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Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously. This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action’s Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted. The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246–17,843) at an estimated cost of $23 per DALY averted (95%UI:19–28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition. [ABSTRACT FROM AUTHOR]

Household Air Pollution (HAP) from biomass cooking fuels is a major cause of morbidity and mortality in low-income settings worldwide. In Nepal the use of open stoves with solid biomass fuels is the primary method of domestic cooking. To assess patterns of domestic air pollution we performed continuous measurement of carbon monoxide (CO) and particulate Matter (PM 2.5 ) in 12 biomass fuel households in Janakpur, Nepal. We measured kitchen PM 2.5 and CO concentrations at one-minute intervals for an approximately 48-h period using the TSI DustTrak II 8530/SidePak AM510 (TSI Inc, St. Paul MN, USA) or EL-USB-CO data logger (Lascar Electronics, Erie PA, USA) respectively. We also obtained information regarding fuel, stove and kitchen characteristics and cooking activity patterns. Household cooking was performed in two daily sessions (median total duration 4 h) with diurnal variability in pollutant concentrations reflecting morning and evening cooking sessions and peak concentrations associated with fire-lighting. We observed a strong linear relationship between PM 2.5 measurements obtained by co-located photometric and gravimetric monitoring devices, providing local calibration factors of 4.9 (DustTrak) and 2.7 (SidePak). Overall 48-h average CO and PM 2.5 concentrations were 5.4 (SD 4.3) ppm (12 households) and 417.6 (SD 686.4) μg/m 3 (8 households), respectively, with higher average concentrations associated with cooking and heating activities. Overall average PM 2.5 concentrations and peak 1-h CO concentrations exceeded WHO Indoor Air Quality Guidelines. Average hourly PM 2.5 and CO concentrations were moderately correlated (r = 0.52), suggesting that CO has limited utility as a proxy measure for PM 2.5 exposure assessment in this setting. Domestic indoor air quality levels associated with biomass fuel combustion in this region exceed WHO Indoor Air Quality standards and are in the hazardous range for human health. [ABSTRACT FROM AUTHOR]

Background: Verbal autopsy (VA), the process of interviewing a deceased's family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews.Methods: During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative.Results: Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5-3.5) of an average 65 answered; mean inter-interviewer concordance was 92% (IQR: 92-99%). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather.Conclusions: The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services. [ABSTRACT FROM AUTHOR]

Police investigations involve determining whether a crime has been committed, and if so what type of crime, who has committed it and whether there is the evidence to charge the perpetrators. Drawing on fieldwork in Delhi and Mumbai, this paper explores how police investigations unfolded in the specific context of women's deaths by burning in India. In particular, it focuses on the use of discretion despite its denial by those exercising it. In India, there are distinctive statutes relating to women's suspicious deaths, reflecting the widespread expectation that the bride's family will pay a dowry to the groom's family and the tensions to which this may on occasion give rise in the early years of a marriage. Often, there are conflicting claims influencing how the woman's death is classified. These in turn affect police investigation. The nature and direction of police discretion in investigating women's deaths by burning reflect in part the unique nature of the legislation and the particular sensitivities in relation to these types of death. They also highlight processes that are liable to be at work in any crime investigation. It was found that police officers exercised unacknowledged discretion at seven specific points in the investigative process, with potentially significant consequences for the achievement of just outcomes: first response, recording the victim's ‘dying declaration’, inquest, registering of the ‘First Information Report’, collecting evidence, arrest and framing of the charges. [ABSTRACT FROM PUBLISHER]

Introduction: Neonatal mortality accounts for 40% of under five mortality in developing countries. Strategies to reduce neonatal mortality rates (NMRs) must address the reality that 90% of deliveries in the [...]

Background: Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years. 90% of deliveries in the poorest quintile of households happen at home. We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates.Methods: We pair-matched 42 geopolitical clusters in Makwanpur district, Nepal, selected 12 pairs randomly, and randomly assigned one of each pair to intervention or control. In each intervention cluster (average population 7000), a female facilitator convened nine women's group meetings every month. The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. We monitored birth outcomes in a cohort of 28?931 women, of whom 8% joined the groups. The primary outcome was neonatal mortality rate. Other outcomes included stillbirths and maternal deaths, uptake of antenatal and delivery services, home care practices, infant morbidity, and health-care seeking. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN31137309.Findings: From 2001 to 2003, the neonatal mortality rate was 26.2 per 1000 (76 deaths per 2899 livebirths) in intervention clusters compared with 36.9 per 1000 (119 deaths per 3226 livebirths) in controls (adjusted odds ratio 0.70 [95% CI 0.53-0.94]). Stillbirth rates were similar in both groups. The maternal mortality ratio was 69 per 100000 (two deaths per 2899 livebirths) in intervention clusters compared with 341 per 100000 (11 deaths per 3226 livebirths) in control clusters (0.22 [0.05-0.90]). Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than were controls.Interpretation: Birth outcomes in a poor rural population improved greatly through a low cost, potentially sustainable and scalable, participatory intervention with women's groups. [ABSTRACT FROM AUTHOR]

