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Background: Health care services express social and structural inequalities, especially for Dalits and women, due to the indignity and discrimination experienced in health care facilities. Jagrutha Mahila Sanghatane (JMS), a grass-roots organization led by neo-literate Dalit women in rural Karnataka in India, adopted a human rights-based social accountability (SA) approach to address discrimination and dignity in accessing maternal health services. This approach integrated community-based evidence with multi-pronged and multi-level accountability processes with their goal of socio-political empowerment., Methods: The methodological approach is qualitative and uses document analysis, including thematic and content analysis, in-depth group discussions with the campaign leaders, participant observation and interviews with the community health workers., Results: JMS embedded the practice and processes of SA in the politics of empowerment which was central to addressing the structural issues of discrimination and social exclusion faced by Dalit women. The human rights perspective and the pathway of conscientize-organize-struggle provided by the Dalit liberation leader, Dr B. R. Ambedkar, facilitated the organization to conceptualize SA as a process of claiming dignity and justice for Dalit women. Integrating the evidence generation and its deployment into the community campaign cycles, Dalit women could use the accountability process for intensifying mobilization and empowerment. The cumulative impact of the community enquiry relentlessly pursued through the framework of a campaign brought changes in several aspects of primary health care and specific dimensions of maternal health care. Community ownership of the SA process, participation and empowerment were integral to the generation, synthesis and deploying of evidence. Deploying evidence in multiple forms, both horizontally with the communities and vertically with the authorities deepened communities' mobilization and intensified Dalit women's negotiating power with the authorities. The iterative and persistent process of SA provides insights into re-articulating SA beyond the usual recognition of outputs such as report cards into the politics of meaning-making by the mobilized community of the marginalized. The community-based organization posited the SA itself as the process of resistance to structural injustice and as an avenue or their empowerment., Conclusions: For marginalized communities, the SA process has the potential to be a tool for their empowerment in addressing structural power inequities. For such a repositioning of SA, it is critical to focus not only on the technicality of generating evidence but also on the framework driving such a process, the mode of evidence generation and deployment, and integration into the organizational strategy. Such a process can be equally empowering, efficient in addressing the systemic challenges of increasing marginalized community's access to health care services, and valuable in sustaining those changes. The analysis of the strategies of JMS offers significant insights for researchers and practitioners working on SA and maternal health to re-articulate SA from the point of politics of empowerment of the marginalized communities., (© 2022. The Author(s).)

Background: Utilization of maternal healthcare services has a direct bearing on maternal mortality but is contingent on a wide range of socioeconomic factors, including the sex of the household head. This paper studies the role of the sex of the household head in the utilization of maternal healthcare services in India using data from the National Family Health Survey-V (2019-2021)., Methods: The outcome variable of this study is maternal healthcare service utilization. To that end, we consider three types of maternal healthcare services: antenatal care, skilled birth assistance, and postnatal care to measure the utilization of maternal healthcare service utilization. The explanatory variable is the sex of the household head and we control for specific characteristics at the individual level, household-head level, household level and spouse level. We then incorporate a bivariate logistic regression on the variables of interest., Results: 24.25% of women from male-headed households have complete utilization of maternal healthcare services while this proportion for women from female-headed households stands at 22.39%. The results from the bivariate logistic regression confirm the significant impact that the sex of the household head has on the utilization of maternal healthcare services in India. It is observed that women from female-headed households in India are 19% (AOR, 0.81; 95% CI: 0.63,1.03) less likely to utilize these services than those from male-headed households. Moreover with higher levels of education, there is a 25% (AOR, 1.25; 95% CI: 1.08,1.44) greater likelihood of utilizing maternal healthcare services. Residence in urban areas, improved wealth quintiles and access to healthcare facilities significantly increases the chances of maternal healthcare utilization. The interaction term between the sex of the household head and the wealth quintile the household belongs to, (AOR, 1.39; 95% CI: 1.02, 1.89) shows that the utilization of maternal healthcare services improves when the wealth quintile of the household improves., Conclusion: The results throw light on the fact that the added expenditure on maternal healthcare services exacerbates the existing financial burden for the economically vulnerable female-headed households. This necessitates the concentration of research and policy attention to alleviate these households from the sexual and reproductive health distresses., Trial Registration: Not Applicable., Jel Classification: D10, I12, J16., (© 2024. The Author(s).)

