Neonatal and under-five mortality rate in Indian districts with reference to Sustainable Development Goal 3: An analysis of the National Family Health Survey of India (NFHS), 2015-2016

Health impact evaluation of Aspirational Districts Program in India: Evidence from National Family Health Survey

The Aspirational District Program (ADP) is a unique initiative of Government of India launched in 2018 that aims to reduce inter-district multidimensional inequality. ADP aims to bring the least developed districts to catch up with the rest of the other districts in the country. The program is comprehensive in its scope as it targets improvement of several key development indicators spanning health and nutrition, education, agriculture and water resources, financial inclusion and skill development and basic infrastructure indicators. Aspirational districts (ADs) are eligible for enhanced funding and priority allocation of various initiatives undertaken by the central and the state governments. Our research estimates the causal impact of ADP on the targeted health and nutrition indicators using a combination of propensity score matching and difference-in-differences (PSM-DID). We use the fourth and fifth rounds of National Family Health Survey (NFHS) data collected in 2015-16 and 2019-21 respectively which serve as the pre and post-treatment data for our analysis. Moreover, we take advantage of the transparent mechanism outlined for the identification of ADs under ADP, which we use for propensity score matching for our PSM-DID. While we observe negative impact of ADP on early initiation of breastfeeding, we believe that the impact is confounded with the effects of Covid-19 since part of NFHS-5 data was collected during the pandemic. However, the negative impact of ADP on early initiation of breastfeeding disappears when we only use pre-covid data (i.e. data for districts from states surveyed before the pandemic). Additionally, using pre-covid data we find a reduction in the prevalence of underweight children younger than 5 years to an extent of 2 to 4 percentage points in ADs as an impact of ADP, which is robust across multiple specification. We do not find evidence of a positive or a negative impact of ADP on any other health and nutrition indicators. Future research efforts should be made towards impact evaluation of all the targeted indicators in order to get a comprehensive unbiased evaluation of ADP.

Socioeconomic inequality in child health outcomes in India: analyzing trends between 1993 and 2021

BACKGROUND

The health of India's children has improved over the past thirty years. Rates of morbidity and anthropometric failure have decreased. What remains unknown, however, is how those patterns have changed when examined by socioeconomic status. We examine changes in 11 indicators of child health by household wealth and maternal education between 1993 and 2021 to fill this critical gap in knowledge. Doing so could lead to policies that better target the most vulnerable children.

METHODS

We used data from five rounds of India's National Family Health Survey conducted in 1993, 1999, 2006, 2016, and 2021 for this repeated cross-sectional analysis. We studied mother-reported cases of acute respiratory illness and diarrhea, hemoglobin measurements for anemia, and height and weight measurements for anthropometric failure. We examined how the prevalence rates of each outcome changed between 1993 and 2021 by household wealth and maternal education. We repeated this analysis for urban and rural communities.  RESULTS: The socioeconomic gradient in 11 indicators of child health flattened between 1993 and 2021. This was in large part due to large reductions in the prevalence among children in the lowest socioeconomic groups. For most outcomes, the largest reductions occurred before 2016. Yet as of 2021, except for mild anemia, outcome prevalence remained the highest among children in the lowest socioeconomic groups. Furthermore, we show that increases in the prevalence of stunting and wasting between 2016 and 2021 are largely driven by increases in the severe forms of these outcomes among children in the highest socioeconomic groups. This finding underscores the importance of examining child health outcomes by severity.

CONCLUSIONS

Despite substantial reductions in the socioeconomic gradient in 11 indicators of child health between 1993 and 2021, outcome prevalence remained the highest among children in the lowest socioeconomic groups in most cases. Thus, our findings emphasize the need for a continued focus on India's most vulnerable children.

Influence of Sociodemographic Factors on Stunting, Wasting, and Underweight Among Children Under Two Years of Age Born During the COVID-19 Pandemic in Central India: A Cross-Sectional Study

Introduction The adverse effects of the coronavirus disease 2019 (COVID-19) pandemic on maternal and reproductive health extend beyond the immediate morbidity and mortality attributed directly to the disease. Pandemic-induced disruptions in the healthcare, social and economic infrastructures can exacerbate the already high burden of childhood undernutrition in India. Method A cross-sectional study was conducted in a selected district of the central Indian province of Madhya Pradesh. Data was collected from eligible children born during the COVID-19 pandemic (February 2020 to December 2021) who visited a selected tertiary care hospital for routine immunization during the study period. Weight-for-length, weight-for-age, and length-for-age were compared with reference values to obtain corresponding z-scores. Children with z-scores two standard deviations below the reference values were considered wasting, underweight and stunting, respectively. Descriptive statistics were employed to summarise the sociodemographic characteristics of participants. The association of sociodemographic, nutritional, and pregnancy-related factors with the z-scores were assessed via unpaired t-test and ANOVA. Result The studied 147 children were in the age group of nine to 29 months, of which 61 (58.1%) were males. Forty-two (28.6%) were found to be underweight, 22 (14.9%) had wasting and 51 (34.7%) were stunted. These prevalences were comparable to the estimates of the National Family Health Survey 2019-2021 (NFHS-5) for Madhya Pradesh and lower than the NFHS-4 (2015-2016), showing no discernible effect of being born during the pandemic on growth indicators. However, mothers' employment and family income were independent predictors of stunting whereas gestational age at birth, maternal education, and prolonged breastfeeding were all substantially linked with wasting in this study. Conclusion This study adds to the evidence base by reporting the prevalence of stunting, wasting and underweight along with their determinants in central India among children born during the COVID-19 pandemic. Our data did not reflect the expected increase in child malnutrition due to the COVID-19 pandemic-related disruptions in healthcare, social and economic infrastructure. Future research should incorporate the lessons learnt from our study to design a population-based study of under-five children and compare the prevalence of undernutrition in pandemic-born versus non-pandemic-born children.

Neonatal, Infant, and Child Mortality in India: Progress and Future Directions

In India, considerable progress has been made in reducing child mortality rates. Despite this achievement, wide disparities persist across and socio-economic strata, and persistent challenges, such as malnutrition, poor sanitation, and lack of clean water. This paper provides a comprehensive review of the state of child health in India, examining key risk factors and causes of child mortality, assessing the coverage of child health interventions, and highlighting critical public health programs and policies. The authors also discuss future directions and recommendations for bolstering ongoing efforts to improve child health. These include state- and region-specific interventions, prioritizing social determinants of health, strengthening data systems, leveraging existing programs like the National Health Mission (NHM) and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), and the proposed Public Health Management Cadre (PHMC). The authors argue that reducing child mortality requires not only scaled-up interventions but a comprehensive approach that addresses all dimensions of health, from social determinants to system strengthening.

Predisposition of the Common MC4R rs17782313 Female Carriers to Elevated Obesity and Interaction with Eating Habits

The global rise in obesity is attributed to genetic predisposition interaction with an obesogenic environment. Melanocortin 4 receptor (MC4R) rs17782313 polymorphism has been linked to common obesity with varying influence across different populations. MC4R is a crucial player in the leptin proopiomelanocortin pathway that regulates weight hemostasis. We aimed to study MC4R rs17782313 and its interaction with eating behaviors on obesity predisposition in the Israeli population. Adults' (n = 5785, >18 y) genotype and anthropometric and demographic data were analyzed using logistic regression models adjusting for age, sex, T1DM, and T2DM. MC4R rs17782313 significantly predisposes to elevated obesity risk under the recessive and additive models (OR = 1.38, 95% CI: 1.1-1.72, p = 0.005 and OR = 1.1, 95% CI: 1.01-1.2, p = 0.03, respectively) adjusted for confounders (age, sex, T1DM, and T2DM). Stratification by sex demonstrated that carrying the common MC4R rs17782313 is significantly associated with an elevated predisposition to obesity under the recessive model among females only (OR = 1.41, 95% CI: 1.09-1.82, p = 0.01), with an average of 0.85 BMI increment compared with wild type and one risk allele carriers. MC4R rs17782313 significantly interacted with several eating behaviors to enhance the risk of obesity. Our findings demonstrate that MC4R rs17782313 homozygous female carriers are significantly predisposed to obesity amplified by eating behaviors.

