Bivariate and multivariate linear and logistic regression techniques were employed to identify the factors associated with CFI coverage., Results: In Gujarat, during 2015-2016, 50% of children aged 12-23 months did not receive full immunisation. The odds of receiving CFI was higher among children whose mothers had a Maternal and Child Protection (MCP) card (OR: 1.97, 95% CI 1.48-2.60) and those who received "high" maternal health services utilisation (OR: 1.59, 95% CI 1.10-2.26) compared to their counterparts. The odds of receiving CFI was about three times higher among the richest households (OR: 6.50, 95% CI 3.75-11.55) compared to their counterparts in the poorer households. Macro-level analyses suggest that poverty, maternal health care, and higher-order births are defining factors of CFI coverage in Gujarat., Conclusions: In order of importance, focusing on poverty, economic inequalities, pregnancy registration, and maternal health care services utilisation are likely to improve receiving CFI uptake in Gujarat. The disadvantageous position of urban areas and non-scheduled tribes in CFI coverage needs further investigation., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Maternal and perinatal Health Research collaboration, India (MaatHRI) is a research platform that aims to improve evidence-based pregnancy care and outcomes for mothers and babies in India, a country with the second highest burden of maternal and perinatal deaths. The objective of this paper is to describe the methods used to establish and standardise the platform and the results of the process. Methods: MaatHRI is a hospital-based collaborative research platform. It is adapted from the UK Obstetric Surveillance System (UKOSS) and built on a pilot model (IndOSS-Assam), which has been extensively standardised using the following methods: (i) establishing a network of hospitals; (ii) setting up a secure system for data collection, storage and transfer; (iii) developing a standardised laboratory infrastructure; and (iv) developing and implementing regulatory systems. Results: MaatHRI was established in September 2018. Fourteen hospitals participate across four states in India - Assam, Meghalaya, Uttar Pradesh and Maharashtra. The research team includes 20 nurses, a project manager, 16 obstetricians, two pathologists, a public health specialist, a general physician and a paediatrician. MaatHRI has advanced standardisation of data and laboratory parameters, real-time monitoring of data and participant safety, and secure transfer of data. Four observational epidemiological studies are presently being undertaken through the platform. MaatHRI has enabled bi-directional capacity building. It is overseen by a steering committee and a data safety and monitoring board, a process that is not normally used, but was found to be highly effective in ensuring data safety and equitable partnerships in the context of low and middle income countries (LMICs). Conclusion: MaatHRI is the first prototype of UKOSS and other similar platforms in a LMIC setting. The model is built on existing methods but applies new standardisation processes to develop a collaborative research platform that can be replicated in other LMICs., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 Nair M et al.)

Objective: The main aim is to analyze the prescription forms to evaluate the completeness of these forms, and we also aim to bring to light the factors which need to be emphasized on while writing a prescription. Materials and Methods: This is a prospective cross-sectional study. Prescriptions of 200 patients visiting the gynecology and antenatal outpatient department (OPD) were evaluated using a specially designed questionnaire containing specific questions pertaining about OPD prescriptions, and a score of 0, 1, or 2 was allotted to each question. Results: In an audit of 200 OPD prescription papers, complete name, age, date of consultation, sex, and OPD registration number of the client were present in 100% prescriptions as it was preprinted. Legible handwriting was seen in 93%. Essential medicines advised were available in the hospital dispensary in 77%. Dosage schedule/doses were clearly written in 85%. Prescription duly signed and the name is written (legibly)/stamped in 87%. The highest score for a prescription was found to be 17/17 and the lowest score for a prescription form was 8/13. Conclusion: Many areas are lagging in prescription writing, especially writing presumptive diagnosis and salient features of clinical examination. Physicians need to improve their prescription writing skills for the benefit of patients. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

More than 300,000 women died due to pregnancy related causes in 2015, a global maternal mortality ratio (MMR) of 216 per 100,000 live births (Alkema et al., 2016). Millennium Development Goals have led to a 44% decline in global MMR, but significant variations still remain across geographical regions (United Nations [UN], 2015). India accounts for the second highest maternal deaths in the world (World Health Organization [WHO], 2015). In contrast, the U.S. is the only developed country with an increasing MMR in recent years ("Maternal Mortality," 2015). However, little attention has been given to maternal health in public policy research and practice in both countries. This paper compares and contrasts maternal health status and analyzes maternal health policies in India and the U.S. two health models. Based on comparative case analysis, the overall recommendation is to expand the scope of maternal health from a biomedical health model towards a biopsychosocial model and restructure the policy frameworks. This paper contributes to the maternal health discourse and hopes to garner attention of global and regional health policy scholars and policy makers. [ABSTRACT FROM AUTHOR]