Background: The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care., Methods: Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience., Results: The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%)., Conclusion: While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification., (© 2023. The Author(s).)

Background: In spite of considerable improvement in maternal and neonatal outcomes over the past decade in India, the current maternal mortality ratio and neonatal mortality rate are far from the Sustainable Development Goal targets due to suboptimal quality of maternity care. A package of interventions for improving quality of intrapartum and immediate postpartum care was co-designed with the Ministry of Health as the Dakshata program and implemented in public sector health facilities in selected districts in the state of Rajasthan of India since June 2015. This article describes the key strategies, interventions, results and challenges from four years of Dakshata program implementation., Methods: We have conducted secondary analysis of program data (government data) collected from 202 public facilities across 20 districts of Rajasthan state. The data collected between June-August 2015 (baseline) and the data collected between May-August 2019 (latest) were analyzed. The data sources included: facility assessments, service statistics, monthly progress reports., Results: During the period of program implementation, there were 17,94,249 deliveries accounting for 70% of institutional deliveries in intervention districts. As a result of the intervention, there was a notable increase in competency of health care providers, availability of essential resources, achievement of labour room standards and adherence to evidence-based clinical standards. We also observed reductions in the proportion of referrals for pre-eclampsia/eclampsia, postpartum hemorrhage and neonatal asphyxia by 11, 8 and 3 percentage points respectively. Similarly, data revealed a reduction in stillbirth rates in Dakshata intervention facilities (19.3 vs 15.3) compared to non-Dakshata facilities (21.8 vs 18)., Conclusions: Our experience and findings indicate that the quality of intrapartum and immediate postpartum care can be improved in low- and middle-income countries with the approach presented in this paper., (© 2022. The Author(s).)

Background: Utilisation of continuum of maternal health care services is crucial for a healthy pregnancy and childbirth and plays an important role in attaining Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) related to maternal and child health. This paper aims to assess the percentage of dropouts across various stages of utilization of continuum of maternal health services (CMHS) in India and also investigates the factors hindering the utilization of these services., Methods: We used recent data from National Family Health Survey(NFHS) encompassing a total sample of 1,70,937 pregnant women for the period 2015-16. The percentage of women dropping out while seeking maternal health care is measured using descriptive statistics. While, the factors impeding the utilization of maternal health services is estimated using a Multinomial Logistic Regression Model, where dependent variable (CMHS) is defined as complete care, incomplete care and no care., Results: Only17% of pregnant women availed the utilisation of complete care and 83% either did not seek any care or dropped after seeking one or two services. For instance, it is found that 79% of women who registered for antenatal care services (ANC) did not avail the same adequately. An empirical investigation of determinants of inadequate utilization of CMHS revealed that factors like individual characteristics, for instance- access to media (RRR: 2.06) and mother's education play (RRR: 3.61) a vital role in the uptake of CMHS. It is also found that the interaction between wealth index and place of residence plays a pivotal role in seeking complete care. Lastly, the results revealed that male participation (RRR: 2.69) and contacting multi-purpose worker (MPW) (RRR: 2.33) are also at play., Conclusion: The study suggests that the major determinants of utilisation of CMHS are access to media, mother's education, affordability barriers and male participation. Hence, policy recommendations should be oriented towards strengthening these dimensions and the utilisation of adequate ANC has to be considered as the need of the hour., (© 2022. The Author(s).)

