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Author(s): Audrey Prost 1,2,*, Nirmala Nair 2, Andrew Copas 1, Hemanta Pradhan 2, Naomi Saville 1, Prasanta Tripathy 2, Rajkumar Gope 2, Shibanand Rath 2, Suchitra Rath 2, Jolene Skordis [...], Background Recent data suggest that case fatality from severe acute malnutrition (SAM) in India may be lower than the 10%-20% estimated by the World Health Organization (WHO). A contemporary quantification of mortality and recovery from acute malnutrition in Indian community settings is essential to inform policy regarding the benefits of scaling up prevention and treatment programmes. Methods and findings We conducted a cohort study using data collected during a recently completed cluster-randomised controlled trial in 120 geographical clusters with a total population of 121,531 in rural Jharkhand and Odisha, eastern India. Children born between October 1, 2013, and February 10, 2015, and alive at 6 months of age were followed up at 9, 12, and 18 months. We measured the children's anthropometry and asked caregivers whether children had been referred to services for malnutrition in the past 3 months. We determined the incidence and prevalence of moderate acute malnutrition (MAM) and SAM, as well as mortality and recovery at each follow-up. We then used Cox-proportional models to estimate mortality hazard ratios (HRs) for MAM and SAM. In total, 2,869 children were eligible for follow-up at 6 months of age. We knew the vital status of 93% of children (2,669/2,869) at 18 months. There were 2,704 children-years of follow-up time. The incidence of MAM by weight-for-length z score (WLZ) and/or mid-upper arm circumference (MUAC) was 406 (1,098/2,704) per 1,000 children-years. The incidence of SAM by WLZ, MUAC, or oedema was 190 (513/2,704) per 1,000 children-years. There were 36 deaths: 12 among children with MAM and six among children with SAM. Case fatality rates were 1.1% (12/1,098) for MAM and 1.2% (6/513) for SAM. In total, 99% of all children with SAM at 6 months of age (227/230) were alive 3 months later, 40% (92/230) were still SAM, and 18% (41/230) had recovered (WLZ [greater than or equal to] -2 standard deviation [SD]; MUAC [greater than or equal to] 12.5; no oedema). The adjusted HRs using all anthropometric indicators were 1.43 (95% CI 0.53-3.87, p = 0.480) for MAM and 2.56 (95% CI 0.99-6.70, p = 0.052) for SAM. Both WLZ < -3 and MUAC [greater than or equal to] 11.5 and < 12.5 were associated with increased mortality risk (HR: 3.33, 95% CI 1.23-8.99, p = 0.018 and HR: 3.87, 95% CI 1.63-9.18, p = 0.002, respectively). A key limitation of our analysis was missing WLZ or MUAC data at all time points for 2.5% of children, including for two of the 36 children who died. Conclusions In rural eastern India, the incidence of acute malnutrition among children older than 6 months was high, but case fatality following SAM was 1.2%, much lower than the 10%-20% estimated by WHO. Case fatality rates below 6% have now been recorded in three other Indian studies. Community treatment using ready-to-use therapeutic food may not avert a substantial number of SAM-related deaths in children aged over 6 months, as mortality in this group is lower than expected. Our findings strengthen the case for prioritising prevention through known health, nutrition, and multisectoral interventions in the first 1,000 days of life, while ensuring access to treatment when prevention fails.