Quality Indicators to Evaluate Essential Newborn Care in Low- and Middle-Income Countries

BACKGROUND

Strategies to improve neonatal outcomes rely on accurate collection and analyses of quality indicators. Most low- and middle-income countries (LMICs) fail to monitor facility-level indicators, partly because recommended and consistently defined indicators for essential newborn care (ENC) do not exist. This gap prompted our development of an annotated directory of quality indicators.

METHODS

We used a mixed method study design. In phase 1, we selected potential indicators by reviewing existing literature. An overall rating was assigned based on subscores for scientific evidence, importance, and usability. We used a modified Delphi technique for consensus-based approval from American Academy of Pediatrics Helping Babies Survive Planning Group members (phase 2) and secondarily surveyed international partners with expertise in ENC, LMIC clinical environments, and indicator development (phase 3). We generated the final directory with guidelines for site-specific indicator selection (phase 4).

RESULTS

We identified 51 indicators during phase 1. Following Delphi sessions and secondary review, we added 5 indicators and rejected 7. We categorized the 49 indicators meeting inclusion criteria into 3 domains: 17 outcome, 21 process, and 11 educational. Among those, we recommend 30 for use, meaning indicators should be selected preferentially when appropriate; we recommend 9 for selective use primarily because of data collection challenges and 10 for use with reservation because of scientific evidence or usability limitations.

CONCLUSIONS

We developed this open-access indicator directory with input from ENC experts to enable appraisal of care provision, track progress toward improvement goals, and provide a standard for benchmarking care delivery among LMICs.

Neonatal sepsis and its associated factors among neonates admitted to the neonatal intensive care unit in Wachemo University Comprehensive Specialized Hospital, Southern Ethiopia, 2022

Background

Neonatal sepsis is a major public health problem worldwide. It is one of the leading causes of neonatal mortality and morbidity worldwide. The neonatal mortality rate is higher in developing countries, where the extent and causes of neonatal sepsis are not yet known. Neonatal sepsis is a leading cause of neonatal mortality in Ethiopia. As a result, this study aimed to assess the proportion and identify maternal and neonatal risk factors for neonatal sepsis among neonates admitted to the neonatal intensive care unit.

Methods

An institutional-based cross-sectional study was conducted from May 2022 to July 2022 at the Wachemo University Comprehensive Specialized Teaching Hospital, Neonatal Intensive Care Unit, southern Ethiopia. A total of 205 neonates with indexed mothers participated in the study. Using a consecutive sampling technique, a structured, pretested questionnaire was used to collect data from the study subjects. Data were entered into EpiData Manager version 3.1 for Windows and then exported to SPSS version 22 for further data cleaning and analysis. Descriptive analyses were performed by using frequency, percentage, and summary statistics to describe the key variables. A multivariate regression model was used to identify factors associated with neonatal sepsis. Finally, statistical significance was declared at a p-value of less than 0.05, and an adjusted odds ratio (AOR) with a 95% confidence level was used to declare the variable's association with the outcome variable.

Result

The overall prevalence rate of neonatal sepsis was 39.5% (95% CI: 33.7-45.9). Multivariable analysis was performed by taking a variable that is statistically significant in bivariate logistic regression as a candidate variable. Multivariable model analysis showed that unmarried status AOR = 18.37 (95% CI: 1.56-216.14), maternal fever during delivery AOR = 4.74 (95% CI: 1.63-13.8), and premature rupture of membrane AOR = 7.53 (95% CI: 2.19-25.6) were variables that increased the odds of developing neonatal sepsis.

Conclusion

The study's findings indicate that neonatal sepsis is highly prevalent. Unmarried maternal status, maternal fever during delivery, and premature rupture of the membrane were predictors of neonatal sepsis. Therefore, providing training for health workers and close monitoring and evaluation during obstetric and neonatal care are crucial to halt the occurrence of neonatal sepsis.

Practice environment determinants of job satisfaction among midwives at healthcare facilities in Accra Metropolis: A multicentre study

INTRODUCTION

Sustainable Development Goal 3 (SDG 3) has been one of the key goals for all partners of health globally. The health workforce especially midwives are among the principal skilled experts for achieving the goal. This is evidenced in the role they play in caring for pregnant women from the antenatal stages to the postpartum periods. However, very little has been reported about midwives' job satisfaction in Ghana. The study assessed the practice environment determinants of job satisfaction among registered midwives in Ghana.

MATERIALS AND METHODS

A cross-sectional design was adopted to recruit midwives from public and quasi-government hospitals in Accra Metropolis. Validated scales-'Measure of Job Satisfaction' and 'Practice Environment Scale of Nursing Work Index' were used for data collection. Data was analysed through descriptive statistics, Pearson correlation and linear regression.

RESULTS

Midwives had a positive perception of their work environment. They were generally satisfied with their job but were dissatisfied with their salaries. Key determinants of midwives' job satisfaction included years of work as a midwife, managers' leadership and support, and adequacy of human and material resources.

CONCLUSION

Improving midwives' job satisfaction through enabling the work environment will go a long way to improve healthcare provision in the healthcare delivery points in helping achieve SDG 3.

Relationship between low birth weight and infant mortality: evidence from National Family Health Survey 2019-21, India

BACKGROUND

Low birth weight (LBW) predisposes physical and mental growth failure and premature death among infants. Studies report that LBW predominately explains infant mortality. However, existing studies rarely demonstrate the phenomenon of both observed and unobserved factors, which may influence the likelihood of birth and mortality outcomes simultaneously. In this study, we identified the spatial clustering of the prevalence of LBW along with its determinants. Further, the relationship between of LBW and infant mortality, considering the unobserved factors, has been explored in the study.

METHODS

Data for this study have been extracted from the National Family Health Survey (NFHS) round 5, 2019-21. We used the directed acyclic graph model to identify the potential predictors of LBW and infant mortality. Moran's I statistics have been used to identify the high-risk areas of LBW. We applied conditional mixed process modelling in Stata software to account for the simultaneous nature of occurrences of the outcomes. The final model has been performed after imputing the missing data of LBW.

RESULTS

Overall, in India, 53% of the mothers reported their babies' birth weight by seeing health card, 36% reported by recall, and about 10% of the LBW information was observed as missing. The state/union territory of Punjab and Delhi were observed to have the highest levels of LBW (about 22%) which is much higher than the national level (18%). The effect of LBW was more than four times larger compared to the effect in the analysis which does not account for the simultaneous occurrence of LBW and infant mortality (marginal effect; from 12 to 53%). Also, in a separate analysis, the imputation technique has been used to address the missing data. Covariates' effects showed that female children, higher order births, births that occur in Muslim and non-poor families and literate mothers were negatively associated with infant mortality. However, a significant difference was observed in the impact of LBW before and after imputing the missing values.

CONCLUSIONS

The current findings showed the significant association of LBW with infant deaths, highlighting the importance of prioritising policies that help improve the birth weight of new-born children that may significantly reduce the infant mortality in India.

Linkages of Multi-Dimensional Vulnerabilities with Infant and Child Mortality Rates in India and Its Specific Regions: Are Social Determinants of Health still Relevant?

The present study investigated linkages between multiple socio-economic vulnerabilities with infant and child mortality in India and its specific regions. Data from the National Family Health Survey (2015-16) was used for calculating the key-outcome variables, namely infant mortality and child mortality. The effective sample size for the study was 259,627. Bivariate analysis and binary logistic regression analysis were employed to examine three dimensions of vulnerabilities such as education, wealth, and caste on infant and child mortality. Children born to women with multiple-vulnerabilities were more likely to die than those born to non-vulnerable women. Women who were vulnerable in all the three-dimensions were more likely to have their children die as infants than those who were not vulnerable in any dimensions (predicted probabilities; 0.054 vs 0.026). The predicted probability for child mortality was 0.063 for women who were vulnerable and 0.028 for non-vulnerable women.

Pregnancy and the risk of NICU admissions in Nandom Municipality of Ghana: A cross-sectional retrospective study

Background

Neonatal intensive care units (NICU) are specialized units that provide medical attention to neonates, and thus have become a vital aspect in the provision of critical care to infants who are faced with special challenges following birth.

Aim

To determine antepartum and intrapartum factors that predispose to NICU admissions in the Nandom Municipal of the Upper West Region of Ghana.

