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Background: Timely and skilled care is key to reducing maternal and neonatal mortality. Birth preparedness involves preparation for safe childbirth during the antenatal period to reach the appropriate health facility for ensuring safe delivery. Hence, understanding the factors associated with birth preparedness and its significance for safe delivery is essential. This paper aims to assess the levels of birth preparedness, its determinants and association with institutional deliveries in High Priority Districts of Uttar Pradesh, India.Methods: A community-based cross-sectional survey was conducted between June-October 2018 in the rural areas of 25 high priority districts of Uttar Pradesh, India. Simple random sampling was used to select 40 blocks among 294 blocks in 25 districts and 2646 primary sampling units within the selected blocks. The survey interviewed 9458 women who had a delivery 2 months prior to the survey. Descriptive statistics were included to characterize the study population. Multivariable logistic regression analyses were performed to identify the determinants of birth preparedness and to examine the association of birth preparedness with institutional delivery.Results: Among the 9458 respondents, 61.8% had birth preparedness (both facility and transportation identified) and 79.1% delivered in a health facility. Women in other caste category (aOR = 1.24, CI 1.06-1.45) and those with 10 or more years of education (aOR = 1.68, CI 1.46-1.92) were more likely to have birth preparedness. Antenatal care (ANC) service uptake related factors like early registration for ANC (aOR = 1.14, CI 1.04-1.25) and three or more front line worker contacts (aOR = 1.61, CI 1.46-1.79) were also found to be significantly associated with birth preparedness. The adjusted multivariate model showed that those who identified both facility and transport were seven times more likely to undergo delivery in a health facility (aOR = 7.00, CI 6.07-8.08).Conclusion: The results indicate the need for focussing on marginalized groups for improving birth preparedness. Increasing ANC registration in the first trimester of pregnancy, improving frontline worker contact, and optimum utilization of antenatal care check-ups for effective counselling on birth preparedness along with system level improvements could improve birth preparedness and consequently institutional delivery rates in Uttar Pradesh, India. [ABSTRACT FROM AUTHOR]

Background: Maternal deaths among young women (15-24 years) shares 38% of total maternal mortality in India. Utilizing maternal health care services can reduce a substantial proportion of maternal mortality. However, there is a paucity of studies focusing on young women in this context. This paper, therefore, aimed to examine the trends and determinants of full antenatal care (ANC) and skilled birth attendance (SBA) utilization among young married women in India.Methods: The study analysed data from the four rounds of National Family Health Surveys conducted in India during the years 1992-93, 1998-99, 2005-06 and 2015-16. Young married women aged 15-24 years with at least one live birth in the 3 years preceding the survey were considered for analysis in each survey round. We used descriptive statistics to assess the prevalence and trends in full ANC and SBA use. Pooled multivariate logistic regression was conducted to identify the demographic and socioeconomic determinants of the selected maternity care services. The significance level for all analyses was set at p ≤ 0.05.Results: The use of full ANC among young mothers increased from 27 to 46% in India, and from 9 to 28% in EAG (Empowered Action Group) states during 1992-2016. SBA utilization was 88 and 83% during 2015-16 by showing an increment of 20 and 50% since 1992 in India and EAG states, respectively. Findings from multivariate analysis revealed a significant difference in the use of selected maternal health care services by maternal age, residence, education, birth order and wealth quintile. Additionally, Muslim women, women belonging to scheduled caste (SC)/ scheduled tribe (ST) social group, and women unexposed to mass media were less likely to utilize both the maternal health care services. Concerning the time effect, the odds of the utilization of full ANC and SBA among young women was found to increase over time.Conclusions: In India coverage of full ANC among young mothers remained unacceptably low, with a wide and persistent gap in utilization between EAG and non-EAG states since 1992. Targeted health policies should be designed to address low coverage of ANC and SBA among underprivileged young mothers and increased efforts should be made to ensure effective implementation of ongoing programs, especially in EAG states. [ABSTRACT FROM AUTHOR]

