Individual and facility-level determinants of iron and folic acid receipt and adequate consumption among pregnant women in rural Bihar, India

Drivers of Anemia Reduction among Women of Reproductive Age in the Philippines: A Country Case Study

BACKGROUND

Anemia prevalence among women of reproductive age (WRA) in the Philippines was 25% in 2000, decreasing to 13% in 2018. To date, an in-depth assessment of the determinants associated with this decline has not been conducted.

OBJECTIVE

To conduct a systematic in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in the Philippines between 2008 and 2018.

METHODS

Employing standard Exemplars methodology, we conducted quantitative analyses using the Philippines' National Nutrition Survey, the Expanded National Nutrition Survey, and the Philippines National Demographic and Health Surveys. Qualitative analyses included a comprehnsive literature review, program/policy analysis, and interviews with stakeholders to understand country-level enablers and barriers to WRA anemia decline in the Philippines. A final Oaxaca-Blinder decomposition analysis (OBDA) evaluated the relative contribution of direct and indirect factors.

RESULTS

Among non-pregnant women (NPW), mean hemoglobin (Hb) increased from 12.7 g/dL in 2008 to 13.1 g/dL in 2018 (p<0.01), corresponding to an 11%-point decline in anemia prevalence (23% to 12%). Inequities by geographical region, household wealth, and women's educational attainment narrowed considerably during this time. Important direct and indirect nutrition programs were introduced during our study period, including universal healthcare and food fortification. Country experts interviewed credited programs focused on alleviating micronutrient deficiencies and poverty, and improvements in women's health and well-being, for the country's extraordinary success. OBDA explained ∼50% of the observed change in mean Hb among NPW, with family planning (35%), household socio-demographics (29%), and improvement in women's nutrition (23%) emerging as critical drivers of anemia decline, corroborating our qualitative and policy analyses.

CONCLUSIONS

To protect these gains, WRA anemia prevention efforts in the Philippines should continue to focus on universal healthcare access, women's empowerment, and poverty alleviation.

Do timing and frequency of antenatal care make a difference in maternal micronutrient intake and breastfeeding practices? Insights from a multi-country study in South Asia

Despite the established benefits of vitamins and minerals for maternal and neonatal health, global micronutrient deficiency remains a significant concern. As such, the World Health Organization advocates timely antenatal care (ANC) initiation and micronutrient supplementation for expectant mothers. This study investigates the association between ANC timing and frequency and maternal health behaviours, specifically iron-folic acid (IFA) intake, early breastfeeding initiation, and exclusive breastfeeding among married women in South Asia. By utilizing recent Demographic and Health Survey data, this study focuses on married women aged 15-49 in Bangladesh (N = 966), India (N = 89,472), and Pakistan (N = 1,005), specifically primiparous women with children aged 0-23 months living with the motherMultivariable analysis revealed that women receiving ≥4 ANC visits were more likely to consume IFA ≥90 days compared to those with fewer visits in Bangladesh (AOR: 1.85, 95% CI [1.30, 2.63]), India (AOR: 1.87, 95% CI [1.81, 1.94]), and Pakistan (AOR: 1.92, 95% CI [1.24, 2.97]). Women receiving first ANC in the second or third trimester were less likely to consume IFC for ≥90 days compared to those with first-trimester ANC. While the ANC timing did not significantly influence early breastfeeding initiation, ANC frequency was inversely associated with delayed initiation in all countries. Breastfeeding advice during ANC visits was significantly associated with reduced odds of delayed breastfeeding initiation. Neither ANC timing nor frequency significantly predicted exclusive breastfeeding, except for breastfeeding advice in India. This study highlights the importance of ANC in maternal and child health outcomes. ANC timing and frequency, along with breastfeeding advice during ANC, notably influence maternal IFA consumption and early breastfeeding initiation. These findings underscore the need for targeted interventions during ANC visits to enhance maternal and child health practices in low- and middle-income countries.

Level and factors associated with compliance to iron-folic acid supplementation among pregnant women in rural Soro district, Hadiya Zone, Ethiopia: cross-sectional study

BACKGROUND

Despite the advantages of iron and folic acid supplementation, the compliance status among pregnant women for the supplements is very low in Ethiopia. However, the factors found to be associated with the compliance of iron and folic acid supplementation varies depending on geographical locations and socio-cultural characteristics within the country. Therefore, this study assessed the compliance to iron and folic acid supplements and its associated factors among pregnant women in the rural Soro district, Hadiya Zone, Southern Ethiopia.

METHODS

Cross-sectional study design was applied to conduct the study. The total sample size was 274. This study was conducted from June 10 up to 20, 2018. Women who live in rural Soro district at least for 6months and gave live birth 12 months prior to the survey were included in the study. The study subjects were selected by applying the simple random sampling method. Independent variables with p-value less than or equal to 0.25 during bivariate analysis were candidate for multivariable analysis. Finally, during multivariable analysis the independent variables with P-value less than 0.05 were declared as factors significantly associated with compliance to iron-folic acid supplementation during pregnancy.

RESULTS

Of the whole study participants only 51(18.8%) women had taken iron folic acid supplements for at least 90 days during their last pregnancy. Women who had frequent visits to health facilities for ante natal care were more likely to be compliant with iron-folic acid supplements than their counterparts [AOR(95%CI) = 4.50(1.18, 17.14)].

CONCLUSION

In this study, the higher proportion of pregnant women did not take adequate dose of iron and folic acid tablets during their last pregnancy. Women who had a frequent visit to health facilities for antenatal care were more likely to be compliant for iron folic acid supplements than their counterparts. Every effort should be made in the community and health facilities by concerned bodies working in the maternal health area to mobilize pregnant women to take the antenatal care for at least four times to achieve the minimum dose of iron and folic acid supplements.

What Makes Bangladeshi Pregnant Women More Compliant to Iron-Folic Acid Supplementation: A Nationally Representative Cross-Sectional Survey Result

BACKGROUND

Iron-Folic Acid Supplementation (IFAS) is an effective strategy to prevent iron deficiency anemia during pregnancy. We aimed to explore the key factors associated with compliance to IFA tablets in Bangladesh.

