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Background: In India the proportion of early initiation of breastfeeding is hovering around 50% and the proportion of cesarean deliveries is increasing substantially. Objectives: To compare the prevalence of early initiation of breastfeeding (EIBF) among cesarean and vaginally delivered women in hospitals in Pune District, Maharashtra State, India and to measure any association between EIBF and various socio-demographic, maternal and fetal factors. Methods: This was a multi-site study conducted in 13 selected hospitals in Pune District in 2017-18. Pune District by population is the fourth largest in India. All women delivered by cesarean section in these hospitals and an equal number of age and parity matched vaginally delivered women were enrolled. They were interviewed before discharge by obstetricians or nurses under the supervision of obstetricians, using a structured, validated tool. The data were analyzed by using Statistical Package for Social Sciences, version 25. Results: In each group, 1,556 women were enrolled. The prevalence of EIBF was 81.5% and 63.6% among vaginally and cesarean delivered women. There was a significant association between EIBF and the place of residence, mode of delivery, gestational period, parity, and presence of some disease. Residence in the rural area was the strongest enabling factor with an adjusted odds ratio of 29.6 (95% C.I.; 18.7-46.9) whereas cesarean section, preterm delivery and first para were impeding factors. Conclusions: Among institutional delivered women EIBF was about 70%. Health care workers need to strongly promote EIBF awareness, especially among women from urban areas, and undergoing cesarean section.

Highlights • Prelicensure trials of ROTAVAC® not powered to assess risk of intussusception. • During ROTAVAC® rollout we assessed risk of intussusception in infants in 3 states. • No increased risk of intussusception within 21 days of 1st and 2nd dose. • No increased risk of intussusception within 21 days of any single dose or all 3 doses., Background Pre-licensure trials of ROTAVAC® were not adequately powered to assess risk of intussusception, a rare adverse event associated with other rotavirus vaccines in some settings. We examined the risk of intussusception after ROTAVAC® vaccination among Indian infants during pilot rollout of the vaccine in the public health system in three states - Himachal Pradesh, Maharashtra and Tamil Nadu. Methods Passive surveillance for intussusception was set up in 35 sentinel health facilities covering 26.3 million population in the three states under monitoring of an Interministerial-Interagency Steering Committee. Clinical and immunization data were collected by independent teams. An expert committee blinded to vaccination status, classified intussusception cases using Brighton criteria. The self-controlled case-series method was used to estimate risk of intussusception (Brighton Level 1) after ROTAVAC® vaccination. Results 151 intussusception cases were included in the analysis. The relative incidence (incidence during the risk period compared to the control period) 1–21 days after doses 1 and 2 combined was 1.56 (95% CI, 0.0–5.28) and that for three doses combined was 1.88 (95% CI, 0.76–4.30). Attributable risk 1–21 days after doses 1 and 2 combined was 0.11 (95% CI, 0.0–0.25) and that for 3 doses combined was 0.42 (95% CI, 0.0–0.70) per 100,000 doses. Conclusions No increased risk of intussusception within 21 days of receipt of the first two doses combined or all 3 doses combined of ROTAVAC® was detected.

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.

Purpose A cross-sectional epidemiological survey of children was conducted in two rural clusters to estimate the point prevalence and study various aspects of childhood epilepsy. Material and methods In the first stage, a house-to-house survey was conducted by health workers using a screening questionnaire, which was pre-validated in a pilot study. All screen positive houses were visited by pediatric neurologist for detailed evaluation. Children with a clinical diagnosis of epilepsy underwent EEG and were evaluated for type of seizure, epilepsy syndrome, etiology, co-morbidities and treatment gap. Knowledge, attitude and practice regarding epilepsy was assessed amongst caregivers of the affected children. Results A total population of 75,455 population was screened, 19,181 children aged 2 months to 18 years were identified. Out of 355 screen positive children, 66 were diagnosed with epilepsy. The point prevalence of pediatric epilepsy was 3.44 per 1000 children. 53% had focal epilepsy, 31.8% had an identifiable epilepsy syndrome, 44% had at least one comorbidity. The etiology was identified in 68%, the commonest being perinatal brain insult. The magnitude of treatment gap was 45.45%, with significant deficits in knowledge. Conclusion There are significant deficits in diagnosis and treatment of pediatric epilepsy among the rural population of India. The existing rural health care facilities need to be augmented to facilitate the timely diagnosis and optimum care of these children, including care of associated co-morbidities.