Method

This was a cross-sectional retrospective study, spanning from January 1, 2021 to December 31, 2021. Records covering 1777 women who were delivered or had their babies referred to the St. Theresa's Hospital in the Nandom Municipality were involved in the study. Descriptive statistics and multinomial logistic regression analysis were used to compare variables, and statistical significance was determined where the p-value was less than 0.05.

Results

From the study, the rate of NICU admission was 10.4%. There was a significant association between mothers who attended less than four antenatal sessions (p = 0.004) and admission to NICU. Nulliparous mothers (p = 0.027) and mothers who presented with multiple pregnancy (p < 0.001) were more likely to have their babies sent to NICU. Both preterm delivery (p < 0.001) and post-term delivery (p < 0.001) were prone to admission to NICU. Also, instrumental delivery (p < 0.001), cesarean section (p < 0.001), low birth weight (p < 0.001), and male infants (p = 0.003) had an increased risk of being admitted to NICU. Furthermore, severe (p < 0.001) and moderate (p < 0.001) birth asphyxia in the first minute following delivery were significantly associated with NICU admission whereas severely asphyxiated babies at 5 min (p < 0.001) were associated with NICU admission.

Conclusion

The study revealed a relatively high NICU admission rate in the study area, and the predictors are multifaceted. Tailored intervention programs aimed at curbing these predictors will be required to reduce the rate of NICU admissions in the Nandom Municipality of Ghana.

Comprehensive assessment of age-specific mortality rate and its incremental changes using a composite measure: A sub-national analysis of rural Indian women

Background

Diverse socio-economic and cultural issues contribute to adverse health outcomes and increased mortality rates among rural Indian women across different age categories. The present study aims to comprehensively assess age-specific mortality rates (ASMR) and their temporal trends using a composite measure at the sub-national level for rural Indian females to capture cross-state differences.

Materials and methods

A total of 19 states were included in the study to construct a composite age-specific mortality index for 2011 (base year) and 2018 (reference year) and examine the incremental changes in the index values across these years at the sub-national level in India. Sub-index values were calculated for each component age group and were subsequently used to compute the composite ASMR index using the geometric mean method. Based on the incremental changes, the performance of states was categorized into four different typologies.

Results

Improvement in mortality index scores in the 0-4 years age group was documented for all states. The mortality rates for the 60+ age group were recorded to be high for all states. Kerala emerged as the overall top performer in terms of mortality index scores, while Bihar and Jharkhand were at the bottom of the mortality index table. The overall mortality composite score has shown minor improvement from base year to reference year at all India level.

Conclusion

An overall reduction in the mortality rates of rural Indian women has been observed over the years in India. However, in states like Bihar and Jharkhand, mortality is high and has considerable scope for improvement. The success of public health interventions to reduce the under-five mortality rate is evident as the female rural mortality rates have reduced sizably for all states. Nevertheless, there is still sizable scope for reducing mortality rates for other component age groups. Additionally, there is a need to divert attention toward the female geriatric (60+ years) population as the mortality rates are still high.

An update on explaining the rural-urban gap in under-five mortality in India

Background

Rural Indians have higher mortality rates than urban Indians. However, the rural-urban gap in under-five mortality has changed is less researched. This paper aims to assess 1) whether the rural-urban gap in under-five mortality has reduced over time 2) Whether rural children are still experiencing a higher likelihood of death after eliminating the role of other socioeconomic factors 3) What factors are responsible for India’s rural-urban gap in under-five mortality.

Methods

We used all rounds for National Family Health Survey data for understanding the trend of rural-urban gap in under-five mortality. Using NFHS-2019-21 data, we carried out a binary logistic regression analysis to examine the factors associated with under-five mortality. Fairlie’s decomposition technique was applied to understand the relative contribution of different covariates to the rural–urban gap in under-five mortality.

Results

India has witnessed a more than 50% reduction in under-five mortality rate between 1992 and 93 and 2019–21. From 1992 to 93 to 2019–21, the annual decrease in rural and urban under-five mortality is 1.6% and 2.7%, respectively. Yet, rural population still contributes a higher proportion of the under-five deaths. The rural-urban gap in under-five mortality has reduced from 44 per thousand live births in 1992–1993 to 30 per thousand in 2004–2005 which further decreased to 14 per thousand in 2019–2021. There is no disadvantage for the rural children due to their place of residence if they belong to economically well-off household or their mothers are educated. It is wealth index rather than place of residence which determines the under-five mortality. Economic (50.82% contribution) and educational differential (28.57% contribution) are the main reasons for rural-urban under-five mortality gaps.

Conclusion

The existing rural-urban gap in under-five mortality suggests that the social and health policies need to be need to reach rural children from poor families and uneducated mothers. This call for attention to ensure that the future programme must emphasize mothers from economically and educationally disadvantaged sections. While there should be more emphasis on equal access to health care facilities by the rural population, there should also be an effort to strengthen the rural economy and quality of education.

Barriers in reaching new-borns and infants through home visits: A qualitative study using nexus planning framework

Background

Home visitation has emerged as an effective model to provide high-quality care during pregnancy, childbirth, and post-natal period and improve the health outcomes of mother- new born dyad. This 360⁰ assessment documented the constraints faced by the community health workers (known as the Accredited Social Health Activists, ASHAs) to accomplish home visitation and deliver quality services in a poor-performing district and co-created the strategies to overcome these using a nexus planning approach.

Methods

The study was conducted in the Raisen district of Madhya Pradesh, India. The grounded theory approach was applied for data collection and analysis using in-depth interviews, and focus group discussions with stakeholders representing from health system (including the ASHAs) and the community (rural population). A key group of diverse stakeholders were convened to utilize the nexus planning five domain framework (social-cultural, educational, organizational, economic, and physical) to prioritize the challenges and co-create solutions for improving the home visitation program performance and quality. The nexus framework provides a systemic lens for evaluating the success of the ASHAs home visitation program.

Results

The societal (caste and economic discrimination), and personal (domestic responsibilities and cultural constraints of working in the village milieu) issues emerged as the key constraints for completing home visits. The programmatic gaps in imparting technical knowledge and skills, mentoring system, communication abilities, and unsatisfactory remuneration system were the other barriers to the credibility of the services. The nexus planning framework emphasized that each of the above factors/domains is intertwined and affects or depends on each other for home-based maternal and newborn care services delivered with quality through the ASHAs.

Conclusion

The home visitation program services, quality and impact can be enhanced by addressing the social-cultural, organizational, educational, economic, and physical nexus domains with concurrent efforts for skill and confidence enhancement of the ASHAs and their credibility.

Determinants of neonatal mortality among neonates admitted to neonatal intensive care unit of Dessie comprehensive and specialized hospital, Northeast Ethiopia; An unmatched case-control study

Background

According to the World health organization, neonatal mortality is defined as the death of babies within the first 28 days of their lives. The newborn period is the most vulnerable period for a child's survival, with the bulk of neonatal deaths occurring on the first day and week. According to a recent study, about a third of all newborn deaths occur within the first day of life, and nearly three-quarters occur within the first week. This study aimed to assess the determinants of neonatal mortality among neonates admitted to the neonatal intensive care unit in Dessie comprehensive and specialized hospital, northeast Ethiopia.

Methodology

Health institution-based unmatched case-control study was conducted among neonates admitted to Dessie comprehensive and specialized hospital, Ethiopia from February 01 up to March 30, 2020. After keeping cases and controls in separate frames, study participants were chosen using a simple random sampling procedure until the sample size was met. Epi data version 7.0 and SPSS version 25 were used for data entry and analysis respectively. P ≤ 0.05 was used as a cut point of statistical significance in multivariable binary logistic regression.

Results

A total of 698 (233 cases and 465 controls) participated in the study. Pregnancy induced hypertension (AOR = 3.02; 95% CI; 1.47-6.17), public hospital delivery (AOR = 3.44; 95% CI; 1.84-6.42), prematurity (AOR = 2.06; 95% CI; 1.43-2.96), being referred (AOR = 4.71; 95% CI; 3.01-7.39), and hypothermia (AOR = 2.44; 95% CI; 1.56-3.82) were determinant factors of neonatal mortality.