The caste system is a complex social stratification system which has been abolished, but remains deeply ingrained in India. Scheduled Caste (SC) women are one of the historically deprived groups, as reflected in poor maternal health outcomes and low utilisation of maternal healthcare services. Key government schemes introduced in 2005 mean healthcare-associated costs should now be far less of a deterrent. This paper examines the factors contributing to this low use of maternal health services by investigating the perceptions, health-seeking behaviours and access of SC women to maternal healthcare services in Bihar, India. Eighteen in-depth, semi-structured interviews were conducted with SC women in Bihar. Data were analysed using Framework Analysis and presented using the AAAQ Toolbox. Main facilitating factors included the introduction of accredited social health activists (ASHAs), free maternal health services, the Janani Shishu Suraksha Karyakram (JSSK), and changes in the cultural acceptability of institutional delivery. Main barriers included inadequate ASHA coverage, poor information access, transport costs and unauthorised charges to SC women from healthcare staff. SC women in Bihar may be inequitably served by maternal health services, and in some cases may face specific discrimination. Recommendations to improve SC service utilisation include research into the improvement of postnatal care, reducing unauthorised payments to healthcare staff and improvements to the ASHA programme. [ABSTRACT FROM AUTHOR]

This paper uses care pathway and delay models to better understand the possible social reasons for maternal deaths in a city with good public and private health infrastructure. The findings can inform programmes to reduce maternal mortality. During 2007–15, 136 maternal deaths were reported in Chandigarh, India. Using World Health Organisation’s verbal autopsy questionnaire, interviews were conducted with primary caregivers of 68 (50%) of the 136 deceased women, as majority of the families had returned to their native places. We used process-tracing techniques to construct the care pathways and identify delays, and explored open-ended responses using thematic analysis. The mean age of the deceased women was 27 years, 51% resided in slums, 32% were primigravida, 25% had their deliveries assisted by traditional birth attendants, and 23% had Caesarean section. Eight percent died at home, and 54% died in tertiary level facilities. Post-partum haemorrhage (26.5%), and complications of puerperium (25%) and labour/delivery (14.7%) were the reported medical causes. Male child preference and norms for home delivery were identified as the distal socio-cultural causes. Individual and family level factors included: shame on multiple pregnancies; fear of discrimination from providers; past successful deliveries at home leading to overconfidence and not seeking institutional care; and lack of awareness about family planning, antenatal care, and danger signs of pregnancy. Healthcare system factors were: non-availability of senior doctors at the time of consultation in the emergency that delayed initiation of immediate treatment, and lack of availability of life-saving equipment due to patient load. Empirical evidence was found on social causes of maternal deaths, which could have been prevented by appropriate actions at individual, family, societal, institutional and policy levels. This study identified potential preventable causes of primarily social origin, which could help in taking actionable steps at several levels to further reduce maternal deaths in India. [ABSTRACT FROM AUTHOR]

Hypertensive disorders of pregnancy (HDP), particularly pre-eclampsia and eclampsia, remain one of the leading causes of maternal mortality and are contributory in many foetal/newborn deaths. This editorial discusses a supplement of seven papers which provide the results of the first round of the CLIP (Community Level Interventions for Pre-eclampsia) Feasibility Studies. These studies report a number of enablers and barriers in each setting, which have informed the implementation of a cluster-randomized trial (cRCT) aimed at reducing pre-eclampsia-related, and all-cause, maternal and perinatal mortality and major morbidity using community-based identification and treatment of pre-eclampsia in selected geographies of Nigeria, Mozambique, Pakistan and India. This supplement unpacks the diverse community perspectives on determinants of maternal health, variant health worker knowledge and routine management of HDP, and viability of task sharing for preeclampsia identification and management in select settings. These studies demonstrate the need for strategies to improve health worker knowledge and routine management of HDP and consideration of expanding the role of community health workers to reach the most remote women and families with health education and access to health services. [ABSTRACT FROM AUTHOR]

Background: India has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005).Methods: A cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed.Results: EmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector.Conclusions: The private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector. [ABSTRACT FROM AUTHOR]