Introduction Of the world's 2.9 million neonates who die in the first month of life each year, (1) around 30% (i.e. approximately 876000) are born in India. (2) Meeting the [...], Objective To determine whether a women's group intervention involving participatory learning and action has a sustainable and replicable effect on neonatal survival in rural, eastern India. Methods From 2004 to 2011, births and neonatal deaths in 36 geographical clusters in Jharkhand and Odisha were monitored. Between 2005 and 2008, these clusters were part of a randomized controlled trial of how women's group meetings involving participatory learning and action influence maternal and neonatal health. Between 2008 and 2011, groups in the original intervention clusters (zone 1) continued to meet to discuss post-neonatal issues and new groups in the original control clusters (zone 2) met to discuss neonatal health. Logistic regression was used to examine neonatal mortality rates after 2008 in the two zones. Findings Data on 41 191 births were analysed. In zone 1, the intervention's effect was sustained: the cluster-mean neonatal mortality rate was 34.2 per 1000 live births (95% confidence interval, CI: 28.3-40.0) between 2008 and 2011, compared with 41.3 per 1000 live births (95% CI: 35.4-47.1) between 2005 and 2008. The effect of the intervention was replicated in zone 2: the cluster-mean neonatal mortality rate decreased from 61.8 to 40.5 per 1000 live births between two periods: 2006-2008 and 2009-2011 (odds ratio: 0.69, 95% CI: 0.57-0.83). Hygiene during delivery, thermal care of the neonate and exclusive breastfeeding were important factors. Conclusion The effect of participatory women's groups on neonatal survival in rural India, where neonatal mortality is high, was sustainable and replicable. Objectif Determiner si un groupe feminin menant des activites d'apprentissage et des actions participatives a un effet durable et reproductible sur la survie neonatale dans l'Inde de l'Est rurale. Methodes De 2004 a 2011, les naissances et la mortalite neonatale ont ete suivies dans 36 zones geographiques des Etats du Jharkhand et de l'Odisha. Entre 2005 et 2008, ces zones ont ete integrees dans un essai controle randomise portant sur l'influence sur la sante maternelle et neonatale des reunions de groupes feminins menant des activites d'apprentissage et des actions participatives. Entre 2008 et 2011, les groupes provenant des zones d'intervention d'origine (zone 1) se reunissaient toujours pour debattre des questions post-neonatales, et les nouveaux groupes provenant des zones de controle d'origine (zone 2) se sont reunis pour aborder le sujet de la sante neonatale. On a eu recours a la regression logistique pour analyser les taux de mortalite neonatale apres 2008 dans ces deux zones. Resultats Les donnees de 41 191 naissances ont ete analysees. Dans la zone 1, l'effet de l'intervention s'est revele durable: le taux de mortalite neonatale moyen de la region a ete de 34,2 pour 1 000 naissances vivantes (intervalle de confiance de 95%, IC: 28,3-40) entre 2008 et 2011, par rapport a 41,3 pour 1 000 naissances vivantes (IC de 95%: 35,4-47,1) entre 2005 et 2008. L'effet de l'intervention s'est reprod uit dans la zone 2: le taux de mortalite neonatale moyen de la zone a baisse de 61,8 a 40,5 pour 1 000 naissances vivantes entre les deux periodes: 2006-2008 et 2009-2011 (rapport des cotes, RC: 0,69, IC de 95%: 0,57-0,83). L'hygiene pendant l'accouchement, le maintien de la temperature corporelle du nouveau-ne et l'allaitement maternel exclusif ont ete des facteurs importants. Conclusion L'effet des groupes feminins participatifs sur la survie neonatale dans l'lnde rurale, ou la mortalite neonatale est elevee, s'est revele durable et reproductible. Objetivo Determinar si las intervenciones con aprendizaje y accion participativos con grupos de mujeres tienen un efecto sostenible y reproducible en la supervivencia neonatal en las zonas rurales del este de India. Metodos Desde 2004 hasta 2011 se controlaron los nacimientos y muertes neonatales en 36 agrupaciones geograficas en Jharkhand y Odisha. Entre 2005 y 2008, esas agrupaciones formaron parte de un ensayo controlado aleatorio para averiguar como las reuniones de grupos de mujeres que incluyen un aprendizaje y accion participativos influyen en la salud materna y neonatal. Entre 2008 y 2011, los grupos en las agrupaciones originales de intervencion (zona 1) siguieron reuniendose para debatir sobre cuestiones posneonatales y otros grupos nuevos en las agrupaciones originales de control (zona 2) se reunieron para debatir sobre la salud neonatal. Se empleo una regresion logistica para examinar las tasas de mortalidad neonatal en ambas zonas tras del ano 2008. Resultados Se analizaron los datos de 41 191 nacimientos. En la zona 1, el efecto de la intervencion fue prolongado: la tasa de mortalidad neonatal media en la agrupacion fue de 34,2 por cada 1000 nacidos vivos (intervalo de confianza del 95%, IC: 28,3-40,0) entre 2008 y 2011, comparada con el 41,3 por cada 1000 nacidos vivos (IC del 95%: 35,4-47,1) entre los anos 2005 y 2008. El efecto de la intervencion se repitio en la zona 2: la tasa de mortalidad neonatal media descendio del 61,8 hasta el 40,5 por cada 1000 nacidos vivos entre dos periodos: 2006-2008 y 2009-2011 (cociente de probabilidades: 0,69, IC del 95%: 0,57-0,83). Algunos factores importantes fueron la higiene durante el parto, la atencion termica de los neonatos y la lactancia materna exclusiva. Conclusion El efecto de los grupos participativos de mujeres sobre la supervivencia neonatal en las zonas rurales de India, donde la mortalidad neonatal es elevada, resulto sostenible y reproducible.

Abstract Background Around a quarter of the world's neonatal and maternal deaths occur in India. Morbidity and mortality are highest in rural areas and among the poorest wealth quintiles. Few interventions to improve maternal and newborn health outcomes with government-mandated community health workers have been rigorously evaluated at scale in this setting. The study aims to assess the impact of a community mobilisation intervention with women's groups facilitated by ASHAs to improve maternal and newborn health outcomes among rural tribal communities of Jharkhand and Orissa. Methods/design The study is a cluster-randomised controlled trial and will be implemented in five districts, three in Jharkhand and two in Orissa. The unit of randomisation is a rural cluster of approximately 5000 population. We identified villages within rural, tribal areas of five districts, approached them for participation in the study and enrolled them into 30 clusters, with approximately 10 ASHAs per cluster. Within each district, 6 clusters were randomly allocated to receive the community intervention or to the control group, resulting in 15 intervention and 15 control clusters. Randomisation was carried out in the presence of local stakeholders who selected the cluster numbers and allocated them to intervention or control using a pre-generated random number sequence. The intervention is a participatory learning and action cycle where ASHAs support community women's groups through a four-phase process in which they identify and prioritise local maternal and newborn health problems, implement strategies to address these and evaluate the result. The cycle is designed to fit with the ASHAs' mandate to mobilise communities for health and to complement their other tasks, including increasing institutional delivery rates and providing home visits to mothers and newborns. The trial's primary endpoint is neonatal mortality during 24 months of intervention. Additional endpoints include home care practices and health care-seeking in the antenatal, delivery and postnatal period. The impact of the intervention will be measured through a prospective surveillance system implemented by the project team, through which mothers will be interviewed around six weeks after delivery. Cost data and qualitative data are collected for cost-effectiveness and process evaluations. Study registration ISRCTN: ISRCTN31567106

