Improving quality of intrapartum and immediate postpartum care in public facilities: experiences and lessons learned from Rajasthan state, India.

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.

Effect of social and behavioral change interventions on minimum dietary diversity among pregnant women and associated socio-economic inequality in Rajasthan, India.

BACKGROUND: Maternal dietary diversity is a key to improving the birth and child health outcomes. Besides socio-economic factors, the nutrition specific program- Social and Behavioural Change Communication (SBCC) interventions aimed to improve maternal dietary diversity has varied levels of impact on the socio-economic groups in poor resource setups. OBJECTIVE: To measure the factors associated with the minimum dietary diversity (MDD) among pregnant women in selected districts of Rajasthan with special emphasis on the SBCC components. Additionally, it measures the socio-economic gaps in the behaviour of consumption of diversified diet during pregnancy. METHODS: Data from a cross sectional survey of 6848 pregnant women, who have received a continuous SBCC counselling and registered under a state introduced conditional cash transfer program, during May to June, 2023, in five intervention districts -Banswara, Baran, Dunagrpur, Pratapgarh and Udaipur in Rajasthan was used. A 24 h recall based food consumption behaviour has been gathered to measure the MDD of pregnant women. Study has used descriptive statistics, multivariate regressions, and multivariate decomposition analysis to address the research objectives. RESULTS: Study finds that only 55.2% of pregnant women are consuming diverse diet in the study duration with mean dietary diversity score is 4.8 (+/- 1.5). Logistic regression finds that SBCC components such as frontline workers (aOR = 1.3, CI: 1.1-1.4), community motivators (aOR = 1.9, CI: 1.7-2.1), and participation in MCHND (aOR = 1.0, CI: 0.9-1.2) have significant and higher likelihood on consumption of MDD food on previous day. A higher education and belonging from richer wealth quintile also show higher association for consumption of MDD. Multivariate decomposition shows, among richest and poorest wealth categories there is 19% point difference (58% difference due to coefficient vs. 42% difference due to composition) in MDD consumption. This is positively contributed by the caste and educational categories of women. CONCLUSION: Despite a predominant vegetarian diet consuming population, better maternal dietary diversity was observed among those exposed to higher dose of SBCC intervention package. Educational status and caste of the respondent were significantly associated with minimum dietary diversity and contributed to the socio-economic inequality highlighting the importance of tailored and sustained SBCC interventions.

A positive consequence of the COVID-19 pandemic: how the counterfactual experience of school closures is accelerating a multisectoral response to the treatment of neglected tropical diseases.

Global access to deworming treatment is one of the public health success stories of low-income countries in the twenty-first century. Parasitic worm infections are among the most ubiquitous chronic infections of humans, and early success with mass treatment programmes for these infections was the key catalyst for the neglected tropical disease (NTD) agenda. Since the launch of the 'London Declaration' in 2012, school-based deworming programmes have become the world's largest public health interventions. WHO estimates that by 2020, some 3.3 billion school-based drug treatments had been delivered. The success of this approach was brought to a dramatic halt in April 2020 when schools were closed worldwide in response to the COVID-19 pandemic. These closures immediately excluded 1.5 billion children not only from access to education but also from all school-based health services, including deworming. WHO Pulse surveys in 2021 identified NTD treatment as among the most negatively affected health interventions worldwide, second only to mental health interventions. In reaction, governments created a global Coalition with the twin aims of reopening schools and of rebuilding more resilient school-based health systems. Today, some 86 countries, comprising more than half the world's population, are delivering on this response, and school-based coverage of some key school-based programmes exceeds those from January 2020. This paper explores how science, and a combination of new policy and epidemiological perspectives that began in the 1980s, led to the exceptional growth in school-based NTD programmes after 2012, and are again driving new momentum in response to the COVID-19 pandemic. This article is part of the theme issue 'Challenges and opportunities in the fight against neglected tropical diseases: a decade from the London Declaration on NTDs'.

Low Prevalence of Soil-Transmitted Helminth Infections among Children in the States of Chhattisgarh and Himachal Pradesh, India, 2018.