Background: The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase). Methods: In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness. Discussion: Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally. Trial registration: CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022). Plain language summary: The new WHO Labour Care Guide (LCG) is an innovative partograph that emphasises women-centred, evidence-based care during labour and childbirth. Together with clinicians working at four hospitals in India, we will develop and test a strategy to implement the LCG into routine care in labour wards of these hospitals. We will use a randomised trial design where this LCG strategy is introduced sequentially in each of the four hospitals, in a random order. We will collect data on all women giving birth and their newborns during this period and analyse whether the LCG strategy has any effects on the use of Caesarean section, women's and newborn's health outcomes, and women's experiences during labour and childbirth. While the trial is being conducted, we will also collect qualitative and quantitative data from doctors, nurses and midwives working in these hospitals, to understand their perspectives and experiences of using the LCG in their day-to-day work. In addition, we will collect economic data to understand how much the LCG strategy costs, and how much money it might save if it is effective. Through this study, our international collaboration will generate critical evidence and innovative tools to support implementation of the LCG in other countries. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Background: Medical abortion with mifepristone and misoprostol can be provided up to 63 days' gestation in India. This accounts for 67.5 percent of all abortions in the country. We conducted an assessment to determine the availability of medical abortion medicines, specifically the combi-pack, in India. Methods: We applied the World Health Organization landscape assessment protocol at the national level. The assessment protocol included a five-step adaptation of an existing availability framework, including online data collection, desk review, country-level key informant interviews, and an analysis to identify barriers and opportunities to improve medical abortion availability. The assessment was conducted between August and March 2021. Results: Medicines for medical abortion are included in the national essential drug list and available with prescription in India. The assessment identified 42 combi-pack products developed by 35 manufacturers. The quality of medical abortion medicines is regulated by national authorities; but as health is devolved to states, there are significant inter-state variations. This is seen across financing, procurement, manufacturing, and monitoring mechanisms for quality assurance of medical abortion medicines prior to distribution. There is a need to strengthen supply chain systems, ensure consistent availability of trained providers and build community awareness on use of medical abortion medicines for early abortions, at the time of the assessment. Conclusion: Opportunities to improve availability and quality of medical abortion medicines exist. For example, uniform implementation of regulatory standards, greater emphasis on quality-assurance during manufacturing, and standardizing of procurement and supply chain systems across states. Regular in-service training of providers on medical abortion is required. Finally, innovations in evidence dissemination and community engagement about the recently amended abortion law are needed. Plain language summary: Medical abortion is popular in India and benefits from a liberal legal context. It is important to understand the availability of quality abortion medicines in the country. Using the World Health Organization country assessment protocol and availability framework for medical abortion medicines we examined the availability of these medicines from supply to demand. We used this information to identify opportunities for increasing availability of quality-assured medical abortion medicines. We found that the context for medical abortion varies across states. Strengthening procurement and supply chain management, with a greater emphasis on quality-assurance and regulation of manufacturing should be instituted at the state-level. Training is also needed to increase provider knowledge of the latest national guidelines and laws to ensure respectful and person-centered services. Finally, the public should be informed about medical abortion as a safe and effective choice, especially for early abortions. [ABSTRACT FROM AUTHOR]

Introduction: The health of women is of particular concern because they often have greater health needs than men and many women still lack access to quality healthcare services, preventing their ability to attain the best possible level of health. Hence, this study aimed to assess the accessibility and availability of health services among rural women. Methods: A household survey was conducted by using a multi-stage sample with 407 married women aged 18–45 years, having at least one child and living in Tiruchirappalli District, Tamil Nadu were recruited for this study. A semi-structured questionnaire was used to collect data about the demographic status, and accessibility and availability of health services. Results: Of the 407 respondents, 70% were aged between 26 and 40 years, 73% were working as farmers and labourers and 77% were living in nuclear families. 71% of them had enjoyed hospital facilities near their residence and 83% of the hospitals were run by the government. In village health nurse service (VHN), 34% of the respondents had received all services from VHN and 86% did not face any kind of gender inequality and almost all of them were satisfied with the service provided by the VHN. Almost all the respondents (98%) were satisfied with the availability of health services and 92% of them benefited from the government scheme related to childbirth. Conclusion: This study showed that overall, the women were satisfied with the availability of healthcare services and reproductive health services. Moreover, almost all of them benefited from the government scheme related to childbirth. [ABSTRACT FROM AUTHOR]