METHODS

This study analyzed the 2017-2018 Bangladesh Demographic and Health Survey data of 3828 pregnant women aged 15-49 years. We categorized compliance into two categories; at least 90 days and full 180 days of consumption. We performed multivariable logistic regression to identify the association between key factors and IFAS compliance.

RESULTS

The prevalence of consumption of IFA tablets for at least 90 days was 60.64%, and only 21.72% of women consumed the IFA for the full 180 days. About three-quarters of the women (73.36%) having at least four antenatal care visits (ANC) consumed IFA for at least 90 days, whereas only three in ten women (30.37%) consumed IFA for a minimum of 180 days. For compliance with IFA for at least 90 days, respondent's age of 20-34 years (aOR 1.26, 95% CI 1.03-1.54), respondent's educational qualification of secondary (aOR 1.77, 95% CI 1.16-2.70) or higher (aOR 2.73, 95% CI 1.65-4.53), husband's educational qualification of secondary (aOR 1.33, 95% CI 1.00-1.77) or higher (aOR 1.75, 95% CI 1.22-2.52), and having received at least four antenatal care (ANC) visits from medically skilled providers (aOR 2.53, 95% CI 2.14-3.00) were significantly associated with higher odds of compliance. For compliance with IFA for at least 180 days, respondent's educational qualification of higher (aOR 2.45, 95% CI 1.34-4.48), and having received at least four ANC visits from medically skilled providers (aOR 2.43, 95% CI 1.97-3.00) were significantly associated with higher odds of compliance. Intimate partner violence was negatively associated with compliance with IFA for at least 180 days (aOR 0.62, 95% CI 0.48-0.81).

CONCLUSIONS

The full compliance to IFAS is still sub-optimal in Bangladesh. Further precise context-specific intervention strategies must be developed and implemented with fidelity.

Factors associated with inadequate receipt of components and non-use of antenatal care services in India: a regional analysis

BACKGROUND

Failure to use antenatal care (ANC) and inadequate receipt of components of ANC pose a significant risk for the pregnant woman and the baby. This study aimed to examine a regional analysis of factors associated with receiving no ANC and inadequate receipt of components of ANC services among Indian women.

METHOD

Information from 173,970 women of reproductive age 15-49 years from the 2019-21 India National Family Health Survey (NFSH-5) was analysed. Logistic regression analyses that adjusted for cluster and survey weights were conducted to assess the socio-demographic and other factors associated with receiving non-use of ANC and inadequate receipt of components of ANC, respectively, in the six regions and 28 states, and 8 union territories in India.

RESULTS

Across regions in India, 7% of women reported no ANC, and the prevalence of inadequate and adequate receipt of components of ANC in all six regions ranged from 67 to 89% and 8% to 24%, respectively. Of all the 36 federated entities, the prevalence of inadequate receipt of ANC components was less than two-thirds in Tamil Nadu, Puducherry, Andaman and the Nicobar Islands, Odisha, and Gujarat. Our analyses revealed that associated factors vary by region, state, and union territories. Women from poor households reported increased odds of receiving no ANC in North, East and North-eastern regions. Women who reported no schooling in South, East and Central regions were associated with increased odds of receiving no ANC. Women from poor households in Himachal Pradesh, Bihar, Uttar Pradesh, Nagaland, Manipur, Uttar Pradesh, and Madhya Pradesh states reported significantly higher odds of inadequate components ANC than women from rich households. The receipt of inadequate components of ANC was significantly higher among women who never read magazines in Delhi, Ladakh, Karnataka, Telangana, Jharkhand, Maharashtra, Uttar Pradesh, Chhattisgarh, Arunachal Pradesh, Manipur, and Mizoram states in India.

CONCLUSION

A better understanding of the factors associated with and incorporating them into the short- and long-term intervention strategies, including free financial support from the Indian government to encourage pregnant women from lower socioeconomic groups to use health services across all regions, states and union territories.

Effect of Prenatal Dietary Pattern on Maternal Anemia and Low Birth Weight in Rural Areas of Kanpur

Background: In India, the dietary pattern of women from low socioeconomic status are almost same during pre-pregnant, pregnant and lactating periods. Additional foods are required to improve weight gain in pregnancy and birth weight of infants. Aim & Objective: To identify the impact of prenatal dietary pattern on maternal anemia and low birth weight in rural areas of Kanpur Nagar. Methods: This study was a cross sectional study conducted amongst mothers who recently delivered (RDW) in rural blocks of District Kanpur Nagar. Data was collected by interviewing study subjects using a semi-structured interview schedule after applying multistage random sampling technique. Results: Out of 102 women studied, 39.2% women had consumed >90 IFA tablets, 49.1% of mothers had practiced MMF and 47.1% of women practiced MDD during their prenatal period and 40.1% babies of current pregnancy were born as LBW. IFA consumption during pregnancy was significantly associated with maternal anemia. MMF during pregnancy was significantly associated with LBW. Conclusions: In our study it was found that IFA consumption, MMF and MDD during antenatal is a key preventive measure to reduce anemia status in pregnant females and birth weight of baby during prenatal period.

A Systematic review of factors affecting compliance toward oral iron-folic acid supplementation among pregnant women in India

Background: Iron-folic acid deficiency is the most common complication during pregnancy. Iron deficiency is responsible for various health complications among pregnant women. Compliance with IFA supplementation is variable across India several factors are associated with compliance with IFA supplementation. Objective: The objective of this systematic review is to assess the factors affecting compliance toward oral iron-folic acid supplementation among pregnant women in India. Methods: The primary search was carried out using PubMed, Google scholar, the WHO website, and Research Gate which provide access to full?text research articles from January 2012 to 25th January 2022 published data were searched. Result: A total of 74 studies were identified, and 20 were included in this review. Out of the 20 studies, sixteen were cross-sectional, two mixed methods, and two randomized control trials. knowledge of IFA, education, socioeconomic status, the timing of registration and number of antenatal visits, type of family, and age of the pregnant women were the factors that affect the compliance of IFA supplementation. Conclusion: Knowledge of iron-folic acid supplementation, Timing of registration and number of Antenatal Care visits, educational level of the pregnant women, and age of the pregnant women were factors associated with the compliance of IFA supplementation among pregnant women in India.