Conclusion

Pregnancy-induced hypertension, public hospital delivery, prematurity, referral, and hypothermia were found to be the determinant factors of neonatal mortality. It would be important to give due attention to neonates delivered from mothers with a history of hypertensive disorder. Besides better to give due attention to neonates delivered in public health institutions, prematurely delivered, referred, and hypothermic neonates. Lastly, further research should be conducted to investigate the additional determinants of neonatal mortality.

An ethnographic approach to understand cultural perspectives of tribes on branding practice for sick children in Odisha, India

Background & objectives

Traditional beliefs on child healthcare at time lead to potentially harmful practices like branding. However, there is a gap in people's perceptions, attitudes and beliefs about branding practice. Therefore, the present study was undertaken to document the cultural motivation, ability and opportunity for branding practice in a tribal district of Odisha, India.

Methods

Initially, such practices were observed in the tribal community for three months. Then, 18 in-depth interviews were conducted - ten among women having under-five children, and eight among traditional healers. Six focus group discussions were conducted with community health workers as well. The responses were digitally recorded, transcribed and translated and were further used for thematic framework analysis.

Results

The primary determinants of branding practice were cultural beliefs compounded with low-health literacy, proximity to conventional care and influence of family and friends. The key driver for branding practices was traditional cultural beliefs on child healthcare decisions and health-seeking behaviours. Opportunities in the health system - availability and quality of health services - frequently drive them to seek healthcare from the system structure and routine health communication improves their ability to make better healthcare decisions.

Interpretation & conclusions

Culture significantly affects the conceptualisation of illness and care-seeking pathways in a society. The indigenous community used to consult local traditional healers for their health concerns. While the government has made efforts to increase community health literacy through various platforms and multiple stakeholders' engagements, the doorstep availability of modern care and health promotion interventions remains critical for meeting the health needs of the indigenous community.

Effect of home-based childcare on childhood mortality in rural Maharashtra, India: a cluster randomised controlled trial

Background

Melghat, an impoverished rural area in Maharashtra state, India; has scarce hospital services and low health-seeking behaviour. At baseline (2004) the under-five mortality rate (U5MR) (number of deaths in children aged 0–5 years/1000 live births) was 147.21 and infant mortality rate (IMR) (number of deaths of infants aged under 1 year/1000 live births) was 106.6 per 1000 live births. We aimed at reducing mortality rates through home-based child care (HBCC) using village health workers (VHWs).

Methods

A cluster-randomised control trial was conducted in 34 randomly assigned clusters/villages of Melghat, Maharashtra state, between 2004 and 2009. Participants included all under-five children and their parents. Interventions delivered through VHWs were patient–public involvement, newborn care, disease management and behaviour change communications. Primary outcome indicators were U5MR and IMR. Secondary outcome indicators were neonatal mortality rate (NMR) (number of neonatal deaths aged 0–28 days/1000 live births) and perinatal mortality rate (PMR) (number of stillbirths and early neonatal deaths/1000 total births). Analysis was by intention-to-treat at the individual level. This trial was extended to a service phase (2010–2015) in both arms and a government replication phase (2016–2019) only for the intervention clusters/areas (IA).

Findings

There were 18 control areas/clusters (CA) allocated and analysed with 4426 individuals, and 16 of 18 allocated IA, analysed with 3230 individuals. The IMR and U5MR in IA were reduced from 106.60 and 147.21 to 32.75 and 50.38 (reduction by 69.28% and 65.78%, respectively) compared with increases in CA from 67.67 and 105.3 to 86.83 and 122.8, respectively, from baseline to end of intervention. NMR and PMR in IA showed reductions from 50.76 to 22.67 (by 55.34%) and from 75.06 to 24.94 (by 66.77%) respectively. These gains extended to villages in the service and replication phases.

Interpretation

This socio-culturally contextualised model for HBCC through VHWs backed up with institutional support is effective for significant reduction of U5MR, IMR and NMR in impoverished rural areas. This reduction was maintained in the study area during the service phase, indicating feasibility of implementation in large-scale public health programmes. Replicability of the model was demonstrated by a linear decline in all the mortality rates in 20 new villages during the government phase.

Trial registration number

NCT02473796.

The effects of community clustering on under-five mortality in India: a parametric shared frailty modelling approach

The study of the effect of community clustering of under-five mortality has its implications in both research and policy. Studies have shown the contribution of community factors on under-five mortality. However, these studies did not account for censoring. We examine the presence of community dependencies and determine the risk factors of under-five mortality in India and its six state-regions by employing a Weibull hazard model with gamma shared frailty. We considered every possible way to ensure that the frailty models used in the study are not merely a consequence of how the data are organized rather than representing a substantive assumption about the source of the frailty. Data from the fourth round of the National Family Health Survey has been used. The study found that except for south India, children born in the same community in India and the other five state-regions shared similar characteristics of under-five mortality. The risk of under-five mortality decreased with an increase in mother’s schooling. Except for northern region, female births were less likely to die within first five years of life. We found a U-shaped relationship between preceding birth interval and under-five mortality. History of sibling’s death, multiple births and low-birthweight significantly increases the risk of under-five mortality in all the six state-regions. The Hindu–Muslim mortality gaps and Scheduled Caste or Tribe’s mortality disadvantage is diminishing. Since the factors associated with under-five mortality were not necessarily the same across the six state-regions of India, adopting a uniform approach in dealing with under-five mortality in India may not benefit all the regions equally.

Out-of-pocket expenditure and its predictors for illness of under-five children: A cross-sectional study in urban slums of Eastern India

Introduction

Out-of-pocket (OOP) expenditure influences the access to the healthcare of the marginalized and vulnerable population including under-five children (U5C). The aim of the study is to estimate the OOP expenditure and its predictors in Bhubaneswar, a region of eastern India.

Methods

A cross-sectional study was conducted using a semi-structured interview schedule in 20 urban slums of Bhubaneswar. The survey was carried out by using the National Sample Survey Office (NSSO) health consumption schedule 25.0 in which mothers of U5C with illness (n = 530) were interviewed. For data analysis, the nonparametric Wilcoxon rank-sum test and Kruskal-Wallis test were used as tests of significance.

Results

The study revealed that the mean OOP expenditure for outpatient department (OPD) care was ₹375.9 (₹219.48). The mean approximated expenditure was ₹1669.8 (₹1131.9) for inpatient department (IPD) care. In OPD care, doctors' fee and medicine cost constituted 65.01% and 50.46% of OOP expenditure, respectively. In IPD care, medicine cost and doctors' fee contributed to 36.62% and 30.54% of OOP expenditure, respectively. The major significant predictors that contributed to increased OOP were gender and delay in approaching the source of treatment in OPD, whereas in IPD no such predictors were observed.

Conclusions

This study prominently sheds light on the issue of accessibility and affordability of health services without a comprehensive health insurance scheme for U5C illness among the vulnerable urban slum dwellers to achieve universal health coverage.

Obesity, dyslipidaemia and candidate gene polymorphisms: a cross-sectional study among the Liangmai and Mizo tribes of Manipur, India

BACKGROUND

The prevalence of obesity and dyslipidaemia was observed to be increased among the tribal populations, due to globalization.

MATERIALS AND METHODS

In the present study, data on demographic, somatometric and blood samples were collected from 613 participants of both sex, age 18-60 years, further lipid profiling and genotyping was executed. Multifactor dimensionality reduction (MDR) software was used for gene-gene interactions analysis.

RESULTS

Significantly differences were observed with respect to the general characteristic and selected gene polymorphisms in both the tribes. Among the Liangmai tribe, MC4R gene was found to pose significant decreased risk for waist-height ratio (WHtR) (OR = 0.56; 95% confidence interval (CI)= 0.32-0.99; p value = .04) and HDL (OR = 0.58; 95% CI = 0.36-0.92; p value = .02). Similar trends of significant decreased risk (OR = 0.39; 95% CI = 0.20-0.76; p value=.006) for BMI were observed among the Mizo tribe. The gene-gene interaction revealed the combined model of FTO+MC4R genes shows an increased risk for BMI in both the tribes. The independent significant increased risk posed by FTO gene was moderated by interaction with MC4R gene.