Background: In India, more than half of the newborns experience delayed breastfeeding, and non-exclusive breastfeeding is practiced in 63% of babies below the age of six months. The goal of this study is to investigate the extent to which external environment, demographic and socioeconomic, pregnancy and birthing characteristics, as well as utilization of maternal care services, are associated with delayed initiation and non-exclusive breastfeeding among children in India. Methods: Data was gathered from the fifth round of the National Family Health Survey (NFHS), which was conducted in 2019-21. This study used information on 85,037 singleton infants aged 0–23 months and 22,750 singleton infants aged 0–5 months. Delayed initiation of breastfeeding and non-exclusive breastfeeding was used as outcome variables in this study. Unadjusted and adjusted multivariable binary logistic regression was performed to analyse the association of delayed breastfeeding and non-exclusive breastfeeding with selected background characteristics. Results: Factors significantly associated with increased risks of delayed initiation of breastfeeding included infants from in the central region (OR 2.19; 95% CI 2.09, 2.29), mothers in the 20 to 29 years age group at the time of childbirth (OR 1.02; 95% CI 0.98, 1.05), caesarean deliveries (OR 1.97; 95% CI 1.90, 2.05). The likelihoods for non-exclusive breastfeeding significantly increased among children belonging to the richest household status (OR 1.30; 95% CI 1.17, 1.45), mothers who had less than nine months of pregnancy period (OR 1.15; 95% CI 1.06, 1.25), and mothers who gave birth in non-health facility (OR 1.17; 95% CI 1.05, 1.31). Conclusions: The connections between several different categories of factors and non-exclusive breastfeeding and delayed breastfeeding initiation show the need for comprehensive public health programmes using a multi-sectoral approach to promote breastfeeding behaviours in India. [ABSTRACT FROM AUTHOR]

Background: Despite recognition of the adverse impacts of the mistreatment of women during pregnancy, labour and birth, there remains limited evidence on interventions that could reduce mistreatment and build a culture of respectful maternity care (RMC) in health facilities. The sustainability of effective individual interventions and their adaptability to various global contexts remain uncertain. In this systematic review, we aimed to synthesise the best available evidence that has been shown to be effective in reducing the mistreatment of women and/or enhancing RMC during women's maternity care in health facilities. Methods: We searched the online databases PubMed, CINAHL, EBSCO Nursing/Academic Edition, Embase, African Journals Online (AJOL), Scopus, Web of Science, and grey literature using predetermined search strategies. We included cluster randomized controlled trials (RCTs) and pre-and-post observational studies and appraised them using JBI critical appraisal checklists. The findings were synthesised narratively without conducting a meta-analysis. The certainty of evidence was assessed using GRADE criteria. Results: From the 1493 identified records, 11 studies from six sub-Sahara African countries and one study from India were included: three cluster RCTs and nine pre- and post-studies. We identified diverse interventions implemented via various approaches including individual health care providers, health systems, and policy amendments. Moderate certainty evidence from two cluster RCTs and four pre- and post-studies suggests that multi-component interventions can reduce the odds of mistreatment that women may experience in health facilities, with odds of reduction ranging from 18 per cent to 66 per cent. Similarly, women's perceptions of maternity care as respectful increased in moderate certainty evidence from two cluster RCTs and five pre- and post-studies with reported increases ranging from 5 per cent to 50 per cent. Conclusions: Multi-component interventions that address attitudes and behaviors of health care providers, motivate staff, engage the local community, and alleviate health facility and system constraints have been found to effectively reduce mistreatment of women and/or increase respectful maternity care. Such interventions which go beyond a single focus like staff training appear to be more likely to bring about change. Therefore, future interventions should consider diverse approaches that incorporate these components to improve maternal care. [ABSTRACT FROM AUTHOR]