Iron-folic acid adherence and associated factors among pregnant women attending antenatal care at Metema District, Northwest Ethiopia

Background

Iron deficiency accounts for about half of anemia cases worldwide. Iron and folate supplementation can effectively control and prevent anemia during pregnancy. Despite the efforts to reduce iron deficiency anemia during pregnancy, only a few women took an iron supplement as recommended. The aim of this study is to assess adherence to iron-folic acid supplementation and associated factors.

Methods

A facility-based cross-sectional study was conducted from April 1 to May 31, 2021, among pregnant women attending the antenatal care clinic at Metema district governmental health institutions. Data was collected through face-to-face interviews with an interviewer-administered questionnaire. Epi info version 7.1 and SPSS 20 were used for data entry and analysis. Binary logistic regression analysis was done to identify factors associated with iron-folic acid supplementation for pregnant women. Significant associations were determined based on the adjusted odds ratio (AOR) and 95% confidence, with a p-value < 0.05.

Results

The proportion of pregnant women adhering to iron-folic acid supplementation was 34.9% (95% CI: 31, 38.8%). Maternal educational status [AOR = 6.09, 95% CI (3.26, 11.4)], time of first antenatal consultation [AOR = 1.95, 95% CI (1.25, 3.06)], having good knowledge of iron with folic acid supplementation [AOR = 2.80, 95% CI (1.83, 4.28)], having a good understanding of anemia [AOR = 1.61, 95% CI (1.06, 2.43)], and a history of anemia during current pregnancy [AOR = 2.31, 95% CI (1.36, 3.94)] were factors affecting iron-folic acid supplementation adherence.

Conclusions

Iron-folic acid supplementation adherence was low in the study area. Increasing maternal awareness, having good knowledge about the benefits of iron-folate supplements, and early registration to antenatal care were positive determinants of iron with folic acid adherence.

Iron and Folic Acid Supplementation in Pregnancy: Findings from the Baseline Assessment of a Maternal Nutrition Service Programme in Bangladesh

Effective coverage of antenatal iron and folic acid (IFA) supplementation is important to prevent adverse maternal and newborn health outcomes. We interviewed 2572 women from two rural districts in Bangladesh who had a live birth in the preceding six months. We analysed the number of IFA tablets received and consumed during pregnancy and examined the factors influencing IFA consumption by multiple linear regression and user adherence-adjusted effective coverage of IFA (consuming ≥180 IFA tablets) by Poisson regression. Overall, about 80% of women consumed IFA supplements in any quantity. About 76% of women received antenatal care at least once, only 8% received ≥180 IFA tablets, and 6% had user adherence-adjusted coverage of antenatal IFA supplementation. Multivariable analysis showed a linear relationship between the number of antenatal care (ANC) visits and the number of IFA supplements consumed, which was modified by the timing of the first ANC visit. Women’s education, free IFA, and advice on IFA were also associated with higher IFA consumption. Interventions targeting at least eight ANC contacts, starting early in pregnancy, providing advice on the importance of IFA, and providing IFA supplements in higher quantity at ANC contacts are likely to increase effective coverage of antenatal IFA supplementation.

Leverage the power of ritual to improve community health worker efficacy and public health outcomes: Lessons from Bihar, India

Biomedical health interventions now have global reach and interact in complex and often poorly understood ways with traditional medical rituals that precede biomedicine. People often experience biomedical practices and treatments as rituals because they are very similar from an experiential perspective.1 Yet the global public health community often views ritual practices of communities as obstacles to adopting new health-promoting behaviors. The lack of engagement with the biomedical and traditional medical rituals of local populations has obscured understanding the critical functions of these behaviors, limited the potential to leverage ritualization to increase behavioral uptake, and stymied social and behavioral change efforts. Our large-scale, mixed methods research with Community Health Workers (CHW) in Bihar, India, has shown that understanding the rituals of a community provides critical insight into their identities, norms, values, and goals. We propose that health interventions should be informed by, and build upon, knowledge of health rituals. A deep understanding of existing beliefs and behaviors will allow local health "influencers" such as CHW to encourage new and modified rituals that integrate the best of biomedical and traditional health practices in ways that preserve their meaning and shared purpose.

Funding

Grants INV-008582 and INV-016014 to C.L. from The Bill & Melinda Gates Foundation funded this manuscript.

Critical assessment of the current indicator for antenatal iron‐containing supplementation coverage: Insights from a mixed‐methods study

Daily consumption of iron‐containing supplements is recommended for all pregnant women but there is no approved global standard indicator for assessing supplementation coverage. Furthermore, the validity of commonly used coverage indicators for iron‐containing supplement consumption is questionable. The WHO–UNICEF Technical Expert Advisory Group on Nutrition Monitoring, and partners, have systematically worked to identify a feasible and valid indicator of iron‐containing supplement coverage for reporting by countries. In 2019, we conducted key informant interviews with respondents in eight countries, fielded an online survey (in three languages using SurveyMonkey) to which 142 nutrition professionals from 52 countries responded, and used Demographic and Health Surveys (DHS) data from four countries to assess determinants of the quality of iron‐containing supplement coverage data. Less than half (45%) of online survey respondents were satisfied with the current methods for collecting iron‐containing supplement coverage data in their context. Recommended changes by study respondents include recall period <5 years, adding questions about counselling, including other beneficiary groups, and assessing supply chain functionality. The DHS analysis suggested an association between time since pregnancy and data quality. Data heaping on multiples of 30 was observed in 40%–75% of data. There is a clear demand for a revised indicator and measurement guidance for coverage of iron‐containing supplementation during pregnancy. Future research should continue the development and validation of a global indicator, to more precisely validate the quality of recall data, including the distinction between distribution and consumption using various question formulations.

Health and nutrition professionals have described concerns with current methods for reporting coverage of daily iron‐containing supplementation in pregnant women.

The long recall period (5 years) of commonly used iron‐containing supplement consumption indicators calls into question the validity of these indicators.

Our study indicates that there is demand for a revised indicator and guidance for data collection.