Introduction: The state of Chhattisgarh today faces several challenges in improving the health status of its people. The on-going problems of maternal and child mortality, communicable diseases, and HIV/AIDS pandemic still need greater interventions/support from the already overburdened health systems. In addition, the public health challenges include the escalating burden of chronic noncommunicable diseases. Keeping all these things in mind a study was carried out to have an overview of the public health scenario of Chhattisgarh. Aim: This paper aims to review the different public health indicators of Chhattisgarh. Materials and Methods: This study comprised of reviewing different health indicators of Chhattisgarh adopting three different methods during the period March-April 2013. The methods were: (i) extensive online search, (ii) reviewing the related literatures from different journals and other authentic printed materials, and (iii) information collected from public health experts through e-mail, telephone, or direct interaction. Results: Out of 2.55 crore populations in the state (as per Census 2011), 78% lives in rural areas and 37% of the population is tribal. The sex ratio is 968 and the literacy rate is 65.5% in population above 7 years of age. There is a shortage of trained health care providers in Chhattisgarh. The crude birth rate is 23.5 per 1000 (population Annual Health Survey [AHS] 2011-2012). The infant mortality rate is 48 per 1000 live births (SRS 2012). Malnutrition, anemia, sickle cell hemoglobinopathy, Beta thalassemia trait, and G6 PD enzyme defi ciency are very high among the tribes of Chhattisgarh. Malaria has been a major health problem. Chhattisgarh is one of the states with annual parasite index >5 (MRC report). The other states are Rajasthan, Gujarat, Karnataka, Goa, Southern Madhya Pradesh, Jharkhand, Odisha, and Northeastern states. Conclusion: From a public health point of view, most of the health indicators are below national average and unsatisfactory. The human resources gap, poor physical infrastructure, inadequate health education and awareness, poor health-seeking behavior, and inadequate healthcare utilization compound the problem. Indicators related to health and health care delivery are outcomes of research in diverse fi elds other than the department of health. Putting them together and projecting them in a public health view point encourage others to focus on the neglected indicators/areas. However, further research is needed to have a clear database in this regard. [ABSTRACT FROM AUTHOR]

Background: Millennium Development Goal (MDG) 5 is focused on reducing maternal mortality and achieving universal access to reproductive health care. India has made extensive efforts to achieve MDG 5 and in some regions much progress has been achieved. Progress has been uneven and inequitable however, and many women still lack access to maternal and reproductive health care. Objective: In this review, a framework developed by the Commission on Social Determinants of Health (CSDH) is used to categorize and explain determinants of inequity in maternal and reproductive health in India. Design: A review of peer-reviewed, published literature was conducted using the electronic databases PubMed and Popline. The search was performed using a carefully developed list of search terms designed to capture published papers from India on: 1) maternal and reproductive health, and 2) equity, including disadvantaged populations. A matrix was developed to sort the relevant information, which was extracted and categorized based on the CSDH framework. In this way, the main sources of inequity in maternal and reproductive health in India and their inter-relationships were determined. Results: Five main structural determinants emerged from the analysis as important in understanding equity in India: economic status, gender, education, social status (registered caste or tribe), and age (adolescents). These five determinants were found to be closely interrelated, a feature which was reflected in the literature. Conclusion: In India, economic status, gender, and social status are all closely interrelated when influencing use of and access to maternal and reproductive health care. Appropriate attention should be given to how these social determinants interplay in generating and sustaining inequity when designing policies and programs to reach equitable progress toward improved maternal and reproductive health. [ABSTRACT FROM AUTHOR]

