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Improvement of water and sanitation conditions may reduce infant mortality, particularly in countries like India where open defecation is highly prevalent. We conducted a quasi-experimental study to investigate the association between the Swachh Bharat Mission (SBM)—a national sanitation program initiated in 2014—and infant (IMR) and under five mortality rates (U5MR) in India. We analyzed data from thirty-five Indian states and 640 districts spanning 10 years (2011–2020), with IMR and U5MR per thousand live births as the outcomes. Our main exposure was the district-level annual percentage of households that received a constructed toilet under SBM. We mapped changes in IMR and U5MR and toilet access at the district level over time. We fit two-way fixed effects regression models controlling for sociodemographic, wealth, and healthcare-related confounders at the district-level to estimate the association between toilets constructed and child mortality. Toilet access and child mortality have a historically robust inverse association in India. Toilets constructed increased dramatically across India following the implementation of SBM in 2014. Results from panel data regression models show that districts with > 30% toilets constructed under SBM corresponds with 5.3 lower IMR (p < 0.05), and 6.8 lower U5MR (p < 0.05). Placebo, falsification tests and robustness checks support our main findings. The post-SBM period in India exhibited accelerated reductions in infant and child mortality compared to the pre-SBM years. Based on our regression estimates, the provision of toilets at-scale may have contributed to averting approximately 60,000–70,000 infant deaths annually. Our findings show that the implementation of transformative sanitation programs can deliver population health benefits in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Purpose: Indian states at greater levels of economic development report more suicides. This relation appears stronger among women relative to men. We test the hypothesis, suggested in the literature, that conflict between rapid economic growth and inadequate female autonomy (approximated using total fertility rate) varies positively with female suicides. Methods: We used state-level data on female suicides for all 35 Indian states and union territories, from 2001 to 2011, from the National Crime Records Bureau. We specified, as our outcome, age-adjusted female suicides per 100,000 population per state-year. We retrieved data on key covariates, namely, gross state domestic product (GSDP) per capita, total fertility rate (TFR), and other control variables from multiple national surveys and publicly available data sources. We examined whether and to what extent age-adjusted female suicides (per 100,000 population) correspond with total fertility rate (lower TFR indicates greater female autonomy and vice versa) within the context of greater economic development (GSDP per capita). Linear longitudinal mixed effect regressions controlled for state-specific random intercepts, son preference (male:female sex ratio at birth), literacy gap (percentage difference between literate males and females), access to health systems (institutional deliveries), female to male employment ratio, and linear time trends. Results: At constant levels of GSDP per capita, a one unit decline in TFR corresponds with 0.27 fewer female suicides per 100,000 population (P value = 0.008). Sensitivity tests indicate that this relation does not hold for male age-adjusted suicides (per 100,000 population). Conclusion: Our findings, if replicated, indicate that at constant levels of economic development, lower TFR (indicating greater female autonomy) may reduce suicide risk among women. [ABSTRACT FROM AUTHOR]

Background: Lack of toilets and the widespread practice of open defecation may contribute to India's large burden of child undernutrition.Objectives: We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India.Methods: In this observational study, we used district-level data from before (2013-2014) and after (2015-2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates.Results: Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: -0.10, -0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM.Conclusions: An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign. [ABSTRACT FROM AUTHOR]

Background: Conditional cash transfers (CCTs) are demand-side interventions that link cash receipt to fulfilment of health-promoting conditions such as regular health check-ups and investment in human capital. In 2011, the Indian state of Odisha, implemented a statewide CCT program-the Mamata Scheme-towards improving maternal/child health outcomes and promoting health-seeking behavior. Mamata targets pregnant and lactating women aged ≥19 y, and provides a sizable financial incentive relative to household income levels.Objectives: We aimed to longitudinally examine whether, and to what extent, initiation of the Mamata scheme corresponded with changes in health and nutrition outcomes in Odisha, relative to comparison states in India.Methods: Outcomes included maternal health service utilization [antenatal care (ANC), iron-folic acid supplementation, breastfeeding counseling, full child immunization, tetanus vaccination, vitamin A supplementation] and nutrition [anemia during pregnancy and stunting, anemia in children <5 y old (U5)]. Data on outcomes and covariates were obtained from 3 waves of India's National Family Health Surveys corresponding to the years 1999, 2006, and 2016. We used difference-in-differences (DID) estimation strategy to estimate the impact of the program.Results: The pooled sampled size comprised >200,000 mother-child dyads. Tests of parallel trends indicated that preintervention trends were similar across all outcomes in Odisha with the exception of anemia. When comparing Odisha with other states for health services, DID models indicated that exposure to Mamata corresponded with increased odds of counseling for breastfeeding (OR: 2.74; 95% CI: 1.97, 3.80), ANC receipt (OR: 1.51; 95% CI: 1.15, 1.99), and full immunization (OR: 1.69; 95% CI: 1.37, 2.08). DID models also indicated decline in stunting (OR: 0.92; 95% CI: 0.84, 1.02) and anemia (OR: 0.62; 95% CI: 0.54, 0.71) among U5 children in Odisha following Mamata, relative to comparison states. Models comparing poor with nonpoor groups indicated the presence of heterogeneous effects.Conclusions: This study provides proof-of-concept for potential improvements in maternal and child nutrition outcomes following CCTs that incentivize health care utilization in India. [ABSTRACT FROM AUTHOR]