Large-scale impact assessments of soil-transmitted helminth (STH) programs are essential for determining the frequency of mass drug administration (MDA). In baseline surveys, the prevalence of STHs in the Indian States of Chhattisgarh and Himachal Pradesh was 80.2% in 2015 and 29.0% in 2016, respectively. In 2018, we estimated the prevalence and intensity of STHs after six rounds of biannual MDA in Chhattisgarh and annual MDA in Himachal Pradesh. We conducted multistage cluster sampling surveys in preschool-age children (PSAC), school-age children (SAC), and adolescent cohorts. Stool samples from 3,033 respondents (PSAC, n = 625; SAC, n = 1,363; adolescents, n = 1,045) in Chhattisgarh and 942 respondents (PSAC, n = 192; SAC, n = 388; adolescents, n = 362) in Himachal Pradesh were examined for presence of STH infection using the Kato-Katz method. The overall cluster-adjusted prevalence in Chhattisgarh was 11.6% among all age groups (95% CI, 5.6-22.4)-an 85.5% reduction in the prevalence since 2015. Prevalence was not significantly different across cohorts (PSAC, 11.0% [95% CI, 5.0-22.6]; SAC, 10.9% [95% CI, 5.2-21.6]; adolescents, 12.8% [95% CI, 6.2-24.5]). Ascaris lumbricoides was the most common helminth, with most infections of light intensity. In Himachal Pradesh, only three STH infections were detected in 2018, resulting in a cluster-adjusted prevalence of 0.3% (95% CI, 0.1-1.7)-a 99.0% reduction in prevalence since 2016. All infections were of light intensity. Both states showed substantial improvements in socioeconomic and water, sanitation, and hygiene (WASH) indicators since the baseline surveys. Extensive reductions in prevalence and intensity are linked to sustained, high deworming coverage, as well as socioeconomic WASH indicators.

RAPIDIRON Trial follow-up study - the RAPIDIRON-KIDS Study: protocol of a prospective observational follow-up study.

BACKGROUND: Anemia is a worldwide problem with iron deficiency being the most common cause. When anemia occurs in pregnancy, it increases the risk of adverse maternal, fetal, and postnatal outcomes. It induces preterm births and low birth weight (LBW) deliveries, long-term neurodevelopmental sequelae, and an increased risk of earlier onset of postnatal iron deficiency. Anemia rates are among the highest in South Asia, and India's National Family Health Survey (NFHS-5) for 2019-2021 indicated that over half of pregnant women, and more than 65% of children, in the country are classified as anemic (Sciences IIfP, National Family Health Survey-5, 2019-21, India Fact Sheet). In 2021, the parent RAPIDIRON Trial (Derman et al., Trials 22:649, 2021) was initiated in two states in India, with the goal of assessing whether a dose of intravenous (IV) iron given to anemic women during early pregnancy results in a greater proportion of participants with normal hemoglobin concentrations in the third trimester and a lower proportion of participants with LBW deliveries compared to oral iron. As a follow-up to the RAPIDIRON Trial, the RAPIDIRON-KIDS Study will follow the offspring of previously randomized mothers to assess, neurobehavioral, hematological, and health outcomes. METHODS: This prospective observational cohort study will follow a subset of participants previously randomized as part of the RAPIDIRON Trial and their newborns. Study visits occur at birth, 6 weeks, 4 months, 12 months, 24 months, and 36 months and include blood sample collection with both maternal and infant participants and specific neurobehavioral assessments conducted with the infants (depending on the study visit). The primary outcomes of interest are (1) infant iron status as indicated by both hemoglobin and ferritin (a) at birth and (b) at 4 months of age and (2) the developmental quotient (DQ) for the cognitive domain of the Bayley Scales of Infant Development Version IV (BSID-IV) at 24 months of age. DISCUSSION: This RAPIDIRON-KIDS Study builds upon its parent RAPIDIRON Trial by following a subset of the previously randomized participants and their offspring through the first 3 years of life to assess neurodevelopmental and neurobehavioral (infants, children), hematological, and health outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT05504863 , Registered on 17 August 2022. Clinical Trials Registry - India CTRI/2022/05/042933 . Registered on 31 May 2022.

Sensitizing the teachers towards school mental health issues: an Indian experience.

The School Mental Health (SMH) services play critical roles fostering positive mental health and helping children with psychological problems. Despite its proven value, SMH services remain less developed in India. In this context, sensitizing teachers about child mental health issues could be considered as an important step in SMH promotion. Towards this goal, a large scale sensitization program for school teachers on SMH issues was carried out in an Indian city. This paper reports the process and the outcome of this sensitization program.

Association between anthropometric criteria and body composition among children aged 6-59 months with severe acute malnutrition: a cross-sectional assessment from India.

