Causes and Predictors of Neonatal, Post-neonatal and Maternal Deaths in India: Analysis of a Nationwide District-Level Household Survey-4 (DLHS-4), 2012-13.

INTRODUCTION: There is lack of reliable mortality estimates in India about maternal, neonatal and infant deaths. As we move towards achieving the targets under Sustainable Development Goals, information on cause of death is essential to prioritize our resources and planning. Therefore, the present study describes the causes and characteristics of neonatal, post-neonatal and maternal deaths in India. METHODS: The study analysed nationwide District-Level Household Survey-4 conducted by the Ministry of Health and Family Welfare, Government of India, in 2014. The household questionnaire collected information on the socio-economic characteristics of the household and deaths within the household, including neonatal, post-neonatal, maternal and adult deaths. RESULTS: Of 1324 neonatal deaths, 46% occurred at home and 73% in the first week of life. Among 2032 post-neonatal deaths reported, 70% occurred at home. Birth injuries, low birth weight and neonatal infections were the leading causes of neonatal deaths. Acute respiratory infection was the most common cause of post-neonatal deaths, whereas excessive bleeding and pregnancy-induced hypertension were the common causes of maternal deaths. Nearly 39% of neonatal and 50% of post-neonatal deaths were either classified as others or could not be ascertained. Household characteristics such as use of unclean fuel, poor sanitation, poor drinking water source, type of house (kachha) and below poverty line family are associated with mortality. CONCLUSION: A high proportion of avoidable deaths still occur at home. These findings indicate the need for an efficient ambulance transport system, promoting health-seeking behaviour, better knowledge of danger signs and strengthening community-facility linkages. A more accurate verbal autopsy tool and proper administration of the tool are required to accurately ascertain cause of death and reduce the number of deaths that are assigned an ill-defined cause.

How effective was implementation of the package of essential non-communicable disease (PEN) interventions: A review of evidence?

AIMS: This paper reviewed the outcomes, cost-effectiveness and challenges of implementation of WHO PEN protocol in LMICs. METHODS: MEDLINE databases, the Cochrane Central Register of Controlled Trials and Google Scholar were searched and content analysis of the included studies was done. RESULTS: A total of 14 articles were included. Lack of essential medicines and manpower, poor recording and mis-calculation of CVD risk score, suboptimal recording of patient information and loss-to-follow-up were the key challenges reported in various PEN implementation settings. CONCLUSION: The study has highlighted concerns and recommendations which need to be addressed before scale up.

Cost of hospitalization for childbirth in India: how equitable it is in the post-NRHM era?

BACKGROUND AND OBJECTIVE: Information on out-of-pocket (OOP) expenditure during childbirth in public and private health facilities in India is needed to make rational decisions for improving affordability to maternal care services. We undertook this study to evaluate the OOP expenditure due to hospitalization from childbirth and its impact on households. METHODS: This is a secondary data analysis of a nationwide household survey by the National Sample Survey Organization in 2014. The survey reported health service utilization and health care related expenditure by income quintiles and type of health facility. The recall period for hospitalization expenditure was 365 days. OOP expenditure amounting to more than 10% of annual consumption expenditure was termed as catastrophic. RESULTS: Median expenditure per episode of hospitalisation due to childbirth was US$54. The expenditure incurred was about six times higher among the richest quintile compared to the poorest quintile. Median private sector OOP hospitalization expenditure was nearly nine times higher than in the public sector. Hospitalization in a private sector facility leads to a significantly higher prevalence of catastrophic expenditure than hospitalization in a public sector (60% vs. 7%). Indirect cost (43%) constituted the largest share in the total expenditure in public sector hospitalizations. Urban residence, poor wealth quintile, residing in eastern and southern regions of India and delivery in private hospital were significantly associated with catastrophic expenditure. CONCLUSIONS: We strongly recommend cash transfer schemes with effective pro-poor targeting to reduce the impact of catastrophic expenditure. Strengthening of public health facilities is required along with private sector regulation.

Penta-L-lysine Potentiates Fibrin-Independent Activity of Human Tissue Plasminogen Activator.

The therapeutic action of tissue plasminogen activator (t-PA) is a two-step process: (1) binding to lysine-rich fibrin (Km event) and (2) converting local plasminogen into plasmin (Kcat event). Overcoming limitations of other structural biophysics methods, we wanted to employ small-angle X-ray scattering (SAXS) to visualize what shape changes occur/accompany t-PA activation, but the prime hurdle was the polydisperse nature of the fibrin, which occluded scattering information from t-PA. Earlier, larger polylysine peptides have been used to potentiate activation of t-PA, so while screening short polylysine peptides as alternatives to fibrin or larger peptides, we found that penta-polylysine (P5) specifically activates t-PA in a dose-dependent manner, averaging to almost 3-fold more than in the absence of any peptide. SAXS data analysis confirmed that P5 does not induce association of t-PA molecules, and a narrower peak profile of the Kratky plot indicated that P5 binding quenches inherent motion in t-PA. Shape reconstruction of t-PA ∓ P5 revealed that P5 closes the "gap" between the two gross domains of t-PA, viz. fused F/E, K1 and K2 domains, and the P domain. Docking experiments suggested that, while other polylysine peptides preferentially interacted with the surfaces of kringle domains, P5 "slipped into" the gap/groove between K2 and P domains, thereby mediating a substantial increase in the number of long-range interactions between the K2 domain and exosites in the P domain. We report here dissection of shape events involved in between Km/Kcat steps of t-PA activation, which can pave the way toward the search for small molecule function regulator(s) of t-PA.