CONCLUSIONS

The observed differences can possibly attribute to both their respective ancestries resulting in different gene pools and the physical environment. The results of the study highlight the importance of gene-gene and gene-environment interactions in adverse phenotype groups.KEY MESSAGEAmong the tribal population, the prevalence of obesity and dyslipidaemia has been increased.Differential distribution and associations of selected markers hint towards differential genetic architecture in these populations.MC4R rs17782313 polymorphism was found to show a significantly decreased risk for WHtR and low HDL among the Liangmai tribe and BMI among the Mizo tribe.Significant increased risk posed by FTO rs9939609 gene polymorphism was moderated by the interaction with MC4R rs17782313.

Risk factors for childhood illness and death in rural Uttar Pradesh, India: perspectives from the community, community health workers and facility staff

BACKGROUND

Uttar Pradesh (UP), India continues to have a high burden of mortality among young children despite recent improvement. Therefore, it is vital to understand the risk factors associated with under-five (U5) deaths and episodes of severe illness in order to deliver programs targeted at decreasing mortality among U5 children in UP. However, in rural UP, almost every child has one or more commonly described risk factors, such as low socioeconomic status or undernutrition. Determining how risk factors for childhood illness and death are understood by community members, community health workers and facility staff in rural UP is important so that programs can identify the most vulnerable children.

METHODS

This qualitative study was completed in three districts of UP that were part of a larger child health program. Twelve semi-structured interviews and 21 focus group discussions with 182 participants were conducted with community members (mothers and heads of households with U5 children), community health workers (CHWs; Accredited Social Health Activists and Auxiliary Nurse Midwives) and facility staff (medical officers and staff nurses). All interactions were recorded, transcribed and translated into English, coded and clustered by theme for analysis. The data presented are thematic areas that emerged around perceived risk factors for childhood illness and death.

RESULTS

There were key differences among the three groups regarding the explanatory perspectives for identified risk factors. Some perspectives were completely divergent, such as why the location of the housing was a risk factor, whereas others were convergent, including the impact of seasonality and certain occupational factors. The classic explanatory risk factors for childhood illness and death identified in household surveys were often perceived as key risk factors by facility staff but not community members. However, overlapping views were frequently expressed by two of the groups with the CHWs bridging the perspectives of the community members and facility staff.

CONCLUSION

The bridging views of the CHWs can be leveraged to identify and focus their activities on the most vulnerable children in the communities they serve, link them to facilities when they become ill and drive innovations in program delivery throughout the community-facility continuum.

Effect of a maternal counselling intervention delivered by community health workers on child nutrition: secondary analysis of a cluster randomised controlled trial in India

Background

India suffers from a double burden of malnutrition and anaemia. The Karnataka anaemia project indicated that a counselling intervention delivered by community health workers improved anaemia cure rates.

Objective

To evaluate the effect of maternal counselling on nutritional aspects of anaemia prevention.

Methods

Secondary analysis of a cluster randomised controlled trial (55 simultaneously randomised villages using random number generator in Chamrajnagar district, Northern India). In the intervention group mothers of anaemic children received five monthly counselling sessions plus usual care (iron and folic acid supplements), while mothers of anaemic children in the control group received usual care alone. Daily intake of nutrients related to anaemia prevention, i.e. iron (mg) and vitamin C (mg), was estimated using the 24-h dietary recall method at baseline and 6 months follow-up. Linear and logistic mixed regression models were used to assess between-groups difference in changes in nutrients intake from baseline to end of follow-up. Data collectors and analysts were blinded to the group assignment.

Results

Participants were 534 (intervention n = 303; usual treatment n = 231) anaemic children, aged 1 to 5 years and their caregivers, of whom 521(intervention n = 299 from 28 villages; usual treatment n = 222 from 27 villages) were retained at 6 months follow-up and included in the analysis. This study provides inconclusive evidence of improvement in the intake of nutrients that prevent anaemia from baseline to follow-up among the intervention compared to the control group; increase in iron intake was 0.24 mg/day (95% CI -0.67; 1.15) and increase in vitamin C intake was 4.61 mg/day (95% CI -0.69, 9.91). Although encouraging, it is notable that the overall intake of nutrients that prevent anaemia remained well below the national recommended daily allowance.

Conclusion

This study provides inconclusive evidence of the effect of parental counselling on nutritional aspects of anaemia prevention. The results highlight the need to devise multi-component anaemia-prevention interventions that include facilitators of the availability of nutritious food and should be evaluated in studies that are adequately powered to detect nutritional changes.

Trial registration

International Standard Randomized Controlled Trial Number ISRCTN68413407, prospectively registered on 17/12/2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11998-w.

Effectiveness of participatory women's groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India: a pragmatic cluster non-randomised controlled trial

INTRODUCTION

The WHO recommends community mobilisation with women's groups practising participatory learning and action (PLA) to improve neonatal survival in high-mortality settings. This intervention has not been evaluated at scale with government frontline workers.

METHODS

We did a pragmatic cluster non-randomised controlled trial of women's groups practising PLA scaled up by government front-line workers in Jharkhand, eastern India. Groups prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies and evaluated progress. Intervention coverage and quality were tracked state-wide. Births and deaths to women of reproductive age were monitored in six of Jharkhand's 24 districts: three purposively allocated to an early intervention start (2017) and three to a delayed start (2019). We monitored vital events prospectively in 100 purposively selected units of 10 000 population each, during baseline (1 March 2017-31 August 2017) and evaluation periods (1 September 2017-31 August 2019). The primary outcome was neonatal mortality.

RESULTS

We identified 51 949 deliveries and conducted interviews for 48 589 (93.5%). At baseline, neonatal mortality rates (NMR) were 36.9 per 1000 livebirths in the early arm and 39.2 in the delayed arm. Over 24 months of intervention, the NMR was 29.1 in the early arm and 39.2 in the delayed arm, corresponding to a 24% reduction in neonatal mortality (adjusted OR (AOR) 0.76, 95% CI 0.59 to 0.98), including 26% among the most deprived (AOR 0.74, 95% CI 0.57 to 0.95). Twenty of Jharkhand's 24 districts achieved adequate meeting coverage and quality. In these 20 districts, the intervention saved an estimated 11 803 newborn lives (min: 1026-max: 20 527) over 42 months, and cost 41 international dollars per life year saved.

CONCLUSION

Participatory women's groups scaled up by the Indian public health system reduced neonatal mortality equitably in a largely rural state and were highly cost-effective, warranting scale-up in other high-mortality rural settings.

TRIAL REGISTRATION

ISRCTN99422435.

Utilizing "Positive deviance inquiry" to explore factors influencing child health: A qualitative study

BACKGROUND

India is a lower middle-income country with one of the fastest growing economies in the world. Despite improvements in its economy, it has a high child mortality rate, with significant differences in child mortality both between and within different states. In this research, we tend to explore factors as to how a particular child's growth is optimal. With this aim, we utilized positive deviance inquiry to study the factors influencing under five child's health.

MATERIALS AND METHODS

This qualitative study was carried out in Naigoan, an urban health setting of metropolitan city with 37 sample size between July 2020 and September 2020. It consisted of total 16 in-depth interviews (IDIs), 3 focus group Discussion (FGDs), and 7 key informant interviews (KIIs) which were performed by predesigned guides.

RESULTS

Various themes evolved with the interviews; however, triangulation of the concept (from FGDs, IDIs, and KIIs) occurred with the following themes: satisfaction among mothers for health-care services, community participation, family support, and new interventions.

CONCLUSION

Mothers' satisfaction to health-care services, community participation, family support, and innovations by the health-care providers are the influencing factors in promoting child's health. Further research can be conducted to understand the in-depth understanding of each factor.

Differential and Determinants of Neonatal Mortality: A Comparative Study in Northern and Southern Regions of India

BACKGROUND

The Government of India initiated different programs to reduce neonatal mortality. However, the variability of neonatal deaths occurs among states of India.

OBJECTIVE

This study aimed to identify the differential determinants associated with neonatal deaths in northern and southern regions of India.

MATERIALS AND METHODS

Bivariate analysis and Cox regression analysis have been performed to evaluate the predictors of neonatal mortality from National Family Health Survey (NFHS-4) data.

RESULTS

For neonatal mortality, mother and child factors became more consistent in the southern region than northern regions of the country, while household factor was almost the same in both regions of India.

