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Background: India has the second-highest number of under-five deaths in any country in the world. WHO and the Government of India recommended the rollout of preconception care (PCC) to reduce maternal and child mortality. However, very few countries, including India, have started a comprehensive package of PCC services. It implies that women, mainly from rural and tribal areas, are not aware of PCC. PCC has been rolled out through the government health system in two blocks of Nashik district in Maharashtra state, India, among all women who desire to be pregnant within 1 year. This project is the first of its kind in India. To assess basic perceptions, knowledge, and behavior of women on PCC before the implementation of the project, focus group discussions (FGDs) were carried out. The authors think that the finding may help to develop strategies for behavioral change communication.Methods: From each of the four blocks, two villages having subcenter were selected for conducting FGD. A house-to-house survey was conducted by Accredited Social Health Activist (ASHA) to enlist women who desire a baby in 1 year and invite them to subcenter for FGDs, which were conducted in June 2018.Results: A total of 76 women having a mean age of 23.97 years participated in the FGDs. Most of them (46.05%) had completed 10 years of education. About 50% of pregnancies were planned. The decision about the timing of the first pregnancy is influenced by the mother-in-law. Women knew that they should not conceive before 20 years of age, and their suboptimal weight may have an adverse impact on the health of the newborn. There are many myths about food like “hot and cold foods” and “forbidden food” etc. Women had some knowledge about the adverse effects of tobacco and alcohol; very few consumed these. Most of them did not practice behaviors or accessed services related to PCC.Conclusions: Women neither have the knowledge nor adopt behaviors or accessed services related to PCC. Roll out of PCC among them may help in further reduction of maternal and neonatal morbidity and mortality in India.

BackgroundThe preconception phase of women’s life cycle is critical but comparatively ignored. The presence of health risks is judged as hazardous to the wellbeing of women and their offspring. This study aimed to estimate the prevalence of various pregnancy outcomes and assess the association between certain risk factors and adverse outcomes.MethodsAs a part of a preconception care intervention project, a baseline survey was conducted in four blocks of Nashik District, India. In this population-based cross-sectional analytical study, we compared cases in the study group (randomly selected one tribal and one non-tribal block) with those of the control group (one tribal and one non-tribal block). A comparison was also made between the tribal and non-tribal blocks in each group. All women who had a pregnancy outcome in the preceding 12 months (01 April 2017 to 31 March 2018) were interviewed. Trained Accredited Social Health Activists conducted the survey under the direct supervision of Auxiliary Nurse Midwives and Medical Officers. Multivariate analysis was carried out to find the adjusted prevalence ratio of having a particular adverse outcome because of the prespecified potential risk factors.ResultsA total of 9307 women participated in the study. The prevalence of adverse pregnancy outcomes was as follows: abortion in 4.1%, stillbirth in 1.7%, preterm birth in 4.1%, low birth weight in 13.2%, and congenital physical defect in 2.8%. Prevalence of parental consanguinity, pre-existing maternal illness at conception, heavy work during the last six months of pregnancy, tobacco consumption, alcohol consumption, direct exposure to pesticides and domestic violence during pregnancy was 18.5, 2.2, 18.7, 5.6, 0.5, 2.3, and 0.8% respectively. Risk factors associated with abortion included pre-existing illness and heavy work in the last six months of the pregnancy. Consanguinity, tobacco consumption during pregnancy and pre-existing illness were identified as risk factors for stillbirth. Significant risk factors of low birth weight were heavy work in the last six months of pregnancy, pre-existing illness and residence in a tribal area.ConclusionThere is a need to emphasize on maternal behaviour, including tobacco consumption, and heavy work during pregnancy, as well as on parental consanguinity and pre-existing maternal illnesses, in order to achieve the best possible pregnancy outcomes.

Background: The health of women during the preconception phase though critical, is a comparatively ignored part in her life cycle. The presence of health risks is judged as hazardous to the wellbeing of women and their forthcoming progeny. The study aimed to estimate the prevalence of various pregnancy outcomes and assess the association between various risk factors and adverse outcomes. Methods: It was a population-based cross-sectional analytical study. The study was carried out in Nashik District, having a large mountainous area. It included two randomly selected blocks, one tribal and one nontribal, in which interventions were planned in the later stage. For comparison, two adjacent blocks, one tribal and one nontribal, were also included. All women who had a pregnancy outcome in the preceding 12 months (01 April 2017 to 31 March 2018) were interviewed. Trained Accredited Social Health Activists under the direct supervision of Auxiliary Nurse Midwives and Medical Officers conducted the survey. Multivariate analysis was carried out to find the adjusted risk ratio of having a particular adverse outcome because of the specified potential risk factors.Results: A total of 9,307 women participated in the study. The prevalence of adverse pregnancy outcomes was abortion 4.1%; stillbirth 1.6%; preterm birth 4.1%; LBW 11.2%; congenital physical defect 2.6%. Prevalence of consanguineous marriage, heavy work during the last six months of pregnancy, pre-existing illness, tobacco consumption, direct exposure to pesticides and domestic violence during pregnancy was 17.6%; 16.9%; 2.2%; 5.6%; 2.3%; and 0.8%, respectively. Risk factors that were significantly associated with abortion include existing illness at the time of conception and performing heavy work in the last six months of pregnancy. Consanguinity, tobacco consumption during pregnancy and pre-existing illness were identified as risk factors for stillbirth. Significant risk factors of LBW were heavy work in the last six months of pregnancy, pre-existing illness and residence in a tribal area. Conclusion: The survey showed that risk factors differentially affect outcomes of pregnancy. Preconception and antenatal care should include counselling about consanguineous marriages, identifying and managing a pre-existing illness, avoiding tobacco consumption in the prenatal and natal period, and avoiding heavy work during pregnancy.