A multicentric study is being conducted in which children with severe acute malnutrition (SAM) aged 6-59 months are identified with only weight-for-height z-score (WHZ) < - 3 criteria. The present study aimed to assess associations of anthropometric parameters and body composition parameters, to improve treatment of SAM. We conducted a cross-section assessment using the enrolment data of children who participated in a multi-centric longitudinal controlled study from five Indian states. Fat-free mass (FFM) and fat mass (FM) were determined by bio-electrical impedance analysis (BIA). Six hundred fifty-nine children were enrolled in the study using WHZ < -3 criteria. Available data shows that WHZ, WAZ and BMIZ were significantly associated with FFMI while MUACZ was significantly associated with both FMI and FFMI. Children with both severe wasting and severe stunting had significantly lower FFMI compared to those who were only severely wasted. All forms of anthropometric deficits appear to adversely impact FFM and FM.Trial registrationThe study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 dated 24/09/2020).

Evaluating the effect of strengthening nurse midwifery pre-service education in two Indian states: A single group pre - and post - intervention study.

BACKGROUND: The high focus states of India have higher maternal and neonatal mortality rates as compared to the national average. The quality of pre-service education (PSE) in nursing midwifery institutions in these states was found to be suboptimal. In 2013, Government of India implemented the PSE strengthening program across all public sector nursing midwifery institutions. The program focused on strengthening educational processes, training infrastructure, institutional management and clinical site practices by implementing a set of performance standards. OBJECTIVE: To evaluate the effect of PSE strengthening program on institutional performance and maternal neonatal health (MNH) related competences of nursing midwifery students and faculty. DESIGN: Single group pre-post intervention study. SETTINGS: 15 sampled public sector nursing midwifery institutions in the states of Madhya Pradesh and Odisha, India. PARTICIPANTS: Final-year students and faculty involved in teaching MNH subjects. METHODS: Performance of 15 sampled institutions was assessed at baseline, midline and endline using the performance standards. Additionally, competences of 232, 295 and 298 students and 64, 62 and 63 faculty members at baseline, midline and endline respectively were assessed on six MNH related practices using objective structured clinical examination (OSCE). RESULTS: None of the institutions met 70% standards during baseline. At endline, 13 of the 15 institutions met these standards. The mean OSCE scores of students and faculty at baseline was 17.1 (SD: 8.0) and 23.5 (SD: 14.3) out of 76 respectively. It significantly increased to 66.4 (SD: 8.0) and 71.1 (SD: 5.2) during the endline. The proportion of students and faculty found competent (achieved 75% in OSCE) also significantly increased from none at baseline to 91% and 98% respectively, at endline. CONCLUSION: The combination of attributes included in the PSE strengthening program may have contributed to improvements in institutional performance as well as MNH related competences of nursing midwifery students and faculty.

Effectiveness of community-based treatment programs for treatment of uncomplicated severe acute malnourished children aged 6-59 months using locally produced nutrient dense foods: protocol for a multicentric longitudinal quasi-experimental study.

BACKGROUND: Severe acute malnutrition (SAM) is a major underlying cause of mortality among children. Around one third of the world's acutely malnourished children live in India. The WHO recommends community-based management of acute malnutrition (CMAM) for managing children with SAM. In India, different states are implementing community-based SAM treatment programme, hereinafter called CSAM, using varieties of locally produced nutrient dense food items with different nutrient compositions. The study will assess the effectiveness of these state specific CSAM interventions. METHODS: The longitudinal quasi-experimental study will be undertaken in two purposively selected blocks of one district each in the four intervention states and one comparison state. From each state, 200 SAM children identified using weight-for-length/height z-score (WHZ) < - 3 criteria will be enrolled in the study. Their anthropometric data and skinfold thickness will be taken on admission, at sixth week and at discharge by trained field investigators. Other child details, incidence of morbidity and socio-economic details will be collected on admission. To assess food consumption pattern including consumption of locally produced nutrient dense food supplements, dietary assessment, using 24-h dietary recall will be conducted on admission, at sixth week and at discharge. In addition, body composition parameters will be assessed for a sub-set of children using bio-electrical impedance analysis on admission and at discharge to analyse changes in total body water, fat-free mass, and fat mass. Post discharge, all study participants will be followed up monthly until 6 months. Atleast 10% of the sample will be checked for quality assessment. The study's primary outcome is cure rate defined as children attaining WHZ ≥ -2. Secondary outcomes include mean weight gain, mean length of stay, body composition parameters, relapse and mortality rates. Additionally, process evaluation and cost effectiveness analysis will be conducted. DISCUSSION: There is a shortage of robust evidence regarding the effectiveness of locally produced nutrient dense food supplements provided as part of the CSAM intervention in India. This study will contribute to evidence on effective strategies to manage children with uncomplicated SAM in India. The study protocol has all necessary ethical approvals. Written informed consent will be obtained from caregivers of the children. TRIAL REGISTRATION: The study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 ) Date of registration 24/09/2020.