CONCLUSIONS

Primary intervention is also required to reduce public health problem as neonatal mortality. It should be focused on education of mother, birth interval, age at birth, antenatal care, poverty reduction programs, and proper heath facility to pregnant mothers.

Understanding inequalities in child immunization in India: a decomposition approach

The importance of childhood immunization for healthy child growth and development is well recognized and is considered to be the best and most cost-effective lifesaver. Low socioeconomic status has been shown to be associated with low child immunization and health care utilization, but the inequalities in immunization coverage due to social and economic factors are poorly understood. This study aimed to explore the association between child immunization coverage and various socioeconomic factors and to quantify their contributions to generating inequalities in immunization coverage in India. The study data are from the National Family Health Survey-4 conducted in 2015-16. The association between socioeconomic determinants and child full immunization coverage was estimated using the χ2 test and binary logistic regression. Concentration indices were estimated to measure the magnitude of inequality, and these were further decomposed to explain the contribution of different socioeconomic factors to the total disparity in full immunization coverage. The results showed that the uptake of immunization in 2015-16 was highly associated with mother's educational status and household wealth. The concentration index decomposition revealed that inequality (immunization disadvantage) was highest among poorer economic groups and among children whose mothers were illiterate. The overall concentration index value indicates that the weaker socioeconomic groups in India are more disadvantaged in terms of immunization interventions. The results offer insight into the dynamics of the variation in immunization coverage in India and help identify vulnerable populations that should be targeted to decrease socioeconomic inequalities in the country.

Is newborn survival influenced by place of delivery? A comparison of home, public sector and private sector deliveries in India

In 2005 and again in 2011, the Government of India launched schemes to encourage institutional delivery among poor women, with the aim of improving maternal and newborn health outcomes. Partly as a result of these initiatives, the proportion of children born in a health facility rose steeply from 42% in 2000-2005 to 81% a decade later. In this context, the objective of this paper was to determine the association between place of delivery (public sector, private sector, home) and early neonatal mortality, defined as death in the first 7 days after birth. The focus was on early neonatal mortality because over half of all under-five deaths occur in his period and because the protective effect of an institutional place of birth should be strongest in those few early days. Both bivariate methods and multivariate logistic regression analysis were applied to data from the fourth round of the National Family Health Survey conducted in 2015-16. For the country as a whole, it was found that the adjusted odds of death in the early neonatal period were lower for deliveries in public health facilities than for home deliveries (OR 0.833 p<0.01), but no significant difference was found between deliveries in private health facilities and at home. Adjusted odds of death were higher for deliveries in private than public sector facilities (OR 1.41 p<0.01). On further investigation, for the poor in Bihar and Uttar Pradesh, it was found that the risks of dying in the early neonatal period were even higher for babies delivered in private health facilities than for home deliveries with adjusted odds of over 2.0. These results raise serious questions about quality of care in the private sector in India. In the context of increased emphasis on public-private partnerships in health services provision in the country, it becomes imperative to enforce better inspection, licensing and quality control of private sector facilities, especially in the states of Bihar and Uttar Pradesh.

Influence of publicly funded conditional cash transfer programms on utilization patterns of healthcare services for acute childhood illness

Background

Conditional cash transfers are widespread and effective for utilization of targeted health services, but there is little evidence of their influence on the utilization of non-targeted or extended general healthcare services. Using data from a population-based health utilization survey, we evaluated the influence of conditional cash transfers for maternal and immunization services on the utilization of healthcare services for acute childhood illnesses.

Methods

Participants included mothers or primary caretakers of children <2 y of age residing in 2407 households in urban Vellore, Tamil Nadu, India. Mothers of children with illness in the preceding month were interviewed on presenting symptoms, provider choice and beneficiary status of maternal and immunization-based conditional cash transfer programs.

Results

Of 2407 children <2 y of age, about 48% reported being beneficiaries of maternal and immunization-based conditional cash transfers. Beneficiary status was associated with an increased use of public services (adjusted relative risk [aRR] 3.14 [95% confidence interval {CI} 1.96 – 5.02]) but not the use of private services (aRR 1.42 [95% CI 0.97 – 2.08]) relative to home or informal care.

Conclusions

Our findings indicate financial incentives for use of maternal and immunization services could have an indirect, non-targeted effect on utilization of formal healthcare for acute childhood illnesses.

Fertility transition and socioeconomic development in districts of India, 2001-2016

The fertility-development relationship is bi-directional, context-specific, multi-phased and inconsistent over time. Indian districts provide an ideal setting to study this association due to their size, diversity and disparity in socioeconomic development. The objective of this study was to understand the association of fertility and socioeconomic development among the 640 districts of India. Data were drawn from multiple sources: Censuses of India 2001 and 2011; DLHS-2; NFHS-4; and other published sources. A district-level data file for Total Fertility Rate (TFR) and a set of developmental indices were prepared for the 640 districts for 2001 and 2016. Computation of a composite index (District Development Index, DDI), Ordinary Least Squares, Two Stage Least Squares and panel regressions were employed. By 2016, almost half of all Indian districts had attained below-replacement fertility, and 15% had a TFR of above 3.0. The DDI of India increased from 0.399 in 2001 to 0.511 by 2016 and showed large variations across districts. The correlation coefficient between TFR and DDI was -0.658 in 2001 and -0.640 in 2016. Districts with a DDI of between 0.3 and 0.6 in 2001 had experienced a fertility decline of more than 20%. The fertility-development relationship was found to be strongly negative, convex and consistent over time, but the level of association varied regionally. For any given level of DDI, fertility in 2016 was lower than in 2001; and the association was stronger in districts with a DDI below 0.45. The negative convex association between the two was prominent in the northern, central and eastern regions and the curves were flatter in the west, south and north-east. The increasing number of districts with low fertility and low development draws much attention. Some outlying districts in the north-eastern states had high TFR and high DDI (>0.6). Based on the findings, a multi-layered strategy in districts with low socioeconomic development is recommended. Additional investment in education, child health, employment generation and provisioning of contraceptives would improve the human development to achieve India's demographic goals.

Precision-weighted estimates of neonatal, post-neonatal and child mortality for 640 districts in India, National Family Health Survey 2016

BACKGROUND

The conventional indicators of infant and under-five mortality are aggregate deaths occurring in the first year and the first five years, respectively. Monitoring deaths by <1 month (neonatal), 1-11 months (post-neonatal), and 12-59 months (child) can be more informative given various etiological causes that may require different interventions across these three mutually exclusive periods. For optimal resource allocation, it is also necessary to track progress in robust estimates of child survival at a smaller geographic and administrative level.

METHODS

Data on 259 627 children came from the 2015-2016 Indian National Family Health Survey. We used a random effects model to account for the complex survey design and sampling variability, and predicted district-specific probabilities of neonatal, post-neonatal, and child mortality. The resulting precision-weighted estimates are more reliable as they pool information and borrow strength from other districts that share the same state membership. The Pearson correlation and Spearman's rank correlation were assessed for the three mortality estimates, and the Moran's I measure was used to detect spatial clustering of high burden districts for each outcome.

RESULTS

The majority of under-five deaths was disproportionately concentrated in the neonatal period. Across all districts, the predicted probability of neonatal, post-neonatal, and child mortality varied from 6.0 to 63.9 deaths, 3.8 to 47.6 deaths, and 1.7 to 11.8 deaths per 1000 live births, respectively. The overall correlation between district-wide probabilities of mortality for the three mutually exclusive periods was moderate (Pearson correlation = 0.47-0.58, Spearman's rank correlation = 0.58-0.64). For each outcome, a relatively strong spatial clustering was detected across districts that transcended state boundaries (Moran's I = 0.61-0.76).

CONCLUSIONS

Sufficiently breaking down the under-five mortality to distinct age groups and using the precision-weighted estimations to monitor performances at smaller geographic and administrative units can inform more targeted interventions and foster accountability to improve child survival.

Gauging Class and Caste differences in Mortality: The Indian Experience

This study is an exposition of class-caste based differences in mortality experience based on an indicator called household prevalence of death. It involves 75,432 death cases collected in National Family Health Survey-4, analysed using Relative Deprivation Index (RDI). We found, the prevalence of death found to be 11.8% in India, which varies across states and social and economic groups. The RDI values depict that the poorer households along with social group identities like schedule tribe and schedule caste households displayed a uniform disadvantage as regarding mortality across many states. The analysis offers evidence on differential experience of mortality across socio-economic identities. The evidence suggests poorer states having a marked disadvantage along with social and economic classes.