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.

Context: Many women have postpartum sexual dysfunction. The mode of delivery is an important determinant. Aims: To calculate the risk ratio of non-resumption of vaginal sex and dyspareunia during the postpartum period among cesarean-delivered women. Settings and Design: This large multisite study was conducted in 13 selected hospitals in Pune District during 2017–19. Methods and Material: A total of 3,112 women (half cesarean delivered and half vaginally) were interviewed by trained health workers using a structured questionnaire. Women were interviewed at 4 weeks, 6 weeks, and 6 months. Statistical analysis used: Chi-square test was applied. A risk ratio with a 95% confidence interval was calculated. Results: At 6 weeks, the risk ratio of non-resumption of vaginal sex was significantly high among cesarean-delivered participants (1.14). Cesarean-delivered women had a lesser risk ratio of dyspareunia at both follow-ups (0.59, 0.49). Even at 6 months, about one-third vaginally delivered women had dyspareunia. The proportion of women non-resuming vaginal sex gradually decreased from 6 weeks to 6 months. The proportion of women having dyspareunia also decreased from 6 weeks to 6 months following childbirth. Residence in the rural area and cesarean delivery were the significant determinants of an early resumption of vaginal sex. Dyspareunia was significantly high among vaginal delivered than cesarean. About 25% of women continued to have dyspareunia up to 6 months. Conclusions: A large number of women suffer from dyspareunia; hence antenatal and postnatal care should include some counseling and management about the resumption of sex and dyspareunia.

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.

IntroductionNeonatal infections are a common cause of death in India, but many families cannot access appropriate hospitals for its treatment due to various reasons. We implemented the World Health Organization PSBI management guideline when referral is not feasible within the public health system in Pune, India to evaluate feasibility, barriers and facilitators for its implementation.MethodsA national-level consultative meeting between government officials and study partners resulted in a consensus on adaptation and implementation in four demonstration sites in selected states in India. At the state and district levels, similar meetings to plan the implementation strategy and roles were held between KEM Hospital Research Centre (KEMHRC) Pune and the public health system Pune, Maharashtra. The public health system was responsible for implementation of the intervention at eight tribal primary health centres (PHC) in Pune district, India, including delivering the intervention and ensuring supplies of all commodities while KEMHRC was responsible for technical support including training of health workers, assistance in PSBI identification and management, data collection and documentation of the implementation strategy.ResultsA total of 175 young infants with PSBI were identified and managed. Of these, 34 had critical illness (CI), 46 had clinical severe infection (CSI) and 10 were infants aged 0-6 days with fast breathing (FB) while 85 infants aged 7-59 days had fast breathing. Assuming a 10% incidence of PSBI among all live births, with 3071 live births recorded, the actual incidence of PSBI found in the study was 5.7%, resulting in an actual coverage was of 57%. Among the 90 infants with CI, CSI and FB in 0-6 days, who were advised referral to government tertiary care centre as per the PSBI guideline algorithm, 81 (90%) accepted referral while 9 (10%) refused and were offered treatment at primary health centres (PHC) with a seven-day course of injectable gentamicin and oral amoxicillin. All infants with FB in 7-59 days were offered treatment at PHCs as per the PSBI guideline algorithm with a seven-day course of oral amoxicillin. All except six infants who died and one with FB in 7-59 days, who was lost to follow-up, were successfully cured. Of the six who died, five had CSI and one had CI. Among the 81 infants with CI, CSI and FB in 0-6 days who accepted referral; 48(53%) were successfully referred to government tertiary facility while 33 (36.6%) preferred to visit a private tertiary health facility. The implementation strategy demonstrated a relatively high fidelity, acceptance and intervention penetration. Lack of training and confidence of the public health staff were major challenges faced, which were resolved to a large extent through supportive supervision and re-trainings.ConclusionManagement of PSBI is feasible to implement in out-patient facilities in the public health system, but technical support to the health system is required to jump-start the process. Fast breathing in 7-59 days old infants can be managed with oral amoxicillin without referral. A sustainable adoption of this intervention by the health system can lead to decrease in neonatal mortality and morbidity.

