Build the cradle later: An examination of perinatal care and mortality in village nepal.

Background: As perinatal and neonatal mortality move to the foreground of the debate on how best to improve child survival in poor countries, there appears a pressing need to test potential interventions. Implicit in testing is the ability to document birth and neonatal outcomes in rural communities. The thesis sets perinatal events in the context of the child survival literature and critically examines current knowledge about practices, outcomes and interventions. This knowledge is found to be limited, particularly in terms of practices and outcomes in rural settings in developing countries. Methods: Two methods are described to document perinatal events in villages in Makwanpur district, Nepal. (1) a census of women of reproductive age, collecting information about previous pregnancies and most recent live births (2) a prospective system of registration that tracked women through childbirth and infants through the neonatal period. Both methods yielded information on pregnancies, birth outcomes, care practices and health care seeking patterns. Results: The census collected information from 12,170 women, of whom 4867 had given birth in the preceding two years. The prospective surveillance collected information on 3522 pregnancies over two years. The thesis presents results under two broad themes: (1) a description of the birth experience of women in rural Makwanpur, its outcomes, practices and care seeking patterns (2) a comparison of the two methods of data collection. Poverty was the norm in rural Makwanpur and only a quarter of participants were literate. 30% of pregnant women had any antenatal care, which tended to be both late and limited, and 95% gave birth at home. Three percent of women were helped by trained health workers and there were compromises in hygiene and warmth at the time of delivery. Breastfeeding rates were high. The prospective registration process suggested a neonatal mortality rate of 37 per thousand live births, a figure higher than that from the census (27 per thousand), and thus higher than would be estimated by existing methodologies. Discussion: Antenatal, delivery, postnatal and neonatal care practices and care seeking are compared with existing knowledge from other studies. Their implications for programmatic intervention are considered. The issue of recall-based data collection is discussed as it bears upon the evaluation of public health interventions. The feasibility of registration systems is assessed and recommendations made for increasing reliability, expansion and replication, and reducing system costs. 386 words

Barriers to and incentives for achieving partograph use in obstetric practice in low- and middle-income countries: a systematic review.

The partograph is a graphic display of the progress of labour, recommended by the World Health Organization, but often underused in practice in low- and middle-income countries. We were interested in going beyond demonstration of potential efficacy - on which the existing literature concentrates - through a systematic review to identify barriers to and incentives for achieving partograph use

Inequalities in maternity care and newborn outcomes: one-year surveillance of births in vulnerable slum communities in Mumbai

Background: Aggregate urban health statistics mask inequalities. We described maternity care in vulnerable slum communities in Mumbai, and examined differences in care and outcomes between more and less deprived groups. Methods: We collected information through a birth surveillance system covering a population of over 280 000 in 48 vulnerable slum localities. Resident women identified births in their own localities and mothers and families were interviewed at 6 weeks after delivery. We analysed data on 5687 births over one year to September 2006. Socioeconomic status was classified using quartiles of standardized asset scores. Results: Women in higher socioeconomic quartile groups were less likely to have married and conceived in their teens (Odds ratio 0.74, 95% confidence interval 0.69–0.79, and 0.82, 0.78–0.87, respectively). There was a socioeconomic gradient away from public sector maternity care with increasing socioeconomic status (0.75, 0.70–0.79 for antenatal care and 0.66, 0.61–0.71 for institutional delivery). Women in the least poor group were five times less likely to deliver at home (0.17, 0.10–0.27) as women in the poorest group and about four times less likely to deliver in the public sector (0.27, 0.21–0.35). Rising socioeconomic status was associated with a lower prevalence of low birth weight (0.91, 0.85–0.97). Stillbirth rates did not vary, but neonatal mortality rates fell non-significantly as socioeconomic status increased (0.88, 0.71–1.08). Conclusion: Analyses of this type have usually been applied across the population spectrum from richest to poorest, and we were struck by the regularly stepped picture of inequalities within the urban poor, a group that might inadvertently be considered relatively homogeneous. The poorest slum residents are more dependent upon public sector health care, but the regular progression towards the private sector raises questions about its quality and regulation. It also underlines the need for healthcare provision strategies to take account of both sectors

Newborn Health in Urban India

The rapid population growth in urban India has outpaced the municipal capacity to build essential infrastructures that make life in cities safe and healthy. Local and national governments alike are grappling with the challenges of urbanization, with thousands migrating from villages to cities. Many of them ultimately end up living in slums, which are, in fact, a product of this uncontrolled migration. Thus urbanization in India has been accompanied by a concentration of poverty and urban public health has emerged as one of the most pressing priorities facing our country. Children’s health is primarily determined by socioeconomic conditions, which in turn are shaped by the distribution of power and resources. The consequences of having too little of both are evident in informal settlements and slums. This chapter focuses on newborn health in urban areas in India. It discusses the challenges, roadblocks, efforts, and initiatives by the government and other national and international organizations, possible options, research priorities and the other requirements needed to gear up the urban health systems to cater to newborn health

Body composition in Nepalese children using isotope dilution: the production of ethnic-specific calibration equations and an exploration of methodological issues.