Background: India contributes 15% of the total global maternal mortality burden. An increasing proportion of these deaths are due to Pregnancy Induced Hypertension (PIH), Gestational Diabetes Mellitus (GDM), and anaemia. This study aims to evaluate the effectiveness of a tablet-based electronic decision-support system (EDSS) to enhance routine antenatal care (ANC) and improve the screening and management of PIH, GDM, and anaemia in pregnancy in primary healthcare facilities of Telangana, India. The EDSS will work at two levels of primary health facilities and is customized for three cadres of healthcare providers – Auxiliary Nurse Midwifes (ANMs), staff nurses, and physicians (Medical Officers). Methods: This will be a cluster randomized controlled trial involving 66 clusters with a total of 1320 women in both the intervention and control arms. Each cluster will include three health facilities—one Primary Health Centre (PHC) and two linked sub-centers (SC). In the facilities under the intervention arm, ANMs, staff nurses, and Medical Officers will use the EDSS while providing ANC for all pregnant women. Facilities in the control arm will continue to provide ANC services using the existing standard of care in Telangana. The primary outcome is ANC quality, measured as provision of a composite of four selected ANC components (measurement of blood pressure, blood glucose, hemoglobin levels, and conducting a urinary dipstick test) by the healthcare providers per visit, observed over two visits. Trained field research staff will collect outcome data via an observation checklist. Discussion: To our knowledge, this is the first trial in India to evaluate an EDSS, targeted to enhance the quality of ANC and improve the screening and management of PIH, GDM, and anaemia, for multiple levels of health facilities and several cadres of healthcare providers. If effective, insights from the trial on the feasibility and cost of implementing the EDSS can inform potential national scale-up. Lessons learned from this trial will also inform recommendations for designing and upscaling similar mHealth interventions in other low and middle-income countries. Trial Registration. ClinicalTrials.gov, NCT03700034, registered 9 Oct 2018, https://www.clinicaltrials.gov/ct2/show/NCT03700034 CTRI, CTRI/2019/01/016857, registered on 3 Mar 2019, http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=28627&EncHid=&modid=&compid=%27,%2728627det%27 [ABSTRACT FROM AUTHOR]

Background: Since 2005, India has implemented conditional cash transfer [CCT] programs to promote the uptake of institutional delivery services [ID]. The study aims to assess changes in wealth-based inequality in the use of ID and other maternal health care services during the first decade of Janani Suraksha Yojana and related CCT programs.Methods: Data from two Demographic and Health Surveys were used to calculate changes in service inequality from 2005 to 2015-16 in the use of three or more antenatal care [ANC] visits, ID, and postnatal care [PNC]. The changes were assessed at the national level, within high and low performing states [HPS and LPS, respectively] and within urban and rural areas of each state category. Erreygers Index [EI] and Wagstaff Index [WI], superior to concentration index, were used to gain different insights into the nature of inequality. EI is an objective measure of inequality irrespective of prevalence while WI is a combined measure of inequality and the average distribution of an indicator that puts more weight on the poor.Results: The results suggest that wealth-based inequalities decreased significantly at the national level. For ID, both indices showed a decline in both HPS and LPS though the change in WI in HPS was insignificant. For ANC, there was a significant decrease in inequality using both indices in HPS but not in LPS. For PNC, there was a significant decrease in inequality using both indices in HPS, and when using WI in LPS, but not when using EI in LPS.Conclusion: Overall, the first decade of India's CCT programs saw an impressive reduction in EI for ID but less so for WI suggesting that the benefit of CCTs did not go disproportionately to the poor, which suggests that there is a need to reduce or eliminate the evident leakages. The improvement in uptake and inequality in ANC and PNC was not at par with ID, stressing the need to place greater focus on the continuum of care. The urban rural difference in HPS versus LPS in the changes in inequality reveals that infrastructure is important for CCTs to be more effective. [ABSTRACT FROM AUTHOR]

Background: Continuum of Maternal Health Care Services (CMHS) has garnered attention in recent times and reducing socio-economic disparity and geographical variations in its utilisation becomes crucial from an egalitarian perspective. In this study, we estimate inequity in the utilisation of CMHS in India between 2005 and 06 and 2015-16. Methods: We used two rounds of National Family Health Survey (NFHS) - 2005-06 and 2015-16 encompassing a sample size of 34,560 and 178,857 pregnant women respectively. The magnitude of horizontal inequities (HI) in the utilisation of CMHS was captured by adopting the Erreygers Corrected Concentration indices method. Need-based standardisation was conducted to disentangle the variations in the utilisation of CMHS across different wealth quintiles and state groups. Further, a decomposition analysis was undertaken to enumerate the contribution of legitimate and illegitimate factors towards health inequity. Results: The study indicates that the pro-rich inequity in the utilisation of CMHS has increased by around 2 percentage points since the implementation of National Rural Health Mission (NRHM), where illegitimate factors are dominant. Decomposition analysis reveals that the contribution of access related barriers plummeted in the considered period of time. The results also indicate that mother's education and access to media continue to remain major contributors of pro-rich inequity in India. Considering, regional variations, it is found that the percentage of pro-rich inequity in high focus group states increased by around 3% between 2005 and 06 and 2015-16. The performance of southern states of India is commendable. Conclusions: Our study concludes that there exists a pro-rich inequity in the utilisation of CMHS with marked variations across state boundaries. The pro-rich inequity in India has increased between 2005 and 06 and high focus group states suffered predominantly. Decentralisation of healthcare policies and granting greater power to the states might lead to equitable distribution of CMHS. [ABSTRACT FROM AUTHOR]