Prevalence and determinants of anaemia among men in rural India: Evidence from a nationally representative survey

Anaemia among men is a significant health issue which has not been given due importance. Only a handful of studies have captured the prevalence of anaemia among men. There is dearth of evidence base on anaemia among men in India. Therefore, this study attempts to fill this research gap by examining the socioeconomic, geographic, health-related, and behavioural differentials of anaemia among rural men in India. We analysed a cross-sectional sample of 61,481 men aged between 15-54 and living in rural areas from the National Family Health Survey (NFHS-5), conducted in 2019-21. Bivariate statistics and multivariable logistic regression were employed to assess the factors associated with anaemia. In rural India, three out of ten men were found to be anaemic. Older men [49-54 years] (Odds Ratio: 1.10, 95% CI, 1.00-1.21), men without a formal education (OR: 1.36, 95% CI, 1.26-1.47), those from Scheduled Tribes (OR: 1.48, 95% CI, 1.39-1.58) and men who belonged to the poorest wealth quintile (OR: 1.24, 95% CI: 1.25-1.35) had a higher risk of anaemia. Men who were underweight were more likely to be anaemic (OR: 1.36, 95% CI: 1.30-1.43). When compared to the central region, men from the eastern (OR: 1.47, 95% CI: 1.39-1.55) parts of India had higher a risk of anaemia. The findings suggest the need to recognise anaemia among men as a public health issue. When developing policy, significant variation in socioeconomic, geographic, health-related, and behavioural factors must be taken into account. Men should also be screened on a regular basis in order to reduce the national burden of anaemia.

Individual and community-level determinants of Iron-Folic Acid Intake for the recommended period among pregnant women in Ethiopia: A multilevel analysis

Background

Iron-folic acid (IFA) intake for the recommended period during pregnancy reduces the risk of anemia and congenital anomalies. However, IFA intake for the recommended period is still very low in low-income countries including Ethiopia. Thus, the aim of this study was to assess both individual-and community-level determinants of IFA intake for the recommended period among pregnant women in Ethiopia.

Methods

Data were retrieved from the Demographic and Health Survey program's official database website (http://dhsprogram.com). A two-stage stratified cluster sampling technique was employed to conduct the 2016 Ethiopian Demographic and Health Survey. A sample of 3088 pregnant women who had received at least one dose of IFA in Ethiopia were included in this study. A multivariable multilevel logistic regression analysis model was fitted to identify the determinants of IFA intake below the recommended period [< 90 days] during pregnancy. Akaike's Information Criterion (AIC) was used during the model selection procedure.

Results

This study revealed that 87.6% [95% CI; 86.3%, 88.6%] of the women took IFA below the recommended period during the index pregnancy. After adjusting for the covariates: living in rural areas [AOR = 1.74: 95% CI 1.37, 2.50], and women's illiterate proportion [AOR = 1.43: 95% CI 1.06, 1.70] were community level factors. Whereas, primary education level [AOR = 0.63: 95% CI 0.40, 0.78], poorer wealth index [AOR = 1.53: 95% CI 1.08, 3.09], 4 + antenatal care visits [AOR = 0.43: 95% CI 0.31, 0.69], and receive nutritional counseling during pregnancy [AOR = 0.63: 95% CI 0.37, 0.84] were the individual-level factors of IFA intake below the recommended period during pregnancy.

Conclusions

In this study, nearly nine out of ten pregnant women did not take IFA for the recommended period. Thus, promoting recommended ANC visits, enhancing the quality of nutritional counseling, strengthening the expansion of media, and educate rural women towards the importance of optimal intake of IFA during pregnancy. Besides, the policymakers should design essential strategies based on identified barriers to improve the IFA intake for the recommended period.

Prevalence and determinants of anemia during the third trimester of pregnancy

BACKGROUND

Anemia during pregnancy is a significant health problem. We aim to measure the prevalence of anemia in the third trimester of pregnancy in a specific geographical area and identify its risk factors.

METHODS

A cross-section study was conducted in the antenatal clinic at Beni-Suef University Hospital on 383 pregnant women in the third trimester of pregnancy. All enrolled women were interviewed about age, education, occupation, family income, vitamin intake, medical history, and nutritional history. A blood sample was examined for hemoglobin concentration from each enrolled woman.

RESULTS

The prevalence of anemia was 72%. Multiparity, infrequent antenatal visits, irregular intake of iron supplements, low weekly intake of meat and fruits, and frequent daily tea consumption were identified as risk factors for anemia. About 23.6% of the anemic women had small-for-gestational-age fetuses (RR = 25.2).

CONCLUSION

Anemia by the third trimester of pregnancy represents a major health problem in Beni-Suef, Egypt.

Missed opportunities for delivering nutrition interventions in first 1000 days of life in India: insights from the National Family Health Survey, 2006 and 2016

Objectives

Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through the continuum of care in India between 2006 and 2016 and and (2) assessed inequalities in these opportunity gaps.

Methods

We used two rounds of the National Family Health Survey data from 2005 to 2006 and 2015–2016 (n=36 850 and 190 898 mother–child dyads, respectively). We examine the opportunity gaps over time for seven nutrition interventions and their associated delivery platforms at national and state levels. We assessed equality and changes in equality between 2006 and 2016 for opportunity gaps by education, residence, socioeconomic status (SES), public and private platforms.

Results

Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms; opportunity gaps ranging from 9 to 32 percentage points (pp) during the pregnancy, 17 pp during delivery and 9–26 pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators, but coverage increases for nutrition interventions was lower than for associated delivery platforms. The opportunity gaps were larger among women with higher education (22–57 pp in 2016), higher SES status and living in urban areas (23–57 pp), despite higher coverage of most interventions and the delivery platforms among these groups. Opportunity gaps vary tremendously by state with the highest gaps observed in Tripura, Andaman and Nicobar islands, and Punjab for different indicators.

Conclusions

India’s progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equality gaps remained. It is critical to close these gaps by addressing policy and programmatic delivery systems bottlenecks to achieve universal coverage for both health and nutrition within the delivery system.