OBJECTIVE: To improve the awareness and knowledge regarding Maternal Near Miss (MNM) among health service providers in the selected districts and women’s hospitals in Maharashtra, India. METHODS: A one-day training programme on MNM was conducted at four Family Welfare Training Centres in the state of Maharashtra, India, for the health service providers, viz. gynaecologists, pathologists, anaesthesiologists, medical officers, staff nurses, other paramedical workers of the selected 29 districts/women’s hospitals in Maharashtra. A total of 147 participants participated in the training programme. The participants filled a questionnaire before (pretest) and after the training (post-test) with the same set of questions pertaining to knowledge on the basic and operational aspects of MNM. RESULTS: There was a significant improvement in the level of knowledge (post-test responses vs pretest responses) about the correct definition and classification of MNM, as per the instructions in the MNM-R guidelines by the Government of India. The service providers informed regarding the challenges in the implementation of the MNM-R guidelines at their hospitals such as shortage of manpower in terms of specialists and need of quality assurance. CONCLUSION: The training programme improved the knowledge of the service providers about MNM, which would help them to implement the MNM-R guidelines effectively at their hospitals. This training effectively upgraded the knowledge level, and therefore, such trainings should be organized for all obstetricians, high-dependency unit (HDU) personnel and critical care teams. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13224-019-01259-7) contains supplementary material, which is available to authorized users.

Background: Timely administration of vaccines, particularly for hepatitis B birth dose within 24 hours of birth is of immense importance. It is considered as an indicator of quality of immunization programme. This study aimed to assess effect of mode of delivery and type of hospital on immunization among newborns. Methods: This large multi-site study was conducted in Pune district having population of 9.43 million. A total of 13 hospitals were selected which included all government hospitals performing more than five cesarean sections per month, and one government and one private medical college hospital. Cesarean section and vaginally deliveries were enrolled in 1:1 ratio. Their children were followed till discharge. Data were collected by obstetrician or qualified nurse.Results: During study period 3,112 women were enrolled. The relative risk of not getting vaccine Hepatitis B birth dose before 24 hours among cesarean delivered newoborns was 1.08. The relative risk of not getting zero polio and BCG among cesarean delivered newborns was 0.71 and 0.76 respectively. All these differences were significant. The coverage for all vaccines was better in sub district hospitals than others. Coverage of all vaccines in government teaching hospital was better than private.Conclusions: Cesarean section enabled better coverage among newborns probably due to length of stay. Whereas the physical and mental stress after cesarean section resulted lesser coverage of hepatitis B birth dose within 24 hours. Opportunities of timely Hepatitis B birth dose administration were missed probably due to lack of knowledge among health workers about ideal timing.

The year 2006 witnessed an extensive outbreak of Chikungunya fever in Maharashtra state. Out of 6467 sera of suspected patients sent to National Institute of Virology, Pune, 804 were serologically confirmed. This retrospective study was carried out by interrogating all those patients for their sickness experience. Adult females from rural area were more affected than males. In 68.2% families, there were multiple cases. Fever and multiple joint involvement were almost invariable. In 36.5% patients, there was history of recurrence. Along with pain, slight swelling was noticed in 55% patients. The commonest joints involved were wrist, inter-phalangeal, elbow, knee and ankle, in that order. The pain and swelling persisted for more than a month. After health education during outbreak, there was positive improvement in behavior pertaining to source reduction of vector. Inter-personal communication was best remembered. In health education, the role of paramedical workers and government doctors was prominent.

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.