Incidence of neonatal mortality and its predictors among live births in Ethiopia: Gompertz gamma shared frailty model

Background

Neonatal mortality remains a serious public health concern in developing countries including Ethiopia. Ethiopia is one of the countries with the highest neonatal mortality in Africa. However, there is limited evidence on the incidence and predictors of neonatal mortality at the national level. Therefore, this study aimed to investigate the incidence of neonatal mortality and its predictors among live births in Ethiopia. Investigating the incidence and predictors of neonatal mortality is essential to design targeted public health interventions to reduce neonatal mortality.

Methods

A secondary data analysis was conducted based on the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total weighted sample of 11,022 live births was included in the analysis. The shared frailty model was applied since the EDHS data has hierarchical nature, and neonates are nested within-cluster, and this could violate the independent and equal variance assumption. For checking the proportional hazard assumption, Schoenfeld residual test was applied. Akakie Information Criteria (AIC), Cox-Snell residual test, and deviance were used for checking model adequacy and for model comparison. Gompertz gamma shared frailty model was the best-fitted model for this data since it had the lowest deviance, AIC value, and the Cox-Snell residual graph closet to the bisector. Variables with a p-value of less than 0.2 were considered for the multivariable Gompertz gamma shared frailty model. In the multivariable Gompertez gamma shared frailty model, the Adjusted Hazard Ratio (AHR) with a 95% confidence interval (CI) was reported to identify significant predictors of neonatal mortality.

Results

Overall, the neonatal mortality rate in Ethiopia was 29.1 (95% CI: 26.1, 32.4) per 1000 live births. In the multivariable Gompertz gamma shared frailty model; male sex (AHR = 1.92, 95% CI: 1.52, 2.43), twin birth (AHR = 5.22, 95% CI: 3.62, 7.53), preceding birth interval less than 18 months (AHR = 2.07, 95% CI: 1.51, 2.85), small size at birth (AHR = 1.64, 95% CI: 1.24, 2.16), large size at birth (AHR = 1.53, 95% CI: 1.16, 2.01) and did not have Antenatal Care (ANC) visit (AHR = 2.10, 95% CI: 1.44, 3.06) were the significant predictors of neonatal mortality.

Conclusion

Our study found that neonatal mortality remains a public health problem in Ethiopia. Shorter birth interval, small and large size at birth, ANC visits, male sex, and twin births were significant predictors of neonatal mortality. These results suggest that public health programs that increase antenatal care service utilization should be designed to reduce neonatal mortality and special attention should be given for twin births, large and low birth weight babies. Besides, providing family planning services for mothers to increase birth intervals and improving accessibility and utilization of maternal health care services such as ANC is crucial to improve neonatal survival.

Disparity in childhood stunting in India: Relative importance of community-level nutrition and sanitary practices

Despite rapid macro-economic growth, one-third of the global burden of childhood stunting is contributed by India. This burden is characterized by wide-spread geographical variation within the country. This paper explores two research questions: (i) are the drivers of severe and moderate stunting similar? (ii) differential endowments or policy-effect, how do community-level nutrition and sanitary practices affect inter-state differences? Using data from Indian National Family and Health Survey 4, 2015-16, six states holding different ranks in the stunting continuum are compared to Tamil Nadu, taken as the benchmark state due to its laudable performance in the health care sector. Applying quantile regression approaches, the difference in state-level performance is decomposed into detailed covariate effects (differential endowments) and coefficient effects (differential strength of association between the drivers and outcome). The explanatory variables are not similarly associated with severe and moderate stunting. Decomposition results demonstrate a significant role of community-level sanitation practices compared to child nutrition behaviour in explaining the inter-state disparity. Coefficient effects play a dominant role in the lower tail of HAZ distribution for the poor performing states indicating that the worse outcomes of these states are due to weaker policy effects of the control variables on stunting. Multi-sectoral approach, identification and differentiation between severe and moderate stunting cases can be more instrumental in managing and reducing the scourge. This paper also advocates the potential benefits of customizing centrally-launched policies as per the state's performance and introducing the concept coproduction in the existing nutrition and health policy framework. This will instigate a feeling of ownership of the problem of childhood stunting among the policy consumers and strengthen the influence of policies on the outcomes.

Factors explaining regional variation in under-five mortality in India: An evidence from NFHS-4

Although child mortality has declined in India, pronounced regional and socioeconomic inequality exists. The study examines the effects of individual- and community-level characteristics on under-five mortality and investigates the extent to which they affect regional variation. The study is based on Indian National Family and Health Survey 4, 2015-16 data. A two-level logistic regression model was performed to examine the effects of the socio-economic characteristics, and multivariate decomposition analysis was done to assess the contribution of factors in the inter-regional under-five mortality differentials. Regional variation in the selected variables is observed. For instance, the percentage of children with small childbirth size varied from 9.7% in the southern to 21.6% in the northeastern region. The percentage of poor households, low educated mothers, and childbirths delivered at home facility were higher in the central and eastern region compared to the southern region. The multilevel analysis shows that the region of residence explained 15.8% variance, and community-level characteristics alone could explain 25.3% variation in the risk of under-five deaths. The decomposition analysis indicates that the average number of excess deaths in the central and eastern regions is higher compared to the other regions. The compositional differences account for 50.9% of the under-five mortality gaps between the south and north region, 80.9% of the gap between the south and east, and 42.9% of the gap between the south and central region of India. Special attention and targeted action are needed to address the underlying causes of low birth weight of children in all the regions of India. Region-specific interventions might be priorities; for example, north, and central regions, need an economic and educational uplift, while infrastructural and economic policies should be prioritized for the northeastern region. Also, region-specific community-level interventions are needed to improve child survival in India.

Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000-17

BACKGROUND

India has made substantial progress in improving child survival over the past few decades, but a comprehensive understanding of child mortality trends at disaggregated geographical levels is not available. We present a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the India National Health Policy (NHP) and Sustainable Development Goal (SDG) targets for child mortality.

METHODS

We assessed the under-5 mortality rate (U5MR) and neonatal mortality rate (NMR) from 2000 to 2017 in 5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sources including surveys with subnational geographical information. The 31 states and groups of union territories were categorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burden of Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using the coefficient of variation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from 2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and 25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). We assessed the causes of child death and the contribution of risk factors to child deaths at the state level.

FINDINGS

U5MR in India decreased from 83·1 (95% uncertainty interval [UI] 76·7-90·1) in 2000 to 42·4 (36·5-50·0) per 1000 livebirths in 2017, and NMR from 38·0 (34·2-41·6) to 23·5 (20·1-27·8) per 1000 livebirths. U5MR varied 5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied 4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88%) districts had a U5MR of 40 or more per 1000 livebirths and 291 (93%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate of change from 2010 to 2017 varied among the districts from a 9·02% (95% UI 6·30-11·63) reduction to no significant change for U5MR and from an 8·05% (95% UI 5·34-10·74) reduction to no significant change for NMR. Inequality between districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states for NMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to 2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either of the NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districts for NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 death in India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediate decline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude of decline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which 68·2% (65·8-70·7) of under-5 deaths and 83·0% (80·6-85·0) of neonatal deaths in India could be attributed in 2017; 10·8% (9·1-12·4) of under-5 deaths could be attributed to unsafe water and sanitation and 8·8% (7·0-10·3) to air pollution.

INTERPRETATION

India has made gains in child survival, but there are substantial variations between the states in the magnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality between districts within states has increased for the majority of the states. The district-level trends presented here can provide crucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survival targets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the risk factors in this Article provide a comprehensive reference for further planning of child mortality reduction in India.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Diagnosis and Management of Critical Congenital Heart Diseases in the Newborn

Congenital heart disease (CHD) has been one of the most important contributors to neonatal mortality in the western world for the past 2 decades. With improvement in basic neonatal medical care in most parts of our country, the traditional contributors to neonatal mortality such as birth asphyxia and infections have reduced in numbers. This has hence thrust greater focus on CHD. Facilities with capability to diagnose and intervene on neonates with critical CHD are available in most states. Refinements in surgical techniques and advances in post-operative care have ensured that most neonates with critical CHD can undergo surgical or interventional procedures with very low mortality and can be expected to survive to adulthood with a reasonable quality of life. Unrecognized critical CHD could however result in death in the neonatal period. Focus has hence shifted towards sensitizing pediatricians about timely recognition of neonates with CHD. In this article, authors discuss the presentation and initial stabilization of neonates with CHD and attempt to provide practical solutions which can aid early diagnosis of CHD in the Indian scenario.