Objective: Persistent exposure to faecal pathogens due to open defecation may cause environmental enteropathy that, in turn, may lead to undernutrition and vaccine failure in under 5-year-old (u5) children. The Swachh Bharat Mission (SBM) programme in India, launched in 2014, aimed to construct toilets for every household nationwide and reduce open defecation. This programme, if successful, had the potential to reduce the burden of four vaccine preventable diseases (VPDs): diphtheria, pertussis, tetanus and measles. We examine whether increased household toilet availability in Indian districts following SBM corresponds with a reduction in diphtheria, pertussis, tetanus and measles in u5 children., Design: Observational, ecological study., Setting: 532 districts in 28 Indian states, from 2013 to 2016., Primary Outcome and Exposure: We retrieved data on district-level change in the annual incidence (per 1000 u5 children) of four VPDs, from 2013 (pre-SBM) to 2016 (post-SBM). We obtained data on our exposure, the change in the percentage of households with toilets (per district), from three large national surveys conducted in 2013 and 2016. We used linear regression analysis, which controlled for change over time in socioeconomic factors, health system-related covariates and pre-SBM annual incidence of VPDs., Results: A one percentage point increase in households with toilets corresponds with 0.33 fewer measle cases per 1000 u5 children in a district (coefficient: -0.33, 95% CI -0.0641 to -0.014; p<0.05). About 12% of this association is mediated by a reduction in u5 stunting. We observe no relation of the exposure with diphtheria, pertussis or tetanus. Findings remain robust to sensitivity analyses., Conclusion: Rapid improvements in ambient sanitation through increased toilet availability correspond with a reduction in the annual incidence of measles in u5 children. We encourage replication of findings and further research to identify potential pathways by which SBM may reduce measle burden in u5 children., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Much research on sanitation and linear growth in low- and middle-income countries focuses on children younger than 5 years. However, poor sanitation may be associated with growth faltering during middle and late childhood to a greater extent than previously recognized., Objective: To characterize the association of poor sanitation with height-for-age z (HAZ) scores in children and adolescents in India aged 0 to 18 years., Design, Setting, and Participants: This cross-sectional study examined 134 882 children and adolescents aged 0 to 18 years who were surveyed in the fourth round of India's District Level Household and Facilities Survey (survey conducted August 2012 to February 2014). Data were analyzed from June 1, 2019, to August 20, 2019., Exposures: Proportion of households reporting open defecation at the village level (to account for its high negative externality) and household-level access to boiled or filtered drinking water., Main Outcomes and Measures: Individual-level HAZ scores were measured in standard deviations. The association of exposures with outcomes was estimated using ordinary least-squares regression stratified by sex (boys and girls) and 4 age groups (≤1, >1 to ≤7, >7 to ≤12, >12 to ≤18 years). Models controlled for parental height and education, socioeconomic status, maternal age at birth, hemoglobin level, and indicators for state and birth year to adjust for regional (state) and temporal (birth year) fixed effects., Results: The sample comprised 70 463 male (52.5%) and 64 419 female (47.8%) children and adolescents aged 0 to 18 years; 46 722 participants (34.6%) were aged older than 12 to 18 years. Open defecation was inversely associated with HAZ score among all age groups except boys aged 1 year and younger (>1 to ≤7 years: β, -0.22; 95% CI, -0.35 to -0.10; >7 to ≤12 years: β, -0.15; 95% CI, -0.24 to -0.06; >12 to ≤18 years: β, -0.10; 95% CI, -0.19 to -0.01) and among girls aged between 7 and 18 years (>7 to ≤12 years: β, -0.22; 95% CI, -0.33 to -0.12; >12 to ≤18 years: β, -0.16; 95% CI, -0.23 to -0.09). Boiled or filtered drinking water was positively associated with HAZ score among younger girls (≤1 year: β, 0.26; 95% CI, 0.07 to 0.45; >1 to ≤7 years: β, 0.07; 95% CI, 0.01 to 0.14) and across all age groups in boys (≤1 years: β, 0.19; 95% CI, 0.03 to 0.35; >1 to ≤7 years: β, 0.07; 95% CI, 0.00 to 0.14; >7 to ≤12 years: β, 0.08; 95% CI, 0.03 to 0.13; >12 to ≤18 years: β, 0.06; 95% CI, 0.01 to 0.11)., Conclusions and Relevance: In this study, open defecation and lack of boiled or filtered drinking water were inversely associated with height-for-age measures across all ages in children and adolescents in India. Improved sanitation may benefit growth among children and adolescents older than 5 years.