Background: Despite a significant increase in the skilled birth assisted (SBA) deliveries in India, there are huge gaps in availing maternity care services across social gradients - particularly across states and regions. Therefore, this study applies the spatial-regression model to examine the spatial distribution of SBA across districts of India. Furthermore, the study tries to understand the spatially associated population characteristics that influence the low coverage of SBA across districts of India and its regions.Methods: The study used national representative cross-sectional survey data obtained from the fourth round of National Family Health Survey, conducted in 2015-16. The effective sample size was 259,469 for the analysis. Moran's I statistics and bivariate Local Indicator for Spatial Association maps were used to understand spatial dependence and clustering of deliveries conducted by SBA coverage in districts of India. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of deliveries conducted by SBA.Results: Moran's I value for SBA among women was 0.54, which represents a high spatial auto-correlation of deliveries conducted by SBA over 640 districts of India. There were 145 hotspots for deliveries conducted by SBA among women in India, which includes almost the entire southern part of India. The spatial error model revealed that with a 10% increase in exposure to mass media in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Interestingly, also with the 10% increase in the four or more antenatal care (ANC) in a particular district, the deliveries conducted by SBA increased significantly by 2.5%. Again, if there was a 10% increase of women with first birth order in a particular district, then the deliveries conducted by SBA significantly increased by 6.1%. If the district experienced an increase of 10% household as female-headed, then the deliveries conducted by SBA significantly increased by 1.4%.Conclusion: The present study highlights the important role of ANC visits, mass media exposure, education, female household headship that augment the use of an SBA for delivery. Attention should be given in promoting regular ANC visits and strengthening women's education. [ABSTRACT FROM AUTHOR]

Background: The incidence of preterm birth and subsequent low birth weight (LBW) are vital global public health issues. It contributes to high infant and child mortality in the early stages of life and later on in adult life; it increases the risk for non-communicable diseases. The study aims to understand the socio-economic status-related inequality for LBW among children in India. It hypothesises that there is no association between the socio-economic status of the household and the newborn's LBW in India.Methods: The study utilised data from the fourth round of the National Family Health Survey, a national representative cross-sectional survey conducted in 2015-16 (N = 127,141). The concentration index (CCI) and the concentration curve (CC) measured socio-economic inequality in low birth status among newborns. Wagstaff decomposition further analysed key contributors in CCI by segregating significant covariates.Results: About 18.2% of children had low birth weight status. The value of concentration was - 0.05 representing that low birth weight status is concentrated among children from lower socio-economic status. Further, the wealth quintile explained 76.6% of the SES related inequality followed by regions of India (- 44%) and the educational status of mothers (43.4%) for LBW among children in India. Additionally, the body mass index of the women (28.4%), ante-natal care (20.8%) and residential status (- 15.7%) explained SES related inequality for LBW among children in India.Conclusion: Adequate attention should be given to the mother's nutritional status. Awareness of education and usage of health services during pregnancy should be promoted. Further, there is a need to improve the coverage and awareness of the ante-natal care (ANC) program. In such cases, the role of the health workers is of utmost importance. Programs on maternal health services can be merged with maternal nutrition to bring about an overall decline in the LBW of children in India. [ABSTRACT FROM AUTHOR]