In Nepal, India, Bangladesh and Pakistan, policy focused on improving access to maternity services has led to measures to reduce cost barriers impeding women's access to care. Specifically, these include cash transfer or voucher schemes designed to stimulate demand for services, including antenatal, delivery and post-partum care. In spite of their popularity, however, little is known about the impact or effectiveness of these schemes. This paper provides an overview of five major interventions: the Aama (Mothers') Programme (cash transfer element) in Nepal; the Janani Suraksha Yojana (Safe Motherhood Scheme) in India; the Chiranjeevi Yojana (Scheme for Long Life) in India; the Maternal Health Voucher Scheme in Bangladesh and the Sehat (Health) Voucher Scheme in Pakistan. It reviews the aims, rationale, implementation challenges, known outcomes, potential and limitations of each scheme based on current available data. Increased use of maternal health services has been reported since the schemes began, though evidence of improvements in maternal health outcomes has not been established due to a lack of controlled studies. Areas for improvement in these schemes, identified in this review, include the need for more efficient operational management, clear guidelines, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity. Au Népal, en Inde, au Bangladesh et au Pakistan, la politique centrée sur l'élargissement de l'accès aux services de maternité a débouché sur des mesures de réduction des obstacles financiers qui empêchent les femmes d'avoir accès aux soins, plus précisément des transferts de fonds ou des chèques conçus pour stimuler la demande, notamment de soins prénatals, obstétricaux et du post-partum. Pourtant, en dépit de leur popularité, on sait peu de choses de l'impact de ces programmes. L'article décrit cinq interventions majeures : le programme Aama (des mères) (élément de transfert de fonds) au Népal, le Janani Suraksha Yojana (plan de maternité sans risque) en Inde, le Chiranjeevi Yojana (plan pour une longue vie) en Inde, le projet de chèques de santé maternelle au Bangladesh et le système de chèques Sehat (santé) au Pakistan. Il examine les objectifs, les justificatifs, les obstacles à l'application, les résultats connus, le potentiel et les limites de chaque projet, avec les données disponibles. Un recours accru aux services de santé maternelle a été enregistré depuis le début des projets, mais sans qu'il soit possible de déterminer les améliorations de la santé maternelle, faute d'études contrôlées. L'étude recense les domaines d'amélioration des projets qui ont besoin d'une gestion opérationnelle plus efficace, de directives claires, de transparence financière, de plans de viabilité, de preuves d'équité et, surtout, de confirmer leur impact sur la qualité des soins, et la mortalité et morbidité maternelles. En Nepal, India, Bangladesh y Pakistán, debido a políticas centradas en mejorar el acceso a los servicios de maternidad, se ha intentado reducir las barreras de costo que impiden el acceso de las mujeres a los servicios: específicamente, transferencias de dinero o programas de cupones diseñados para estimular la demanda de los servicios, incluida la atención antes, durante y después del parto. Pese a su popularidad, no se sabe mucho acerca de su impacto o eficacia. En este artículo se resumen cinco intervenciones importantes: el Programa de Madres (transferencias de dinero) en Nepal; el Plan por una Maternidad sin Riesgos y el Plan por una Vida Larga, ambos en India; el Programa de Cupones para Servicios de Salud Materna en Bangladesh; y el Programa de Cupones para servicios de salud, en Pakistán. Se analizan los objetivos, la justificación y los retos de la implementación, los resultados, el potencial y las limitaciones de cada plan según los datos. Desde el inicio de estos planes, ha aumentado el uso de los servicios de salud materna, aunque por falta de estudios controlados no hay evidencia de mejoras en los resultados. Entre las áreas a mejorar figuran: la eficiencia de la administración operativa, directrices claras, transparencia financiera, planes de sostenibilidad, evidencia de equidad y, sobre todo, un impacto comprobado en la calidad de la atención y en las tasas de mortalidad y morbilidad maternas. [ABSTRACT FROM AUTHOR]

The struggle for reproductive self-determination has specific significance for women and girls in India, where a maternal death occurs every five minutes. This paper analyses the role litigation played in seeking redress for violations of the reproductive rights of Shanti Devi, who died in childbirth in 2010 in Haryana state, and some of the socio-economic, cultural, political and legal factors involved. It provides a brief overview of India's national and international obligations with regard to maternal health, and through the lens of the litigation in Shanti Devi's case, it examines how the government failed to protect, respect and fulfill her right to life and health. Litigation can be used to ensure accountability in further cases by building on case law, informing communities about these decisions and their rights, and holding government accountable at local, state and central level. Litigation also has limits, most importantly due to people's lack of awareness of their rights and entitlements, the lack of government outreach programmes informing them of these, and the lack of accountability mechanisms within health programmes when they are not transparent or functioning effectively. Thus, although constitutional justice is an important tool for democratic progress and social change, social justice will only be achieved through broader social struggle. La lutte pour l'autodétermination génésique revêt une importance particulière pour les femmes et les filles en Inde, où un décès maternel se produit toutes les cinq minutes. Cet article analyse le rôle joué par le procès intenté pour demander réparation des violations des droits génésiques de Shanti Devi, morte en couches en 2010 dans l'État d'Haryana, et certains facteurs socio-économiques, culturels, politiques et juridiques en jeu. Il décrit brièvement les obligations nationales et internationales de l'Inde dans le domaine de la santé maternelle, et s'agissant de l'affaire Shanti Devi, il examine comment les autorités ont été incapables de protéger, de respecter et de réaliser le droit à la vie et à la santé de cette femme. Les poursuites peuvent permettre de garantir la responsabilisation dans de nouveaux cas en se fondant sur la jurisprudence, d'informer les communautés de ces décisions et de leurs droits, et de demander des comptes aux autorités locales, étatiques et centrales. L'action en justice a aussi ses limites, en particulier du fait de la méconnaissance de ses droits par la population, de l'absence de programmes officiels de vulgarisation qui informent la population de ces droits et du manque de mécanismes de responsabilisation dans les programmes de santé, quand ils ne sont pas transparents ou ne fonctionnent pas efficacement. Par conséquent, si la justice constitutionnelle est un outil important pour le progrès démocratique et le changement social, seule une lutte sociale élargie apportera la justice sociale. La lucha por la autodeterminación reproductiva tiene un significado específico para las mujeres y niñas en India, donde ocurre una muerte materna cada cinco minutos. En este artículo se analiza el rol que desempeñó el litigio para buscar reparo por violaciones de los derechos reproductivos de Shanti Devi, quien falleció en el parto, en el 2010, en el estado de Haryana, así como algunos de los factores socioeconómicos, culturales, políticos y jurídicos implicados. Se expone un resumen conciso de las obligaciones nacionales e internacionales de la India con respecto a la salud materna, y a través de la lente del litigio en el caso de Shanti Devi, se examina el incumplimiento del gobierno en proteger, respetar y realizar su derecho a la vida y la salud. El litigio se puede utilizar para garantizar responsabilidad en otros casos basándose en jurisprudencia, para informar a las comunidades sobre estas decisiones y sus derechos, y para hacer al gobierno responsable a nivel local, estatal y central. Pero el litigio tiene límites, principalmente debido a que las personas no son conscientes de sus derechos, a la falta de programas gubernamentales de extensión a las comunidades para informarlas de estos derechos, y a la falta de mecanismos de responsabilidad en los programas de salud, cuando no son transparentes o no funcionan eficazmente. Por lo tanto, aunque la justicia constitucional es una herramienta importante para los avances democráticos y el cambio social, la justicia social se alcanzará solo por medio de la lucha social. [ABSTRACT FROM AUTHOR]