Background. Body composition is important as a marker of both current and future health. Bioelectrical impedance (BIA) is a simple and accurate method for estimating body composition, but requires population-specific calibration equations. Objectives. (1) To generate population specific calibration equations to predict lean mass (LM) from BIA in Nepalese children aged 7-9 years. (2) To explore methodological changes that may extend the range and improve accuracy. Methods. BIA measurements were obtained from 102 Nepalese children (52 girls) using the Tanita BC-418. Isotope dilution with deuterium oxide was used to measure total body water and to estimate LM. Prediction equations for estimating LM from BIA data were developed using linear regression, and estimates were compared with those obtained from the Tanita system. We assessed the effects of flexing the arms of children to extend the range of coverage towards lower weights. We also estimated potential error if the number of children included in the study was reduced. Findings. Prediction equations were generated, incorporating height, impedance index, weight and sex as predictors (R (2) 93%). The Tanita system tended to under-estimate LM, with a mean error of 2.2%, but extending up to 25.8%. Flexing the arms to 90° increased the lower weight range, but produced a small error that was not significant when applied to children <16 kg (p 0.42). Reducing the number of children increased the error at the tails of the weight distribution. Conclusions. Population-specific isotope calibration of BIA for Nepalese children has high accuracy. Arm position is important and can be used to extend the range of low weight covered. Smaller samples reduce resource requirements, but leads to large errors at the tails of the weight distribution

Intersectional tension: a qualitative study of the effects of the COVID-19 response on survivors of violence against women in urban India

OBJECTIVES: There is a concern worldwide that efforts to address the SARS-CoV-2 pandemic have affected the frequency and intensity of domestic violence against women. Residents of urban informal settlements faced particularly stringent conditions during the response in India. Counsellors spoke with registered survivors of domestic violence in Mumbai, with two objectives: to understand how the pandemic and subsequent lockdown had changed their needs and experiences, and to recommend programmatic responses. DESIGN: Qualitative interviews and framework analysis. SETTING: A non-government support programme for survivors of violence against women, providing services mainly for residents of informal settlements. PARTICIPANTS: During follow-up telephone counselling with survivors of violence against women who had previously registered for support and consented to the use of information in research, counsellors took verbal consent for additional questions about the effects of COVID-19 on their daily life, their ability to speak with someone, and their counselling preferences. Responses were recorded as written notes. RESULTS: The major concerns of 586 clients interviewed between April and July 2020 were meeting basic needs (financial stress, interrupted livelihoods and food insecurity), confinement in small homes (family tensions and isolation with abusers) and limited mobility (power imbalances in the home and lack of opportunity for disclosure and stress relief). A major source of stress was the increased burden of unpaid domestic care, which fell largely on women. CONCLUSION: The COVID-19 pandemic has increased the burden of poverty and gendered unpaid care. Finance and food security are critical considerations for future response, which should consider inequality, financial support, prioritising continued availability of services for survivors of violence and expanding access to social networks. Decision-makers must be aware of the gendered, intersectional effects of interventions and must include residents of informal settlements who are survivors of domestic violence in the planning and implementation of public health strategies

Measuring the psychological drivers of participation in collective action to address violence against women in Mumbai, India [version 1; peer review: awaiting peer review]

Background: A growing number of global health interventions involve community members in activism to prevent violence against women (VAW), but the psychological drivers of participation are presently ill-understood. We developed a new scale for measuring three proposed drivers of participation in collective action to address VAW in the context of urban informal settlements in Mumbai, India: perceived legitimacy, perceived efficacy, and collective action norms. / Methods: We did a household survey of 1307 men, 1331 women, and 4 trans persons. We checked for 1) social desirability bias by comparing responses to self-administered and face-to-face interviews, 2) acquiescence bias by comparing responses to positive and negatively worded items on the same construct, 3) factor structure using confirmatory factor analysis, and 4) convergent validity by examining associations between construct scores and participation in groups to address VAW and intent to intervene in case of VAW. / Results: Of the ten items, seven showed less than five percentage point difference in agreement rates between self-administered and face-to-face conditions. Correlations between opposite worded items on the same construct were negative (p<0.05), while correlations between similarly worded items were positive (p<0.001). A hierarchical factor structure showed adequate fit (Tucker-Lewis index, 0.920; root mean square error of approximation, 0.035; weighted root mean square residual, 1.952). Perceived legitimacy, efficacy and collective action norms all predicted participation in groups to address VAW and intent to intervene in case of VAW, even after adjusting for social capital (p<0.05). / Conclusion: This is the first study to operationalize a measure of the psychological drivers of participation in collective action to address VAW in a low- and middle-income context. Our novel scale may provide insight into modifiable beliefs and attitudes community mobilisation interventions can address to inspire activism in similar low-resource contexts