Abstract Background Few large and rigorous evaluations of participatory interventions systematically describe their context and implementation, or attempt to explain the mechanisms behind their impact. This study reports process evaluation data from the Ekjut cluster-randomised controlled trial of a participatory learning and action cycle with women's groups to improve maternal and newborn health outcomes in Jharkhand and Orissa, eastern India (2005-2008). The study demonstrated a 45% reduction in neonatal mortality in the last two years of the intervention, largely driven by improvements in safe practices for home deliveries. Methods A participatory learning and action cycle with 244 women's groups was implemented in 18 intervention clusters covering an estimated population of 114 141. We describe the context, content, and implementation of this intervention, identify potential mechanisms behind its impact, and report challenges experienced in the field. Methods included a review of intervention documents, qualitative structured discussions with group members and non-group members, meeting observations, as well as descriptive statistical analysis of data on meeting attendance, activities, and characteristics of group attendees. Results Six broad, interrelated factors influenced the intervention's impact: (1) acceptability; (2) a participatory approach to the development of knowledge, skills and 'critical consciousness'; (3) community involvement beyond the groups; (4) a focus on marginalized communities; (5) the active recruitment of newly pregnant women into groups; (6) high population coverage. We hypothesize that these factors were responsible for the increase in safe delivery and care practices that led to the reduction in neonatal mortality demonstrated in the Ekjut trial. Conclusions Participatory interventions with community groups can influence maternal and child health outcomes if key intervention characteristics are preserved and tailored to local contexts. Scaling-up such interventions requires (1) a detailed understanding of the way in which context affects the acceptability and delivery of the intervention; (2) planned but flexible replication of key content and implementation features; (3) strong support for participatory methods from implementing agencies.

Abstract Background In places with poor vital registration, measurement of maternal mortality and monitoring the impact of interventions on maternal mortality is difficult and seldom undertaken. Mortality ratios are often estimated and policy decisions made without robust evidence. This paper presents a prospective key informant system to measure maternal mortality and the initial findings from the system. Methods In a population of 228 186, key informants identified all births and deaths to women of reproductive age, prospectively, over a period of 110 weeks. After birth verification, interviewers visited households six to eight weeks after delivery to collect information on the ante-partum, intra-partum and post-partum periods, as well as birth outcomes. For all deaths to women of reproductive age they ascertained whether they could be classified as maternal, pregnancy related or late maternal and if so, verbal autopsies were conducted. Results 13 602 births were identified, with a crude birth rate of 28.2 per 1000 population (C.I. 27.7–28.6) and a maternal mortality ratio of 722 per 100 000 live births (C.I. 591–882) recorded. Maternal deaths comprised 29% of all deaths to women aged 15–49. Approximately a quarter of maternal deaths occurred ante-partum, a half intra-partum and a quarter post-partum. Haemorrhage was the commonest cause of all maternal deaths (25%), but causation varied between the ante-partum, intra-partum and post-partum periods. The cost of operating the surveillance system was US$386 a month, or US$0.02 per capita per year. Conclusion This low cost key informant surveillance system produced high, but plausible birth and death rates in this remote population in India. This method could be used to monitor trends in maternal mortality and to test the impact of interventions in large populations with poor vital registration and thus assist policy makers in making evidence-based decisions.

Background: In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community health forums, but there is little information about their composition, functioning and effectiveness. Our study examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of eastern India - West Singhbhum in Jharkhand and Kendujhar, in Odisha.Methods: We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with purposively selected better and poorer performing committees, across the two states. We analysed the quantitative data using descriptive statistics and the qualitative data using a Framework approach.Results: We found that VHSNCs comprised equitable representation from vulnerable groups when they were formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes. Less than 1 % members had received any training. Supervision of committees by district or block officials was rare. Their work focused largely on strengthening village sanitation, conducting health awareness activities, and supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers acted as conveners and record keepers. Links with the community involved awareness generation and community monitoring of VHSNC activities. Key challenges included irregular meetings, members' limited understanding of their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader health system.Conclusions: Our study suggests that VHSNCs perform few of their specified functions for decentralized planning and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need education, mobilisation and monitoring for formal links with the wider health system. [ABSTRACT FROM AUTHOR]