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Pregnancy is a period of major physiologic, hormonal, and psychological change, increasing the risk of nutritional deficiencies and mental disorders. Mental disorders and malnutrition are associated with adverse pregnancy and child outcomes, with potential long‐standing impact. Common mental disorders during pregnancy are more prevalent in low‐ and middle‐income countries (LMICs). In India, studies suggest the prevalence of depression is 9.8%–36.7% and of anxiety is 55.7%. India has seen some promising developments in recent years such as increased coverage of the District Mental Health Program; integration of maternal mental health into the Reproductive and Child Health Program in Kerala; and the Mental Health Care Act 2017. However, mental health screening and management protocols have not yet been established and integrated into routine prenatal care in India. A five‐action maternal nutrition algorithm was developed and tested for the Ministry of Health and Family Welfare, aiming to strengthen nutrition services for pregnant women in routine prenatal care facilities. In this paper, we present opportunities and challenges for integration of maternal nutrition and mental health screening and a management protocol at routine prenatal care in India, discuss evidence‐based interventions in other LMICs including India, and make recommendations for public healthcare providers. Synopsis: The need for incorporated mental‐health services into routine prenatal care in India is reviewed, along with opportunities and challenges. [ABSTRACT FROM AUTHOR]

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources. [ABSTRACT FROM AUTHOR]

Objective: To examine prevalence, risk factors, and consequences of maternal severe thinness in India.Methods: This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India.Results: Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness.Conclusion: This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations. [ABSTRACT FROM AUTHOR]

In 2015, the World Health Organization (WHO) published a guideline on the role of health workers in providing safe abortion and postabortion contraception, with evidence-based recommendations on the range of providers who can perform interventions to provide safe abortion, postabortion care, and postabortion contraception. The WHO guideline is global in nature and must be contextualized to individual country settings. The present paper compares the scenario in India, including the legal and policy frameworks, with the WHO guidelines. It provides legal and policy recommendations that are needed to improve access to comprehensive abortion care in India, with a focus on expanding the provider base. The process used to develop these recommendations was a combination of empirical evidence gathering and multistakeholder consultations. An outcome of this exercise was a policy brief entitled "Improving access to comprehensive abortion care in India with focus on expanding provider base," which is used as an advocacy tool. [ABSTRACT FROM AUTHOR]

Objective: To test an infographic two-pager on medication abortions (MA) aimed to improve pharmacists counseling in India.Methods: A quantitative baseline survey was conducted among 283 pharmacists in three districts around Lucknow, Uttar Pradesh in January 2018. The intervention (infographic) was given to 117 of these pharmacists a few weeks later and a follow-up survey was conducted 3 months later with 281 pharmacists. In addition, mystery clients were sent to 115 of the pharmacists.Results: A statistically significant improvement in knowledge post-intervention was found, compared to pre-, for almost all quality items measured. Difference-in-difference estimators showed a difference in knowledge among indicators related to misoprostol in particular. However, mystery client reports showed few differences in pharmacist behaviors between intervention and control pharmacists.Conclusion: This simple, paper-based intervention, which required no training, showed a significant improvement in pharmacists' knowledge and was welcomed by the providers. Translating knowledge into behavior change, however, seems more difficult to impact. Adapting this simple intervention to motivate providers to change behaviors could improve the quality of care provided by pharmacists in India. [ABSTRACT FROM AUTHOR]

Maternal death review (MDR) is an important strategy to improve the quality of obstetric care and reduce maternal morbidity and mortality. MDR provides detailed information on various factors at community, facility, and district levels that influence maternal health outcomes. One of the key challenges is to analyze large volumes of data collected via a paper-based system that uses facility and community level forms. This database continues to expand quantitatively (multiple forms and data elements), which makes analysis of data increasingly difficult for timely management and analysis. The present paper describes the development process involved in linking the paper-based system with an electronic system for MDR in India. The lessons learnt from this experience can contribute to understanding how innovative technologies can be used to address large-scale public health issues in low-resource countries and in particular solutions to address maternal health. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To investigate the patterns and determinants of postabortion contraceptive use and the rates of method continuation in India. Methods: Population-level retrospective calendar data on 5135 married women who had their last abortion during the 60months preceding the survey were drawn from 2005–2006 Indian National Family Health Surveys. Multinomial logistic regression was used to model the factors associated with postabortion method choices. Method discontinuation rates were estimated using proportional hazard models. Results: Overall, 70.4% of women reported not using any method following abortion, and the levels varied considerably across states. Significant differences were observed in the type of method adopted by women living in large cities, small towns, and rural areas. Poor and socially excluded women were less likely to use any method after abortion, particularly modern reversible methods. Method discontinuation rates were considerably higher among socially disadvantaged groups. Conclusion: Postabortion contraceptive adoption is exceptionally low in India. Reproductive health interventions should urgently consider implementing comprehensive postabortion care policies, integrating family planning with sexual and reproductive healthcare services, and in particular targeting women from disadvantaged communities. [Copyright &y& Elsevier]

Objective: The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs' experience of the program, and identified factors leading to post-training performance.Methods: The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n=14). Data on facility preparedness and monthly case load were also collected.Results: Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.Conclusion: Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program. [ABSTRACT FROM AUTHOR]