Effect of direct monitoring by family members and counseling by health professionals on iron-folic acid supplementation: A cross-sectional study among pregnant women in Puducherry, India

BACKGROUND:

The prevalence of iron-deficiency anemia in pregnant Indian women is reportedly quite high. Despite the sustained efforts of the current national control program and undisputed efficacy of iron-folic acid supplementation (IFAS), the onslaught of anemia has not been curtailed, probably as a result of noncompliance to IFAS. The objective of this study was to assess the effect of direct monitoring of pregnant women by family members, counseling by health professionals, and other variables on adherence to IFAS in Puducherry, India.

MATERIALS AND METHODS:

A cross-sectional study was conducted among 250 pregnant women visiting Outpatient Clinic, Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry. Missing ≥2 doses of IFAS in the preceding 7 days was considered as nonadherence. The Pearson Chi-square test was applied to identify the association between the different variables. Bivariate and multivariate logistic regressions revealed variables affecting adherence.

RESULTS:

Around 34.4% of respondents reported nonadherence to IFAS. Direct monitoring by family members (Adjusted Odds Ratio [aOR] = 7.04; P < 0.001), counseling by health professionals (aOR = 2.97; P = 0.002), and improvement in hemoglobin (Hb) levels (aOR = 2.4; P = 0.01) were associated with better adherence. Vomiting, abdominal pain, and diarrhea were common ADRs. The distance to hospital, improvement in Hb levels, counseling by health professionals, and direct monitoring by family members significantly reduced the odds of ADRs.

CONCLUSION:

Direct monitoring of intake by family members and counseling by health professionals improved adherence to IFAS. Further in-depth formative research studies are recommended for strategies to improve adherence to IFAS in the vulnerable pregnant population of Puducherry and streamline the implementation of anemia national control program in a specific context.

Geospatial variations in trends of reproductive, maternal, newborn and child health and nutrition indicators at block level in Bihar, India, during scale-up of Ananya program interventions

BACKGROUND

Geographical variations in the levels and trajectory of health indicators at local level can inform the adaptation of interventions and development of targeted approaches for efficient scale-up of intervention impact. We examined the hypothesis that time trends of a set of reproductive, maternal, newborn, and child health and nutrition (RMNCHN) indicators varied at block-level during the statewide scale-up phase of the Ananya program in Bihar, India.

METHODS

We used data on 22 selected indicators from four rounds of the Community-based Household Survey carried out between 2014 and 2017. Indicator levels at each round were estimated for each block. We used hierarchical Bayesian spatiotemporal modelling to smooth the raw estimates for each block with the estimates from its neighbouring blocks, and to examine space-time interaction models for evidence of variations in trends of indicators across blocks. We expressed the uncertainty around the smoothed levels and the trends with 95% credible intervals.

RESULTS

There was evidence of variations in trends at block level in all but three indicators: facility delivery, public facility delivery, and age-appropriate initiation of complementary feeding. Fifteen indicators showed trends in opposite directions (increases in some blocks and declines in others). All blocks had at least 97.5% probability of a rise in immediate breastfeeding, early pregnancy registration, and having at least four antenatal care visits. All blocks had at least 97.5% probability of a decline in seeking care for pregnancy complications.

CONCLUSIONS

The findings underscore the value of monitoring and evaluation at local level for targeted implementation of RMNCHN interventions. There is a need for identifying systematic factors leading to universal trends, or variable contextual or implementation factors leading to variable trends, in order to optimise primary health care program impact.

STUDY REGISTRATION

ClinicalTrials.gov number NCT02726230.

Public health interventions to improve maternal nutrition during pregnancy: a nationally representative study of iron and folic acid consumption and food supplements in India

OBJECTIVE

Despite a reduction in maternal mortality in recent years, a high rate of anaemia and other nutrient inadequacies during pregnancy pose a serious threat to mothers and their children in the Global South. Using the framework of the WHO-Commission on Social Determinants of Health, this study examines the socioeconomic, programmatic and contextual factors associated with the consumption of iron and folic acid (IFA) tablets/syrup for at least 100 d (IFA100) and receiving supplementary food (SF) by pregnant women in India.

DESIGN

We analysed a nationally representative cross-sectional survey of over 190 898 ever-married women aged 15-49 years who were interviewed as part of the National Family Health Survey (NFHS) conducted during 2015-16, who had at least one live birth preceding 5 years of the survey.

SETTING

All twenty-nine states and seven union territories of India.

PARTICIPANTS

Ever-married women aged 15-49 years.

RESULTS

Less than one-third of women were found to be consuming IFA100, and a little over half received SF during their last pregnancy. The consumption of IFA100 was likely to improve with women's education, household wealth, early and more prenatal visits, and in a community with high pregnancy registration. Higher parity, early and more prenatal visits, contact with community health workers during pregnancy, belonging to a poor household and living in an aggregated poor community and rural area positively determine whether a woman might receive SF during pregnancy.

CONCLUSIONS

Continuous monitoring and evaluation of provisioning IFA and SF in targeted groups and communities is a key to expanding the coverage and reducing the burden of undernutrition during pregnancy.

Adherence of iron and folic acid supplementation and determinants among pregnant women in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Iron and folic acid deficiency anaemia are one of the global public health challenges that pose 1.45% of all disability-adjusted life-years. It is recognized as a cause for an unacceptably high proportion of maternal and perinatal morbidity and mortality. Adherence to iron and folic acid supplementation during the antenatal period is paramount to reduce anaemia and its associated morbidities. Although several studies have been conducted across the country, their reports were inconsistent and inconclusive for intervention. Therefore, this systematic review and meta-analysis were aimed to estimate the pooled national level adherence to iron and folic acid supplementation and its determinants among pregnant women in Ethiopia.

METHODS

This systematic review and meta-analysis were pursued the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guideline. An extensive search of databases including, PubMed, Google Scholar, and African Journals Online were conducted to access articles. The Newcastle- Ottawa quality assessment tool was used to assess the quality of each study and meta-analysis was conducted using a random-effects model. I² test and Egger's test were used to assess the heterogeneity and publication bias respectively. The meta-analysis of estimating national level adherence were done using STATA version 11 with 95% CI.