Background: Malaria transmission in Nepal is focal and seasonal. Based on data in returning travelers the risk of malaria is low. Sources of advice give contradictory information regarding the need for chemoprophylaxis. As a result, a degree of confusion exists among visitors. The aim of this study was to describe chemoprophylactic practices among travelers to Nepal and to document differences in advice according to its source and the country in which it was given.Methods: A questionnaire survey of tourists attending the CIWEC Clinic Travel Medicine Center, Kathmandu between June 2000 and May 2001. Resident expatriates and indigenous Nepalese were excluded.Results: Completed questionnaires were obtained from 1,303 respondents. Two hundred and eighty-eight respondents were taking chemoprophylaxis specifically for their trip to Nepal (22%), whereas 958 were not. Travelers from the United Kingdom and Denmark were significantly more likely, and those from the United States and Germany significantly less likely, to be taking chemoprophylaxis. Most travelers sought pretravel advice (71%), and all sources were more likely to advise them not to take chemoprophylaxis than to take it. However, travelers advised by a family practitioner were significantly more likely to be taking chemoprophylaxis than those advised by a travel medicine specialist. Of those taking chemoprophylaxis, 53% were doing so for a visit to the Terai alone, 33% for all areas of Nepal, and 6% for the Kathmandu Valley. Nine different chemoprophylactic regimes were in use. Six hundred and forty respondents who were not taking chemoprophylaxis had been advised that it was not necessary; 276 had made the choice themselves; and 131 had been taking chemoprophylaxis but had stopped while in Nepal. Twenty-eight of these respondents had stopped because of side effects. The most common reason for choosing not to take chemoprophylaxis was either the occurrence of side effects or the fear of them (31%).Conclusions: The variable and ultimately low risk of contracting malaria in Nepal has resulted in a lack of consensus and a wide range of opinion regarding the need for chemoprophylaxis. There is a need for clarification and tighter definition of the malaria risk faced by travelers to Nepal to avoid unnecessary chemoprophylaxis use while protecting those at significant risk. [ABSTRACT FROM AUTHOR]

Background: Around 86% of births in Mumbai, India, occur in healthcare institutions, but this aggregate figure hides substantial variation and little is known about urban home births. We aimed to explore factors influencing the choice of home delivery, care practices and costs, and to identify characteristics of women, households and the environment which might increase the likelihood of home birth.Methods: As part of the City Initiative for Newborn Health, we used a key informant surveillance system to identify births prospectively in 48 slum communities in six wards of Mumbai, covering a population of 280,000. Births and outcomes were documented prospectively by local women and mothers were interviewed in detail at six weeks after delivery. We examined the prevalence of home births and their associations with potential determinants using regression models.Results: We described 1708 (16%) home deliveries among 10,754 births over two years, 2005-2007. The proportion varied from 6% to 24%, depending on area. The most commonly cited reasons for home birth were custom and lack of time to reach a healthcare facility during labour. Seventy percent of home deliveries were assisted by a traditional birth attendant (dai), and 6% by skilled health personnel. The median cost of a home delivery was US$ 21, of institutional delivery in the public sector US$ 32, and in the private sector US$ 118. In an adjusted multivariable regression model, the odds of home delivery increased with illiteracy, parity, socioeconomic poverty, poorer housing, lack of water supply, population transience, and hazardous location.Conclusions: We estimate 32,000 annual home births to residents of Mumbai's slums. These are unevenly distributed and cluster with other markers of vulnerability. Since cost does not appear to be a dominant disincentive to institutional delivery, efforts are needed to improve the client experience at public sector institutions. It might also be productive to concentrate on intensive outreach in vulnerable areas by community-based health workers, who could play a greater part in helping women plan their deliveries and making sure that they get help in time. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To ascertain the role of low birth weight (LBW) in neonatal mortality in a periurban setting in Bangladesh. METHODS: LBW neonates were recruited prospectively and followed up at one month of age. The cohort of neonates were recruited after delivery in a hospital in Dhaka, Bangladesh, and 776 were successfully followed up either at home or, in the event of early death, in hospital. FINDINGS: The neonatal mortality rate (NMR) for these infants was 133 per 1000 live births (95% confidence interval: 110-159). The corresponding NMRs (and confidence intervals) for early and late neonates were 112 (91-136) and 21 (12-33) per thousand live births, respectively. The NMR for infants born after fewer than 32 weeks of gestation was 769 (563-910); and was 780 (640-885) for infants whose birth weights were under 1500 g. Eighty-four per cent of neonatal deaths occurred in the first seven days; half within 48 hours. Preterm delivery was implicated in three-quarters of neonatal deaths, but was associated with only one-third of LBW neonates. CONCLUSION: Policy-relevant findings were: that LBW approximately doubles the NMR in a periurban setting in Bangladesh; that neonatal mortality tends to occur early; and that preterm delivery is the most important contributor to the NMR. The group of infants most likely to benefit from improvements in low-cost essential care for the newborn accounted for almost 61% of neonatal mortalities in the cohort. [ABSTRACT FROM AUTHOR]

Abstract: The exposure of children to air pollution in low resource settings is believed to be high because of the common use of biomass fuels for cooking. We used microenvironment sampling to estimate the respirable fraction of air pollution (particles with median diameter less than 4μm) to which 7–9year old children in southern Nepal were exposed. Sampling was conducted for a total 2649h in 55 households, 8 schools and 8 outdoor locations of rural Dhanusha. We conducted gravimetric and photometric sampling in a subsample of the children in our study in the locations in which they usually resided (bedroom/living room, kitchen, veranda, in school and outdoors), repeated three times over one year. Using time activity information, a 24-hour time weighted average was modeled for all the children in the study. Approximately two-thirds of homes used biomass fuels, with the remainder mostly using gas. The exposure of children to air pollution was very high. The 24-hour time weighted average over the whole year was 168μg/m3. The non-kitchen related samples tended to show approximately double the concentration in winter than spring/autumn, and four times that of the monsoon season. There was no difference between the exposure of boys and girls. Air pollution in rural households was much higher than the World Health Organization and the National Ambient Air Quality Standards for Nepal recommendations for particulate exposure. [Copyright &y& Elsevier]