Despite remarkable progress in past few decades India's current maternal and child mortality levels fall significantly short to attain many of the targets of MDGs. The variation in attainments across and within regions has always been a crucial dimension of Indian concerns. The present paper takes a closer look at the spatial variation of maternal and child healthcare status in India by summarising a set of constituent indicators that are instrumental in nature, and result in debilitating outcomes for women and their newborn. Taking the stock of information generated by the third round of District Level Health and Facility Survey (DLHS-3) this paper adopts the Pena Distance Method to gauge the spatial variations. The states are classified first in terms of their MCH status in 2007-2008. At later stage intrastate disparities are captured by measuring rural-urban inequality, and inter-district disparity within states. Key results indicate that the overall state ranking is, to a significant extent, explained by the intrastate variations. However, the major contribution of this paper lies in quantifying the relative role of constituent indicators that are responsible for the existing disparities across and within state boundaries. [ABSTRACT FROM AUTHOR]

Background: Health service and health outcome data collection across many low- and middle-income countries (LMICs) is, to date largely paper-based. With the development and increased availability of reliable technology, electronic tablets could be used for electronic data collection in such settings. This paper describes our experiences with implementing electronic data collection methods, using electronic tablets, across different settings in four LMICs.Methods: Within our research centre, the use of electronic data collection using electronic tablets was piloted during a healthcare facility assessment study in Ghana. After further development, we then used electronic data collection in a multi-country, cross-sectional study to measure ill-health in women during and after pregnancy, in India, Kenya and Pakistan. All data was transferred electronically to a central research team in the UK where it was processed, cleaned, analysed and stored.Results: The healthcare facility assessment study in Ghana demonstrated the feasibility and acceptability to healthcare providers of using electronic tablets to collect data from seven healthcare facilities. In the maternal morbidity study, electronic data collection proved to be an effective way for healthcare providers to document over 400 maternal health variables, in 8530 women during and after pregnancy in India, Kenya and Pakistan.Conclusions: Electronic data collection provides an effective platform which can be used successfully to collect data from healthcare facility registers and from patients during health consultations; and to transfer large quantities of data. To ensure successful electronic data collection and transfer between settings, we recommend that close attention is paid to study design, data collection, tool design, local internet access and device security. [ABSTRACT FROM AUTHOR]

The National Family Health Survey (NFHS) data is useful in setting benchmarks and examining the progress of various health indicators over time. The main objective of the present paper is to critically review the findings of NFHS-5 and NFHS-4 regarding the trends on maternal health indicators and implications for India. Data from NFHS-5 (First round 2019-2020) and NFHS-4 (2015-16) for 17 states and five Union territories (UTs) pertaining to maternal health indicators was extracted from the factsheets. Trends and implications in line with Sustainable Development Goals (SDGs) and National Health Policy (NHP) 2017 have been critically appraised. Substantial improvement in maternal health indicators in NFHS-5 over NFHS-4 is noted; however, there is a lot of interstate variation. NFHS-5 findings indicate that the percentage of women in the age group 15-19 years, already mothers or pregnant, has increased in four states while the percentage of mothers who had antenatal checkup in first trimester has increased in 12 states. Percentage of those with anaemia during pregnancy has increased from 15 to 17 states in NFHS-5 as compared to NFHS-4. Institutional births are over 90% in 14 states while only three states have below 79%. Out of pocket expenditure (OOPE) per delivery at public health facilities has increased in 12 states over the time period and it is above 5000 INR in 8 states. In India, improvement in maternal health indicators can be achieved by increasing quality of care, strengthening the Janani Suraksha Yojana (JSY), skilled birth attendants training program, reduction of anaemia among pregnant women and reduction in OOPEper delivery at public health facilities. [ABSTRACT FROM AUTHOR]

Government of India initiatives through implementation of National Rural Health Mission (NRHM) and Janani Suraksha Yojna (JSY) programs from early 2005 has shown a considerable impact on maternal health care utilization in India. Despite the fact that these programs provide the services free of cost, utilization of maternal health care services is still considered an economic burden on some households. Keeping this into our mind, the research study analyzes the different level of payments to procure maternal health care for different socio-economic characteristics in India. Materials and Methods: This paper has utilized the data collected by the National Sample Survey Organization (NSSO) during January -June, 2014. It is a cross sectional dataset that provides information on Social Consumption and Health scenario of the population. To carry out the research, descriptive statistics, and regression analysis has been used. Findings and Conclusion: The research reveals that women residing at urban place of residence, higher educated, affiliated to other social group and belonging to richest wealth index pay high amount for the maternal healthcare services in India. Indian government need to extend the coverage rendering the services at affordable costs without any further differentiation on the basis of socio-economic characteristics of Indian women. [ABSTRACT FROM AUTHOR]

This paper from India describes anxieties that pregnant and postpartum women reported to obstetricians during the COVID-19 pandemic. Of the 118 obstetricians who responded to an online survey, most had been contacted for concerns about hospital visits (72.65%), methods of protection (60.17%), the safety of the infant (52.14%), anxieties related to social media messages (40.68%) and contracting the infection (39.83%). Obstetricians felt the need for resources such as videos, websites and counselling skills to handle COVID-related anxiety among perinatal women. [ABSTRACT FROM AUTHOR]