RESULTS

Twenty studies with a total of 16,818 pregnant women were included in this meta-analysis. The pooled national level iron and folic acid supplementation's adherence were 46.15% (95%CI:34.75,57.55). The highest adherence was observed in Addis Abeba, 60% (95%CI: 55.93, 64.07) followed by Tigray, 58.9% (95% CI: 33.86, 84.03). Women who received supplemental information [OR = 2.34, 95%CI: 1.05, 5.24], who had good knowledge [OR = 2.2, 95%CI: 1.05, 5.24], began the ANC visit before 16 weeks [OR = 2.41, 95%CI: 1.76, 3.29], and had ≥4 ANC visits [OR = 2.59, 95% CI: 1.09, 6.15] were more likely adhere to the supplementation. Fear of side effects (46.4, 95% CI: 30.9 61.8) and forgetfulness (30.7, 95% CI: 17.6, 43.8) were the major barriers of adherence of the supplementations.

CONCLUSIONS

More than four of nine pregnant women have adhered to the iron and folic acid supplementation. This meta-analysis revealed that receiving supplemental counselling, knowledge of the supplement; early registration and frequent ANC visit were significantly associated with the adherence of the iron and folic acid supplementation. Therefore, provision of strengthened supplemental counselling service, antenatal care services, and improving the knowledge of the supplementation is a crucial strategy to increase the adherence among pregnant women in Ethiopia. Besides, addressing the barriers of the adherence of the supplement mainly counseling or managing of side effects and reducing of forgetfulness to take the tablet through getting family support or male involvement during visit is mandatory.

Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia

The nutritional status of women before pregnancy, during pregnancy, and after delivery has far reaching consequences for maternal health and child survival, growth, and development. In South Asia, the high prevalence of short stature, thinness, and anaemia among women of reproductive age underlie the high prevalence of child undernutrition in the region, whereas overweight and obesity are rising concerns. A systematic review of evidence (2000-2017) was conducted to identify barriers and programme approaches to improving the coverage of maternal nutrition interventions in the region. The search strategy used 13 electronic bibliographic databases and 14 websites of development and technical agencies and identified 2,247 citations. Nine studies conducted in Bangladesh (n = 2), India (n = 5), Nepal (n = 1), and Pakistan (n = 1) were selected for the review, and outcomes included the receipt and consumption of iron and folic acid and calcium supplements and the receipt of information on dietary intake during pregnancy. The studies indicate that a range of barriers acting at the individual (maternal), household, and health service delivery levels affects intervention coverage during pregnancy. Programme approaches that were effective in improving intervention coverage addressed barriers at multiple levels and had several common features: use of formative research and client assessments to inform the design of programme approaches and actions; community-based delivery platforms to increase access to services; engagement of family members, as well as pregnant women, in influencing behavioural change; actions to improve the capacity, supervision, monitoring, and motivation of front-line service providers to provide information and counselling; and access to free supplements.

Better-Educated, Older, or Unmarried Pregnant Women Comply Less with Iron-Folic Acid Supplementation in Southern Ethiopia

Daily iron supplementation, with or without folic acid, is a proven public health intervention. Although maintaining compliance is crucial for the success of the intervention, inconsistent findings are available on compliance and its predictors in Ethiopia. The aim of this study was to estimate the iron-folic acid (IFA) supplementation compliance rate and its predictors among pregnant women in Wolaita Zone, Southern Ethiopia. A cross-sectional study was conducted in eight randomly selected health centers in Wolaita, Southern Ethiopia. A total of 647 pregnant women were included using multistage sampling procedure. Data were entered into Epi Info (a free statistical analysis software) and exported to SPSS. Bivariate relationship was explored through correlation coefficients. A multiple linear regression model was constructed to estimate the variability coefficient of the compliance rate due to selected factors. Of 647 pregnant women, only 18 (2.8%) pregnant women had received the supplement for 90 days or more. Overall, the compliance rate was 73.2% (95% CI, 70.72 to 75.79). Experiencing heartburn and vomiting significantly reduced the compliance rate. Unintended pregnancy and better education were negatively associated with compliance. By contrast, acceptability of IFA supplement, number of antenatal care (ANC) visits, and being ever married were positive predictors. On average, a pregnant woman did not take more than one-fourth of the daily IFA supplementation. During ANC visits, addressing the issues of side effects, unintended pregnancy, and acceptability of the supplement may improve compliance rate. Overall in Ethiopia, educated, older, and unmarried Ethiopian women need additional attention for successful compliance.

Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.

High Under-five Mortality Rate in Rural Madhya Pradesh, Time to Identify High-Risk Districts Using National Family Health Survey-4 Data with Comparison to Low Under-five Mortality Rate in Rural Tamil Nadu, India

BACKGROUND

India had highest number of under-five deaths, 1.2 million deaths out of 5.9 million (2015). As per the results from the first phase of National Family Health Survey (NFHS-4), 2015-2016, under-five mortality rate was highest in rural area of Madhya Pradesh (MP), 69/1000 live birth as compared to urban areas, 52/1000 live birth. The objective of the study was to identify potentially high-risk districts (HRD).

METHODS

This study was carried out from the secondary data of 50 districts of MP State which was available from NFHS-4 with information from 49,164 households. Scoring method was used to identify HRD by comparing variables related to maternal and child health care of rural MP with rural Tamil Nadu.

RESULTS

Eleven HRDs were identified with poor maternal and child health care along with high women's illiteracy and high percentage of child marriages in women. Indore division had 3 topmost HRD, Alirajpur, Jhabua, and Barwani followed by Rewa division with 2, Singrauli and Sidhi along with Sagar division.

CONCLUSIONS

HRDs should be considered for targeted interventions using the strategies for reducing under-five mortality rate in rural MP.

Mothers employed in paid work and their predictors for home delivery in Pakistan

Background

Pakistan has one of the highest rates of maternal and neonatal mortality in the world. It is assumed that employed mothers in paid work will be more empowered to opt for safer institutional deliveries. There is a need to understand the predictors of home deliveries in order to plan policies to encourage institutional deliveries in the region.

Methods

The study aimed to ascertain the predictors for home deliveries among mothers employed in paid work in Pakistan. Data analysis is based on secondary data taken from the Pakistan Demographic Health Survey 2012–13. Bivariate and multivariate logistic regression models were conducted.