Background: Preconception phase in women though critical is comparatively ignored. The presence of risk factors affects well-being of the woman and her forthcoming progeny. The objectives of the study were to measure the prevalence of various risk factors among women and their comparison between blocks.Methods: This was a community based cross-sectional study in two tribal and two non-tribal blocks in Nasik district, Maharashtra, India. The study included women desiring conception within one year. Trained Accredited Social Health Activists collected information through house-to-house visits using a validated interview schedule. They recorded anthropometric measures of women in a standard manner. Results: The study enlisted 7,875 women desiring pregnancy soon. The mean age of women was 23.19 (+3.71) years and 16% of them were adolescents. Women's illiteracy was higher in tribal areas than non-tribal (p+3.51) and higher proportion (40.5%) of women from tribal areas were having BMIConclusions: Health risks namely younger age, illiteracy, high parity, consumption of tobacco, low protein and calories intake were found to be prevalent and the risks were significantly more among tribal women. “Continuum of care” must include preconception care.

Background India has the highest number of under-five deaths in any country in the world. World Health Organization and Government of India recommended roll out of preconception care (PCC) for reduction of maternal and child mortality. However, very few countries including India have implemented a comprehensive package of PCC services. PCC has been rolled out among all women, who desire to be pregnant in one year through the government health system in two blocks of Nashik district of Maharashtra State, India. In order to assess the impact of PCC in these two blocks, baseline and post intervention studies (both quantitative and qualitative) on women’s knowledge and behaviour on PCC, their health status and pregnancy outcomes are planned in these two intervention blocks as well as in two control blocks. To assess women’s knowledge and behaviour on PCC before implementation of the project, focus group discussions (FGDs) were carried out as part of this impact assessment project.Methods From each of the four blocks, two villages having sub centre were selected for conducting FGD. A house to house survey was conducted by Accredited Social Health Activist (ASHA) to enlist women who desire a baby in one year. From the list, eight to twelve women were invited to sub centre for FGDs, which were conducted in June 2018.Results A total of 76 women having mean age 23.97 years participated in the FGDs. Most of them (46.05%) had completed 10 years of education. About 50% of pregnancies are planned. The decision about first pregnancy is influenced by the mother-in-law. Women knew that they should not conceive before 20 years of age and their inadequate weight may have adverse impact on the health of new-born. Women had some knowledge about adverse effects of tobacco and alcohol use, very few consumed these. Most of them did not practice behaviours or accessed services related to PCC.

BACKGROUND: Shortage of skilled birth attendants (SBA) is one of the determinants of maternal mortality in India. To combat this shortage innovative task-shifting strategies to engage providers of the Indian system of medicine (Ayurveda and Homeopathy) called AYUSH practitioners (AP) to provide SBA services is being implemented. METHODS: Engagement of APs for SBA service provision was assessed in 3 states of India (Maharashtra Rajasthan and Odisha) through 73 in-depth interviews (37 with APs and 36 with programme managers). The interviews explored the providers SBA training experience barriers for SBA service provision workplace and community acceptance and the perspective of programme managers on the competence and quality of SBA services provided. RESULTS: SBA training led to skill enhancement with adoption of appropriate maternal and newborn care practices. A dedicated trainer more hands-on practice and strengthening training on newborn care practices and management of complications emerged as the training needs. Conditional involvement in SBA-related work a discriminatory attitude at the workplace and lack of legal/regulatory authorisation were identified as barriers to the inclusion of APs in SBA service provision. CONCLUSIONS: Quality skill enhancement measures an enabling work environment a systematic task-shifting process role definition supportive supervision and credentialing could be key for the integration of APs and their acceptance in the health system. (c) The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions please e-mail: journals.permissions@oup.com.