Background: India launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/ non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India. Methods: A cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery. Results: The majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home. Conclusion: In this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death. [ABSTRACT FROM AUTHOR]

Blood-transfusion services are vital to maternal health because haemorrhage and anaemia are major causes of maternal death in South Asia. Unfortunately, due to continued governmental negligence, blood-transfusion services in India are a highly-fragmented mix of competing independent and hospital-based blood-banks, serving the needs of urban populations. This paper aims to understand the existing systems of blood-transfusion services in India focusing on Maharashtra and Gujarat states. A mix of methodologies, including literature review (including government documents), analysis of management information system data, and interviews with key officials was used. Results of analysis showed that there are many managerial challenges in blood-transfusion services, which calls for strengthening the planning and monitoring of these services. Maharashtra provides a good model for improvement. Unless this is done, access to blood in rural areas may remain poor. [ABSTRACT FROM AUTHOR]

Although India has made slow progress in reducing maternal mortality, progress in Tamil Nadu has been rapid. This case study documents how Tamil Nadu has taken initiatives to improve maternal health services leading to reduction in maternal morality from 380 in 1993 to 90 in 2007. Various initiatives include establishment of maternal death registration and audit, establishment and certification of comprehensive emergency obstetric and newborn-care centres, 24-hour x 7-day delivery services through posting of three staff nurses at the primary health centre level, and attracting medical officers to rural areas through incentives in terms of reserved seats in postgraduate studies and others. This is supported by the better management capacity at the state and district levels through dedicated public-health officers. Despite substantial progress, there is some scope for further improvement of quality of infrastructure and services. The paper draws out lessons for other states and countries in the region. [ABSTRACT FROM AUTHOR]

Objectives: Only 40.7% women in India deliver in an institution; leaving many vulnerable to maternal morbidity and mortality (India has 22% of global maternal deaths). While limited accessibility to functioning institutions may account in part, a common reason why women deliver at home is poverty. A lack of readily available financial resources for families to draw upon at the time of labor to transport the mother to an institution, is often observed. This paper reports a yearlong collaborative intervention (between the University and Department of Health) to study if providing readily available and easily accessible funds for emergency transportation would reduce maternal deaths in a rural, low income, and high maternal mortality setting in central India. It aimed to obviate a deterrent to emergency obstetric care; the nonavailability of resources with mothers when most needed. Issues in implementation are also discussed. Methods: Maternal deaths were actively identified in block Amarpatan (0.2 million population) over a 2-year period. The project, with participation from local government and other groups, trained 482 local health care providers (public and private) to provide antenatal care. Emergency transport money (in cash) was placed with one provider in each village. Maternal mortality in the adjacent block (Maihar) was followed (as a 'control' block). Results: Maternal deaths in Amarpatan decreased during the project year relative to the previous year, or in the control block the same year. Discussion and conclusions: Issues in implementation of the cash incentive scheme are discussed. Although the intervention reduced maternal deaths in this low-income setting, chronic poverty and malnutrition are underlying structural problems that need to be addressed. [ABSTRACT FROM AUTHOR]