Results

The findings show that the majority (53.6%) of employed mothers in Pakistan give birth at home. Employed mothers in paid work with the following characteristics had higher chances for delivering at home: (i) women from rural areas (AOR 1.26; 95% CI: 0.94–1.71), or specific regions within Pakistan, (ii) those occupied in unskilled work (AOR 2.61; 95% CI: 1.76–3.88), (iii) women married to uneducated (AOR 1.70; 95% CI: 1.08–2.66), unemployed (AOR 1.69; 95% CI: 1.21–2.35), or unskilled men (AOR 2.02; 95% CI: 1.49–2.72), (iv) women with more than 7 children (AOR 1.57; 95% CI: 1.05–2.35), (v) women who are unable in the prenatal period to have an institutional check-up (AOR 4.84; 95% CI: 3.53–6.65), take assistance from a physician (AOR 3.98; 95% CI: 3.03–5.20), have a blood analysis (AOR 2.63; 95% CI: 1.95–3.57), urine analysis (AOR 2.48; 95% CI: 1.84–3.33) or taken iron tablets (AOR 2.64; 95% CI: 2.06–3.38), and (vi) are unable to make autonomous decisions with regard to spending their earnings (AOR 1.82; 95% CI: 1.27–2.59) and healthcare (AOR 1.12; 95% CI: 0.75–1.65).

Conclusions

Greater efforts by the central and provincial state bodies are needed to encourage institutional deliveries and institutional access, quality and cost. Maternal and paternal benefits are needed for workers in both the formal and informal sectors of the economy. Finally, cultural change, through education, media and religious authorities, is necessary to support institutional deliveries and formal sector paid employment and out of home work opportunities for mothers of Pakistan.

Intensity of contact with frontline workers and its influence on maternal and newborn health behaviors: cross-sectional survey in rural Uttar Pradesh, India

BACKGROUND

India is committed to improving maternal and newborn health in order to achieve the targets for India's Millennium Development Goal 4. Considering their role as a link between community and health systems, frontline workers (FLWs) can be effectively utilized in strengthening maternal and newborn care. In this paper, we set out to examine the effect of intensity of contact with FLWs on key maternal and newborn health behaviors and to determine if this association varies by status of Self Help Group (SHG) membership.

METHODS

This population-based cross-sectional study included 2208 currently married women aged 15-49 years who had delivered a baby during the last 15 months prior to the survey and selected through a multi-stage cluster sampling from rural villages and urban wards. The outcome of interest included variables related to key knowledge and practice of healthy behavior in relation to maternal and newborn health and exposure variable considered was intensity of contact with FLWs.

RESULTS

Of the women interviewed, 1729 (78%) belonged to SHG household. For knowledge on the need for at least 3 antenatal care (ANC) check-ups, two tetanus toxoid (TT) injections and consumption of 100 or more iron-folic acid (IFA) tablets, proportion of those who were aware of these practices increased with increasing number of contacts with FLWs (P value < 0.001). Practice for TT injections showed an increasing trend with increasing number of contacts with FLW. An increase in the odds of delivering in an institution was observed in those who had higher number of contacts as compared to those with no contacts (P value < 0.001). With regard to newborn healthy behavior practice, breastfeeding within 1 h of delivery showed significant association and the odds of this practice improved in those who had ≥ 3 contacts with FLW as compared to those had no contacts. Except for consumption of 100 or more IFA tablets, there was no interaction of these associations by SHG status.

CONCLUSION

There was an overall low prevalence of both knowledge and practice of key maternal and newborn healthy behaviors and only a few of these were associated with frequency of contacts with FLW. Findings not only highlight the urgent need for effectively leveraging FLWs to strengthen maternal and newborn care but also to improve the quality of services provided by them.

Community-based distribution of iron–folic acid supplementation in low- and middle-income countries: a review of evidence and programme implications

Objective

The present literature review aimed to review the evidence for community-based distribution (CBD) of iron–folic acid (IFA) supplementation as a feasible approach to improve anaemia rates in low- and middle-income countries.

Design

The literature review included peer-reviewed studies and grey literature from PubMed, Cochrane Library, LILAC and Scopus databases.

Setting

Low- and middle-income countries.

Subjects

Non-pregnant women, pregnant women, and girls.

Results

CBD programmes had moderate success with midwives and community health workers (CHW) who counselled on health benefits and compliance with IFA supplementation. CHW were more likely to identify and reach a greater number of women earlier in pregnancy, as women tended to present late to antenatal care. CBD channels had greater consistency in terms of adequate supplies of IFA in comparison to clinics and vendors, who faced stock outages. Targeting women of reproductive age through school and community settings showed high compliance and demonstrated reductions in anaemia.

Conclusions

CBD of IFA supplementation can be a valuable platform for improving knowledge about anaemia, addressing compliance and temporary side-effects of IFA supplements, and increasing access and coverage of IFA supplementation. Programmatic efforts focusing on community-based platforms should complement services and information provided at the health facility level. Provision of training and supportive supervision for CHW on how to counsel women on benefits, side-effects, and when, why, and how to take IFA supplements, as part of behaviour change communication, can be strengthened, alongside logistics and supply systems to ensure consistent supplies of IFA tablets at both the facility and community levels.

Factors influencing maternal nutrition practices in a large scale maternal, newborn and child health program in Bangladesh