Objective: To document an innovative public-private partnership between the government of Gujarat, India and private obstetricians in rural areas that provides delivery care to the poor.Methods: This is a descriptive analysis of the scheme and analysis of secondary data. We estimate the lives of mothers and newborns potentially saved because of the scheme.Results: More than 800 obstetricians have joined the scheme and more than 269000 poor women have delivered in private facilities in 2 years. We estimate that the percentage of institutional deliveries among poor women increased from 27% to 48% between April 2007 and September 2008. In addition, there are fewer reported maternal and newborn deaths among the beneficiaries compared with the number of deaths expected in the absence of the scheme.Conclusions: This innovative program shows that, at least in some areas of India, it is possible to develop a large scale partnership with the private sector to provide skilled birth attendance and emergency obstetric care to poor women at a relatively low cost. This is one way of addressing the human resource deficit in the public sector in rural areas of low-income countries to achieve Millennium Development Goals 4 and 5. We also conclude that the skilled care thus provided can reduce maternal and neonatal mortality among the poor. [ABSTRACT FROM AUTHOR]

Objectives: To obtain an estimate of cesarean section rates and examine the indications and consequences at teaching hospitals in India. Methods: Information was obtained on total number of normal and cesarean deliveries during 1993–1994 and 1998–1999 from 30 medical colleges/teaching hospitals. In addition, prospective data were recorded for a period of 2 months on 7017 consecutive cesarean sections on indications for cesarean delivery, associated complications and mortality. Results: The overall rate of cesarean section increased from 21.8% in 1993–1994 to 25.4% in 1998–1999. Among the 7017 cesarean section cases, 42.4% were primigravidas, 31% had come from rural areas, 20.8% were referred including 8% with history of interference, 66% were booked cases, period of gestation was less than 37 weeks in 21.7% and in 18% the surgery was elective. Major indications for cesarean section included dystocia (37.5%), fetal distress with or without meconium aspiration (33.4%), repeat section (29.0%), malpresentation (14.5%) and PIH (12.5%). Maternal and perinatal mortality was 299/100 000 and 493/1000 deliveries, respectively, and is high in spite of the increase in the cesarean section rates. Conclusions: There is need for standardized collection of information on all aspects of childbirth to ascertain the incidence and indications of cesarean section nationally so that comparison and improvements of care can take place. [Copyright &y& Elsevier]

Abstract: Objective: To explore Indian abortion providers’ knowledge of medical abortion (MA), their personal experiences and practices of providing medical abortion, and their attitudes toward providing MA to eligible women who were poor, uneducated, and/or from rural areas. Methods: In selected districts of India''s Bihar and Maharashtra states, interviews were conducted with 270 physicians who were certified as abortion providers, using a structured questionnaire. Results: The providers’ knowledge of the gestational limit, the recommended doses of mifepristone and misoprostol, and other aspects of the approved protocol was far from universal. Only about two-thirds of these physicians authorized to perform MA actually performed it. Although they all counseled women about the procedure before they took mifepristone, the matters discussed were often limited to pain management and possible complications. Contraception was usually not discussed until the follow-up visit. Most providers thus missed the opportunity to provide sustained counseling to their MA patients, and did not counsel them about the need to protect themselves in the 2weeks following the administration of mifepristone. Moreover, many providers were reluctant to offer MA to poor, uneducated, and/or rural women. Conclusions: These findings shed light on the need to raise awareness and dispel misgivings about MA among certified providers of abortion services. By placing emphasis on the method''s safety and effectiveness, additional training to these would increase their confidence about offering MA to eligible women. [Copyright &y& Elsevier]

Abstract: Objective: This study was carried out to explore whether the rates of postabortion adoption of a contraceptive method, and continuation of contraception over 6months, differ among women undergoing medical abortion (MA) or surgical abortion by manual vacuum aspiration (MVA). Methods: The study was conducted in Bihar and Jharkhand, 2 of the least-developed states of India. The analysis focused on 679 married women who were followed up 6months after they underwent MA (n=308) or MVA (n=371) at clinics run by Janani, a nonprofit organization. Results: The rates of adoption and continuation of contraception were similar in the 2 groups, although with some notable distinctions in the timing of adoption of contraception and the method of contraception adopted. While the women who underwent MA were significantly less likely to adopt contraception in the month following abortion (58% vs 86%), this difference had narrowed considerably by the end of the second month (82% vs 91%); and by the end of the sixth month (89% vs 94%), respectively. There were no significant differences between the MA and the MVA groups with respect to the continuation of reversible contraception. Conclusions: The findings indicate that, in a setting that offers comprehensive counseling and a range of contraceptive methods, and where adoption of contraception is voluntary, a large majority of women will adopt and continue to use a method of contraception after an abortion even in these less developed parts of India. [Copyright &y& Elsevier]

Abstract: A multimedia awareness and advocacy campaign for mainstreaming gestational diabetes mellitus (GDM) in the public health domain is described. The multimedia campaign has created awareness about the relevance of GDM to women''s health and the health of future generations through direct contact, reaching out to over half a million people in 7 districts of 4 states in northern India. Using mass media, over 3.7 million people have received information on GDM. Through multistakeholder forums, more than 1000 key stakeholders have been encouraged to mainstream GDM into the existing health delivery system. The Indian Ministry of Health has introduced free screening for GDM among the 5 services offered to pregnant women below the poverty line in the National Rural Health Mission (NRHM) program. In addition, several state governments, such as in Bihar, Delhi, Jharkhand, and Punjab, have pledged similar initiatives addressing GDM; the Government of Tamil Nadu is already implementing such a policy. Policy development is a complex process that requires action on many fronts. By showcasing evidence, raising awareness, creating public opinion through dialogue and discussion, media can help build a positive environment and momentum for effective policy creation as well as service utilization. [Copyright &y& Elsevier]