Background: India, being a developing country, presents a disquiet picture of maternal and neonatal mortality and morbidity. The majority of maternal and neonatal mortality could be avoided if the continuum of care (CoC) is provided in a structured pathway from pregnancy to the postpartum period. Therefore, this article attempted to address the following research questions: What is the level of completion along CoC for MNCH services? At which stage of care do women discontinue taking services? and what are the factors affecting the continuation in receiving maternal, newborn and child health (MNCH) services among women in India?Methods: The study utilized the data from the National Family Health Survey (NFHS-4) conducted during 2015-16 in India. The analysis was limited to 107,016 women aged 15-49 who had given a live birth in the last 5 years preceding the survey and whose children had completed 1 year. Four sequential fixed effect logit regression models were fitted to identify the predictors of completion of CoC.Results: Nearly 39% of women in India had completed CoC for maternal and child health by receiving all four types of service (antenatal care, institutional delivery, post-natal care and full immunization of their child), with substantial regional variation ranging from 12 to 81%. The highest number of dropouts in CoC were observed at the first stage with a loss of nearly 38%. Further, education, wealth index, and health insurance coverage emerged as significant factors associated with CoC completion.Conclusion: The major barrier in achieving CoC for maternal and child health is the low utilization of ANC services in the first stage of the continuum and hence should be addressed for increasing CoC completion rate in the country. The gaps across all the levels of CoC indicate a need for increased focus on the CoC approach in India. A strategy should be developed that will connect all the components of MNCH avoiding dropouts and the MNCH provision should be standardized to provide services to every woman and child. [ABSTRACT FROM AUTHOR]

Background: To promote institutional delivery, the Government of India, through the Janani Suraksha Yojana (JSY) program, gives monetary reward to all pregnant women who give birth at the government or private health center. Despite providing cash assistance, a higher number of women are still preferring delivering at home. Therefore, this study sought to determine the prevalence of home births and identifying the factors influencing women's choice of home deliveries.Methods: Data from the National Family Health Survey (NFHS) conducted during 2005-06 and 2015-16 were used in the study. The respondents were women 15-49 years; a sample of 36,850 and 190,898 women in 2005-06 and 2015-16 respectively were included in the study. Multivariate logistic regression was used to determine the factors influencing home delivery. Income-related inequality in home delivery was quantified by the concentration index (CI) and the concentration curve (CC), and decomposition analysis was used to examine the inequality in the prevalence of home deliveries.Results: The prevalence of home deliveries has reduced from 58.5% in 2005-06 to 18.9% in 2015-16. The odds of delivering babies at home were lower among women who had full ANC in 2005-06 [AOR: 0.34; CI: 0.28-0.41] and in 2015-16 [AOR: 0.41; CI: 0.38-0.45] and were higher among women with four or higher parity in 2005-06 [AOR: 1.70; CI: 1.49-1.92] and in 2015-19 [AOR: 2.16; CI: 2.03-2.30]. Furthermore, the odds of delivering babies at home were higher among rural women and were lower among women with higher education. It was found that the value of CI increased from - 0.25 to - 0.39 from 2005-06 to 2015-16; this depicts that women delivering babies at home got more concentrated among women from lower socio-economic status.Conclusion: There is a need to promote institutional deliveries, particular focus to be given to poor women, women with higher parity, uneducated women, and rural women. ANC is the most concurring contact point for mothers to get relevant information about the risks and complications they may encounter during delivery. Therefore, effort should be directed to provide full ANC. Targeted interventions are called for to bring improvements in rural areas. [ABSTRACT FROM AUTHOR]

Background: India has achieved impressive gains in child survival over the last two decades; however, it was not successful in attaining MDG 2015 goals. The study's objective is to inquire how the survival status of the preceding child affects the survival of the next born child. Methods: This is a retrospective analysis of data from the National Family Health Survey, 2015–16. Analysis was restricted to women with second or higher-order births because women with first-order births do not have a preceding child. Proportional hazards regression, also called the Cox regression model, has been used to carry out the analysis. Kaplan–Meier (K–M) survival curves were also generated, with a focus on preceding birth intervals. Results: Results found that female children were more likely to experience infant mortality than their male counterparts. Children born after birth intervals of 36+ months were least likely to experience infant mortality. Mother's education and household wealth are two strong predictors of child survival, while the place of residence and caste did not show any effect in the Cox proportional model. Infant and child deaths are highly clustered among those mothers whose earlier child is dead. Conclusion: Maternal childbearing age is still low in India, and it poses a high risk of infant and child death. Education is a way out, and there is a need to focus on girl's education. The government shall also focus on raising awareness of the importance of spacing between two successive births. There is also a need to create a better health infrastructure catering to the needs of rich and poor people alike. [ABSTRACT FROM AUTHOR]