Improving maternal nutrition practices during pregnancy is essential to save lives and improve health outcomes for both mothers and babies. This paper examines the maternal, household, and health service factors influencing maternal nutrition practices in the context of a large scale maternal, newborn, and child health (MNCH) program in Bangladesh. Data were from a household survey of pregnant (n = 600) and recently delivered women (n = 2,000). Multivariate linear and logistic regression analyses were used to examine the determinants of three outcomes: consumption of iron and folic acid (IFA) tablets, calcium tablets, and diverse diets. Women consumed 94 ± 68 IFA and 82 ± 66 calcium tablets (out of 180 as recommended) during pregnancy, and only half of them consumed an adequately diverse diet. Good nutrition knowledge was the key maternal factor associated with higher consumption of IFA (β = 32.5, 95% CI: 19.5, 45.6) and calcium tablets (β ~31.9, 95% CI: 20.9, 43.0) and diverse diet (OR = 1.8, 95% CI: 1.0-3.1), compared to poor knowledge. Women's self-efficacy in achieving the recommended practices and perception of enabling social norms were significantly associated with dietary diversity. At the household level, women who reported a high level of husband's support were more likely to consume IFA (β = 25.0, 95% CI: 18.0, 32.1) and calcium (β = 26.6, 95% CI: 19.4, 33.7) tablets and diverse diet (OR = 1.9, 95% CI: 1.2, 3.3), compared to those who received low support. Health service factors associated with higher intakes of IFA and calcium tablets were early and more prenatal care visits and receipt of free supplements. Combined exposure to several of these factors was attributed to the consumption of an additional 46 IFA and 53 calcium tablets and 17% higher proportions of women consuming diverse diets. Our study shows that improving knowledge, self-efficacy and perceptions of social norms among pregnant women, and increasing husbands' support, early registration in prenatal care, and provision of free supplements will largely improve maternal nutrition practices.

How Non Consumers Differ from Consumers: A Qualitative Approach to Synthesize the Attributes of Iron Folic Acid End Users

INTRODUCTION

Anaemia continues to be a major hurdle to achieve optimum health in Indian population context. Although government continues to promote Iron Folic Acid (IFA) supplementation as one of the key strategies to combat with burden of anaemia, the expected level of IFA consumption and subsequent anaemia reduction could not be achieved. This study tries to investigate those influences, concerns, experiences and behaviour from an end user perspective through a qualitative methodology which may affect the IFA consumption ambi-directionally.

AIM

To explore and understand the several aspects related with anaemia and IFA supplementation with special emphasis to reveal the contributory factors behind low level of IFA consumption at consumer end.

MATERIALS AND METHODS

A community based qualitative study was conducted in clusters identified through multileveled stratification from a state of central India. A conceptual construct was made in priory for this study. As the research question was related with policy, this study adapted a framework technique for making interview topic guides. Two consumers and two non consumers from each identified cluster were interviewed in depth. The data obtained through 160 in depth interviews (from 80 consumers and 80 non consumers) was utilized for thematic framework, linkage association and to typify the phenomenon.

RESULTS

Ignorance, difficult intake, meaninglessness, misconceptions and discontentment with the system were the major dimensions (sub themes) associated with discontinuation. All these sub themes were further converged into major theme of informational discontinuity. Investigators further typified the users/non users into persistent user, potential defaulters, impending defaulters and absolute non users.

CONCLUSION

Informational gap seems to be the fundamental factor behind sub optimum IFA consumption. On a policy perspective, all the attempts should be done to instigate arise felt need' among target groups for IFA consumption.

Making the continuum of care work for mothers and infants: Does gender equity matter? Findings from a quasi-experimental study in Bihar, India

Background

Improvements in continuum of care (CoC) utilization are needed to address inadequate reductions in neonatal and infant mortality in India and elsewhere. This study examines the effect of Ananya, a health system training and community outreach intervention, on reproductive, maternal and newborn health continuum of care (RMNH CoC) utilization in Bihar, India, and explores whether that effect is moderated by gender equity factors (child marriage, restricted mobility and low decision-making control).

Methods

A two-armed quasi-experimental design compared districts in Bihar that did/did not implement Ananya. Cross-sections of married women aged 15–49 with a 0–5 month old child were surveyed at baseline and two year follow-up (baseline n = 7191 and follow-up n = 6143; response rates 88.9% and 90.7%, respectively). Difference-in-difference analyses assessed program impact on RMNH CoC co-coverage, defined by 9 health services/behaviors for the index pregnancy (e.g., antenatal care, skin-to-skin care). Three-way interactions assessed gender equity as a moderator of Ananya’s impact.

Findings

Participants reported low RMNH CoC co-coverage at baseline (on average 3.2 and 3.0 of the 9 RMNH services/behaviors for Ananya and control groups, respectively). The Ananya group showed a significantly greater increase in RMNH CoC co-coverage (.41 services) compared with the control group over time (p<0.001), with the primary drivers being increases in clean cord care, skin-to-skin care and postpartum contraceptive use. Gender equity interaction analyses revealed diminished intervention effects on antenatal care, skilled birth attendance and exclusive breastfeeding for women married as minors.

Conclusion

Ananya improved RMNH CoC co-coverage among these recent mothers, largely through positive health behavior changes. Child marriage attenuated Ananya’s impact on utilization of key health services and behaviors. Supporting the health system with training and community outreach can be beneficial to RMNH CoC utilization; additional support is needed to adequately address the unique issues faced by women married as minors.

Maternal Health Situation in Bihar and Madhya Pradesh: A Comparative Analysis of State Fact Sheets of National Family Health Survey (NFHS)-3 and 4

INTRODUCTION

Maternal health constitutes the health of women during pregnancy, childbirth and the postpartum period. Bihar and Madhya Pradesh (MP) constitute the Empowered Action Group (EAG) states under National Rural Health Mission (NRHM) and are consistently having poor maternal health indicators.

AIM

The main objective of this study was to assess the maternal health situation of Bihar and MP based on National Family Health Survey (NFHS-3) and 4 fact sheets.

MATERIALS AND METHODS

The study adopted a narrative description in which the NFHS fact sheets (NFHS-3 & 4) of both these states were obtained from appropriate sources and compared for various maternal health indicators.

RESULTS AND DISCUSSION

Albeit progress has been observed from NFHS-3 to NFHS-4 however, the progress is very dismal compared with the progress of other similar Indian states. Relatively MP has shown better progress compared to Bihar. Poor performance is being observed in all the three levels of maternal health; pregnancy {Ante-Natal Care (ANC), Tetanus toxoid (TT) and Iron and Folic Acid (IFA)}, child birth (Institutional delivery by Skilled Birth Attendant (SBA), Caesarean Section (CS) and post partum care (hospital stay and Janani Suraksha Yojna (JSY). The poor performance of both these states in all these indicators requires multipronged approach strong political will, health system strengthening, community mobilization and awareness.

CONCLUSION

Given the status of maternal health in India and more especially in states BIMARU (Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh) and EAG states (Empowered action group), improvement in the performance of maternal health related activities is highly necessary.