Does the preference for location of childbirth change for successive births? Evidence from the states and regions of India

Universal health coverage is central to the development agenda to achieve maternal and neonatal health goals. Although there is evidence of a growing preference for institutional births in India, it is important to understand the pattern of switching location of childbirth and the factors associated with it. This study used data from the fourth round of the National Family and Health Survey (NFHS-4) conducted in India in 2015-16. The study sample comprised 59,629 women who had had at least two births in the five years preceding the survey. Bivariate and multivariate logistic regression analyses were applied to the data. About 16.4% of the women switched their location of childbirth between successive births; 9.1% switched to a health facility contributing to a net increment of 1.9% in institutional delivery, varying greatly across states and regions. There was at least a 4 percentage point net increment in institutional births in Chhattisgarh, Bihar, Punjab and Haryana, but the shift was more in favour of home births in Madhya Pradesh, Odisha and West Bengal. Women with high parity and a large birth interval had higher odds of switching their place of childbirth, and this was in favour of a health facility, while women with higher education, from lower social groups, living in urban areas, who had not received four antenatal care visits, and who belonged to a higher wealth quintile had higher odds of switching their place of childbirth to a health facility, despite having lower odds of switching their childbirth location. The study provides evidence of women in India switching their location of childbirth for successive births, and this was more prevalent in areas where the rate of institutional delivery was low. Only a few states showed a higher net increment in favour of a health facility. This suggests that there is a need for action in specific states and regions of India to achieve universal health coverage.

District level inequality in reproductive, maternal, neonatal and child health coverage in India

Background

As India already missed maternal and child health related millennium development goals, the maternal and child health outcomes are a matter of concern to achieve sustainable development goals (SDGs). This study is focused to assess the gap in coverage and inequality of various reproductive, maternal, neonatal and child health (RMNCH) indicators in 640 districts of India, using data from most recent round of National Family Health Survey.

Methods

A composite index named Coverage Gap Index (CGI) was calculated, as the weighted average of eight preventive maternal and child care interventions at different administrative levels. Bivariate and spatial analysis were used to understand the geographical diversity and spatial clustering in districts of India. A socio-economic development index (SDI) was also derived and used to assess the interlinkages between CGI and development. The ratio method was used to assess the socio-economic inequality in CGI and its component at the national level.

Results

The average national CGI was 26.23% with the lowest in Kerala (10.48%) and highest in Nagaland (55.07%). Almost half of the Indian districts had CGI above the national average and mainly concentrated in high focus states and north-eastern part. From the geospatial analysis of CGI, 122 districts formed hotspots and 164 districts were in cold spot. The poorest households had 2.5 times higher CGI in comparison to the richest households and rural households have 1.5 times higher CGI as compared to urban households.

Conclusion

Evidence from the study suggests that many districts in India are lagging in terms of CGI and prioritize to achieve the desired level of maternal and child health outcomes. Efforts are needed to reduce the CGI among the poorest and rural resident which may curtail the inequality.

Coverage, quality, and correlates of childhood immunization in slums under national immunization program of India: A cross-sectional study

Adequate and quality immunization coverage plays a key role in controlling the outbreaks of vaccine preventable diseases. Places where immunization coverage is low, vaccine preventable diseases contribute to worse health outcomes. This is especially true in Indian slum dwellings where 33.0% of the urban population live. The aim of the study was to explore the coverage, quality, and correlates of primary immunization under national immunization program among children aged 12–23 months, living in slums of Mumbai. A community based cross-sectional survey was conducted. Parents or caretakers of 550 eligible children aged 12–23 months were interviewed using a structured interview schedule. Regression analysis was used to detect correlates of full immunization coverage (children who received one dose each of BCG, measles, and three doses each of DPT, OPV, and HBV by his/her first birthday) and of quality immunization coverage (children who received primary vaccines at appropriate age and intervals as mentioned above and had filled immunization card). Out of total 550 children, 402 (73.1%), 131 (23.8%), and 17 (3.1%) were fully, partially, and unimmunized, respectively. Almost 86.0% children received quality immunization coverage. In the regression analysis, reminder for immunization services was found to be the single most significant correlate of full and quality immunization coverage.

In this study, full immunization coverage was found to be below the expected level. This study also revealed that the awareness regarding the importance of adequate immunization was still lacking in the slum population. Emphasizing on reminders for immunization services, encouraging institutional deliveries, and scaling up use of postnatal care services may act as keys to improving the immunization coverage in Indian slums.

The persistent influence of caste on under-five mortality: Factors that explain the caste-based gap in high focus Indian states

OBJECTIVE

Although under-five mortality rate (U5MR) is declining in India, it is still high in a few selected states and among the scheduled caste (SC) and scheduled tribe (ST) population of the country. This study re-examines the association between caste and under-five deaths in high focus Indian states following the implementation of the country's National Rural Health Mission (NRHM) program. In addition, we aim to quantify the contribution of socioeconomic determinants in explaining the gap in under-five death risk between the SC/ST population and non-SC/ST population in high focus states in India.

DATA AND METHOD

Using data from the National Family Health Survey (NFHS), we calculated the U5MR by applying a synthetic cohort probability approach. We applied a binary logistic regression model to examine the association of under-five deaths with the selected covariates. Further, we used Fairlie's decomposition technique to understand the relative contribution of socioeconomic variables on under-five death risk between the caste groups.

FINDINGS

In high focus Indian states, the under-five mortality risk between well-off and deprived caste children has declined in the post-NRHM period, indicating a positive impact in terms of reducing caste-based inequalities in the high focus states. Despite the reduction in under-five death risk, children belonging to the SC population experience higher mortality rates than children belonging to the non-SC/ST population from 1992 to 2016. Both macro level (district level mortality rates) and individual (regression analysis) analyses showed that children belonging to SCs experience the highest likelihood of dying before their fifth birthday. A decomposition analysis revealed that 83% of the caste-based gap in the under-five deaths is due to the distribution of women's level of educational attainment and household wealth between the SC/ST and non-SC/ST population. Program indicators such as place of birth and number of antenatal care (ANC) visit also contributed significantly to widening caste-based gaps in U5MR.

CONCLUSION

The study indicates that there is still room to improve access to health facilities for mothers and children belonging to deprived caste groups in India. Continuous efforts to raise the level of maternal education and the economic status of people belonging to deprived caste groups should be pursued simultaneously.

Inequities in Childhood Vaccination Coverage in Zhejiang, Province: Evidence from a Decomposition Analysis on Two-Round Surveys

Objective: The objectives of this study were to determine the degree and risk factors of the inequity in the childhood coverage of full primary immunization (FPI) in Zhejiang province. Method: We used data from two rounds of vaccination coverage surveys among children aged 24–35 months conducted in 2014 and 2017, respectively. The household income per month was used as an index of socioeconomic status for the inequality analysis. The concentration index (CI) was used to quantify the degree of inequality, and the decomposition approach was applied to quantify the contributions from demographic factors to inequality in the coverage of FPI. Results: The coverage rates of FPI were 80.6%, with a CI value of 0.12028 for the 2014 survey, while the coverage rates of FPI were 85.2%, with a CI value of 0.10129 for the 2017 survey. The results of decomposition analysis suggested that 68.2% and 67.1% of the socioeconomic inequality in the coverage of FPI could be explained by the mother’s education level for the 2014 and 2017 survey, respectively. Other risk factors including birth order, ethnic group, mother’s age, maternal employment status, residence, immigration status, GDP per-capita, and the percentage of the total health spending allocated to public health could also explain this inequality. Conclusion: The socioeconomic inequity in the coverage of FPI still remained, although this gap was reduced between 2014 and 2017. Policy recommendations for health interventions on reducing the inequality in the coverage of FPI should be focused on eliminating poverty and women’s illiteracy.