Developing countries are currently struggling to achieve the Millennium Development Goal Five of reducing maternal mortality by three quarters between 1990 and 2015. Many health systems are facing acute shortages of health workers needed to provide improved prenatal care, skilled birth attendance and emergency obstetric services - interventions crucial to reducing maternal death. The World Health Organization estimates a current deficit of almost 2.4 million doctors, nurses and midwives. Complicating matters further, health workforces are typically concentrated in large cities, while maternal mortality is generally higher in rural areas. Additionally, health care systems are faced with shortages of specialists such as anaesthesiologists, surgeons and obstetricians; a maldistribution of health care infrastructure; and imbalances between the public and private health care sectors. Increasingly, policy-makers have been turning to human resource strategies to cope with staff shortages. These include enhancement of existing work roles; substitution of one type of worker for another; delegation of functions up or down the traditional role ladder; innovation in designing new jobs;transfer or relocation of particular roles or services from one health care sector to another. Innovations have been funded through state investment, public-private partnerships and collaborations with nongovernmental organizations and quasi-governmental organizations such as the World Bank. This paper focuses on how two large health systems in India - Gujarat and Tamil Nadu - have successfully applied human resources strategies in uniquely different contexts to the challenges of achieving Millennium Development Goal Five. [ABSTRACT FROM AUTHOR]

Background: Malaria in pregnancy (MiP) is inadequately researched in India, and the burden is probably much higher than current estimates suggest. This paper models the burden of MiP and associated foetal losses and maternal deaths, in rural Madhya Pradesh, India. Methods: Number of pregnancies per year was estimated from the number of births and an estimate of pregnancies that end in foetal loss. The prevalence of MiP, risk of foetal loss attributable to MiP and case fatality rate of MiP were obtained from the literature. The estimated total number of pregnancies was multiplied by the appropriate parameter to estimate the number of MiP cases, and foetal loss and maternal deaths attributable to MiP per year. A Monte Carlo simulation sensitivity analysis was done to assess plausibility of various estimates obtained from the literature. The burden of MiP in tribal women was explored by incorporating the variable prevalence of malaria in tribal and non-tribal populations and in forested and non-forested regions within Madhya Pradesh. Results: Estimates of MiP cases in rural Madhya Pradesh based on the model parameter values found in the literature ranged from 183,000-1.5 million per year, with 73,000-629,000 lost foetuses and 1,500-12,600 maternal deaths attributable to MiP. The Monte Carlo simulation gave a more plausible estimate of 220,000 MiP cases per year (inter-quartile range (IQR): 136,000-305,000), 95,800 lost foetuses (IQR: 56,800-147,600) and 1,000 maternal deaths (IQR: 650-1,600). Tribal women living in forested areas bore 30% of the burden of MiP in Madhya Pradesh, while constituting 18% of the population. Conclusion: Although the estimates are uncertain, they suggest MiP is a significant public health problem in rural Madhya Pradesh, affecting many thousands of women and that reducing the MiP burden should be a priority. [ABSTRACT FROM AUTHOR]

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

The Jawaharlal Nehru Medical College (JNMC) Women's and Children's Health Research Unit (WCHRU) of the Karnataka Lingayat Education (KLE) Academy of Higher Education and Research Deemed-to-be-University and its collaborators convened the '2nd International Conference on Maternal and Newborn Health -Translating Research Evidence to Practice' to address the common theme of improving maternal and newborn health in low- and middle- income countries (LMIC). This supplement, including 16 manuscripts, reflects much of the research presented at the conference, including analyses of the state of knowledge, as well as completed, ongoing and planned research in these areas conducted by the WCHRU in India together with many collaborators across high-income and LMIC. The first paper reviews maternal, fetal and neonatal mortality in low-income countries, considers their causes, as well as evidence for potential interventions to reduce mortality. A second paper addresses near miss maternal mortality. Several manuscripts address the research conducted by WCHRU and their colleagues in a multi-center research network. One study examines rates of miscarriage and medically terminated pregnancy in India and the risk factors for these occurrences. Another paper addresses stillbirth and its risk factors, both in India as well as in other LMIC. Haemorrhage and preeclampsia/eclampsia, important causes of maternal mortality, stillbirth and neonatal morbidity in LMIC, are addressed in a series of papers summarizing trials of interventions to reduce improve outcomes associated with these conditions. Poor maternal and infant nutritional status, which contribute to adverse outcomes, are addressed through papers which describe a number of important studies that the WCHRU and their colleagues have conducted to attempt to improve nutritional status. Another paper describes a study to investigate causes of stillbirth and deaths among preterm births, which will utilize new techniques to investigate the infectious causes of these deaths. Finally, the supplement addresses the process for dissemination of research results to inform public policy. Together these manuscripts represent a body of research to inform interventions to reduce maternal, fetal and newborn mortality and illustrates what a dedicated research group together with institutional support can accomplish. [ABSTRACT FROM AUTHOR]