Objective to understand the use of the partograph by Skilled Birth Attendance/Basic Emergency Obstetric Care (SBA/BEmOC) trained practitioners from Indian systems of medicine called AYUSH practitioners (APs). Design mixed method observational study, including an exploration of the views of APs, programme managers and SBA trainers on the necessity, feasibility and barriers to the use of partograph. Setting primary and community health centres in two purposively selected districts in each of the three states (Rajasthan, Maharashtra and Odisha) in India where SBA/BEmOC trained APs are deployed to provide SBA services. In-depth interviews with state, district and block level programme managers were held at their respective headquarters. Participants 83 APs plotted the simplified partograph based on a given labour case scenario. In-depth interviews were conducted with 36 programme managers and 37 APs (24 Ayurvedic and 13 Homoeopathic). Measurements and findings the completed simplified partograph was analysed according to a previously devised scoring system with a score of 70% or more indicating competency. APs in Rajasthan and Maharashtra demonstrated good partograph plotting skills (72.1% and 82% respectively) obtaining a competency score of more than 70%. However, overall performance of APs in Odisha was poor (11.1%) and except correct recording of fetal condition, the APs did not score well in the plotting of the other partograph components. Errors occurred mainly in the recording of cervical dilatation and uterine contractions. The in-depth interviews revealed that most APs demonstrated a good understanding of the tool in the context of decision making regarding timely referral in case of prolonged labour or fetal distress. There was a high perception of the need for more hands-on training in the SBA training curriculum. The programme managers also expressed the need for appropriate training and supervision to ensure good plotting of partograph. The barriers for partograph use included increased workload, insufficient training, unavailability of partograph forms and its non-utility for women coming late in labour. Key conclusions knowledge of plotting and correct interpretation of partograph were generally good in two states but more practice is needed to improve providers׳ skills. Identified barriers could be addressed with further training and local managerial support. An analysis of the causes for the poor performance of APs in Odisha should be carried out. Pre-service and periodic in-service training of APs on the completion of the partograph, regular supportive supervision, implementation of programme guidelines on mandatory completion of partograph and an environment that supports its correct and consistent use are recommended. Implications for practice with appropriate training, it is feasible for AYUSH practitioners to use partograph for monitoring progress of labour.

Objective: To study predictive utility of admission test (AT) for perinatal outcome in high risk labours. Method: A hundred patients at risk of fetal jeopardy due to uteroplacental insufficiency were screened by admission test. The traces were classified as per the criteria suggested by Ingemarsson and Arulkumaran (1986). The perinatal outcome was correlated with the initial FHR pattern and Chi square test was applied to the results. Results: Fifty-eight patients had reactive, 35 had equivocal and 7 had ominous tracing. The incidence of operative delivery for fetal distress showed a progressive rise from reactive (5.17%) to ominous (28.5%) pattern group. The perinatal morbidity also showed a rise from 6.89% in the reactive to 31.42% in the equivocal (p < 0.01) and 85.71% in the ominous group (p < 0.02). The reactive pattern was assuring of the fetal well being for next 5 hours. Presence of late decelerations and decelerations of 60 beats or more below the baseline were additional ominous characteristics, associated with a significant increase in perinatal morbidity. Conclusion: Reactive AT appears to be predictive of fetal well being in high risk labours also. Repeat tracing 4 to 5 hours apart may improve the predictive accuracy. Equivocal and ominous patterns require vigilant monitoring.

Objectives: To study the feasibility of use of color-coded rings as a proxy for partograph for early identification of slow progress of labor. Materials and Methods: Color-coded rings were devised as a tool using appropriate technology to translate the partographic principles into simpler, easy to understand methodology. The rings were in pairs of 4 colors i.e., red, blue, yellow, and green, ranging from 3 cm to 10 cm in diameter with a difference of 4 cm between rings of the same color. The midwife performed p/v examination of the woman in labor to assess the initial cervical dilatation and identify corresponding ring. P/V was to be repeated after 4 hours to reassess the cervical dilatation and compare it with the bigger ring of the same color indicating expected cervical dilatation. If existing cervical dilatation measured lesser, it was interpreted as slow progress of labor indicating referral. Results: 44 women [23 (22.1%) primis and 21 (13%) multis] showed delayed progress of labor as judged by use of color-coded rings. 20 women (4 primis and 16 multis) showed satisfactory progress or delivered by the time arrangements for referral were made. Conclusion: Use of color-coded rings may serve as a valuable tool based on appropriate technology to assess slow progress of labor not only in the hands of nurse midwives but it also can serve as a training tool for TBAs to help facilitate timely referral of such cases.

Background: Use of 'Mishri' (Tobacco containing teeth cleaning powder) is common in the central and southern part of India. Objectives: To study the effects of Mishri use on the fetus during pregnancy and the perinatal outcome, and stopping its use. Materials and Methods: All apparently healthy pregnant women were enrolled at 20 weeks of gestation from rural Maharashtra, India. Information related to use and giving up of Mishri, previous obstetrical history, current pregnancy, delivery and outcome during the perinatal period were recorded. Appropriate tests of significance were applied. Results: Out of 705 enrolled pregnant women, 218 (30.9%) were using Mishri. The proportion of women with complications during the previous perinatal period, complaints and complications during the current pregnancy/delivery and the number of stillbirths were significantly more among Mishri users. A relative risk of abnormal delivery was 2.7 for the users. In spite of counseling, 153 women never stopped the use of Mishri and gave birth to babies weighing on an average 169.9 gm less (statistically significant) than babies born from the group that never used it. Babies of 28.8% who stopped/reduced consumption of Mishri were significantly benefited. Conclusions: The improvement seen in babies born to 28.8% mothers who stopped/reduced consumption of Mishri by 32 weeks during the current pregnancy is of paramount importance in the developing world for primary prevention of low birth weight.