Background: Proper utilization of antenatal and postnatal care services plays an important role in reducing the maternal mortality ratio and infant mortality rate. This paper assesses the utilization of health care services during pregnancy, delivery and post-delivery among rural women in Uttar Pradesh (UP) and examines its determinants.Methods: Data from a baseline survey of UP Community Mobilization (UPCM) project (2013) was utilized. A cross-sectional sample of currently married women (15 to 49 years) who delivered a baby 15 months prior to the survey was included. Information was collected from 2208 women spread over five districts of UP. Information on socio-demography characteristics, utilization of antenatal care (ANC), delivery and postnatal care (PNC) services was collected. To examine the determinants of utilization of maternal health services, the variables included were three ANC visits, institutional delivery and PNC within 42 days of delivery. Separate multilevel random intercept logistic regressions were used to account for clustering at a block and gram panchayat level after adjusting for covariates.Results: Eighty-three percent of women had any ANC. Of them, 61% reported three or more ANC visits. Although 68% of women delivered in a health facility, 29% stayed for at least 48 h. Any PNC within 42 days after delivery was reported by 26% of women. In the adjusted analysis, women with increasing number of contacts with the health worker during the antenatal period, women exposed to mass-media and non-marginalized women were more likely to have at least three ANC visits during pregnancy. Non-marginalized women and women with at least three ANC visits were more likely than their counterparts to deliver in an institution. Contacts with health worker during pregnancy, marginalization, at least three ANC visits and institutional delivery were the strong determinants for utilization of PNC services. Self-help group (SHG) membership had no association with the utilization of maternal health services.Conclusions: Utilization of maternal health services was low. Contact with the health worker and marginalization emerged as important factors for utilization of services. Although not associated with the utilization, SHGs can be used for delivering health care messages within and beyond the group. [ABSTRACT FROM AUTHOR]

The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public–private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation. [ABSTRACT FROM AUTHOR]

Background: A variety of mobile-based health technologies (mHealth) have been developed for use by community health workers to augment their performance. One such mHealth intervention—ReMiND program, was implemented in a poor performing district of India. Despite some research on the extent of its effectiveness, there is significant dearth of evidence on cost-effectiveness of such mHealth interventions. In this paper we evaluated the incremental cost per disability adjusted life year (DALY) averted as a result of ReMiND intervention as compared to routine maternal and child health programs without ReMiND. Methods: A decision tree was parameterized on MS-Excel spreadsheet to estimate the change in DALYs and cost as a result of implementing ReMiND intervention compared with routine care, from both health system and societal perspective. A time horizon of 10 years starting from base year of 2011 was considered appropriate to cover all costs and effects comprehensively. All costs, including those during start-up and implementation phase, besides other costs on the health system or households were estimated. Consequences were measured as part of an impact assessment study which used a quasi-experimental design. Proximal outputs in terms of changes in service coverage were modelled to estimate maternal and infant illnesses and deaths averted, and DALYs averted in Uttar Pradesh state of India. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties. Results: Cumulatively, from year 2011 to 2020, implementation of ReMiND intervention in UP would result in a reduction of 312 maternal and 149,468 neonatal deaths. This implies that ReMiND program led to a reduction of 0.2% maternal and 5.3% neonatal deaths. Overall, ReMiND is a cost saving intervention from societal perspective. From health system perspective, ReMiND incurs an incremental cost of INR 12,993 (USD 205) per DALY averted and INR 371,577 (USD 5865) per death averted. Conclusions: Overall, findings of our study suggest strongly that the mHealth intervention as part of ReMiND program is cost saving from a societal perspective and should be considered for replication elsewhere in other states. [ABSTRACT FROM AUTHOR]