RAPIDIRON: Reducing Anaemia in Pregnancy in India-a 3-arm, randomized-controlled trial comparing the effectiveness of oral iron with single-dose intravenous iron in the treatment of iron deficiency anaemia in pregnant women and reducing low birth weight deliveries.

BACKGROUND: Anaemia is a worldwide problem and iron deficiency is the most common cause. In pregnancy, anaemia increases the risk of adverse maternal, foetal and neonatal outcomes. India's anaemia rate is among the highest in the world with India's National Family Health Survey indicating over 50% of pregnant women were affected by anaemia. India's Anaemia Mukt Bharat-Intensified National Iron Plus Initiative aims to reduce the prevalence of anaemia among reproductive-age women, adolescents and children by 3% per year and facilitate the achievement of a Global World Health Assembly 2025 objective to achieve a 50% reduction of anaemia among women of reproductive age. However, preliminary results of the NFHS-5 survey completed in 2020 indicate that anaemia rates are increasing in some states and these targets are unlikely to be achieved. With oral iron being the first-line treatment for iron deficiency anaemia (IDA) in pregnancy, these results are likely to be impacted by the side effects, poor adherence to tablet ingestion and low therapeutic impact of oral iron. These reports suggest a new approach to treating IDA, specifically the importance of single-dose intravenous iron infusions, may be the key to India effectively reaching its targets for anaemia reduction. METHODS: This 3-arm, randomized controlled trial is powered to report two primary outcomes. The first is to assess whether a single dose of two different intravenous formulations administered early in the second trimester of pregnancy to women with moderate IDA will result in a higher percentage of participants achieving a normal for pregnancy Hb concentration at 30-34 weeks' gestation or just prior to delivery when compared to participants taking standard doses of oral iron. The second is a clinical outcome of low birth weight (LBW) (< 2500 g), with a hypothesis that the risk of LBW delivery will be lower in the intravenous iron arms when compared to the oral iron arm. DISCUSSION: The RAPIDIRON trial will provide evidence to determine if a single-dose intravenous iron infusion is more effective and economically feasible in reducing IDA in pregnancy than the current standard of care. TRIAL REGISTRATION: Clinical Trials Registry - India CTRI/2020/09/027730. Registered on 10 September 2020, http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=46801&EncHid=&userName=anemia%20in%20pregnancy.

Rate and risk factors of nocturnal enuresis in school going children.

PURPOSE: The purpose is to find out the rate of nocturnal enuresis in school going children (5-12 years) and the risk factors associated with it. MATERIALS AND METHODS: The parents of children aged between 5 and 12 years studying in two primary schools in Ahmedabad completed a self-administered semi-structured questionnaire comprising of enuresis, sociodemographic profiles, and risk factors. Children with enuresis and those without were compared on demographic characteristics and risk factors using Chi-square and t-test for categorical and quantitative data respectively. The data were analyzed using SPSS version 17. RESULTS: The response rate was 86.54% as 1904 responses were collected out of 2200. The overall rate of nocturnal enuresis was 6.7% (according to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition definition of nocturnal enuresis). As the age increased, the rate of nocturnal enuresis declined. A positive family history was seen in 36.6% of children with enuresis. Enuresis was found to be more frequently in lower socioeconomic class. It was a neglected problem, only 20.6% of children received some kind of treatment. CONCLUSION: The rate of nocturnal enuresis was 6.7% in school going children. Strong correlation was found with family history. Although the rate was high, most of the children with enuresis were not treated.

The antiplaque efficacy of white tea extract mouthrinse.

OBJECTIVE: This study was conducted to assess the antiplaque efficacy of a mouthwash containing white tea. It also assessed the antibacterial properties of white tea against Prevotella intermedia (Pi), Porphyromonas gingivalis (Pg), and Aggregatibacter actinomycetemcomitans (Aa) in vitro. MATERIALS AND METHODS: Forty-five subjects with healthy periodontium were randomly chosen and were divided into three groups and advised to use mouthwashes A, B, and C (Group A, white tea; Group B, distilled water [placebo]; Group C, chlorhexidine) for 4 days. They were advised to refrain from any kind of mechanical oral hygiene techniques. Plaque index (PI) was checked on day 1 and 5. In vitro testing for against Pi, Pg, and Aa against white tea extract was undertaken. RESULTS: PI significantly increased from day 1 to day 5 (P < 0.01) in Groups A, B, and C. In inter-group comparison, there was a statistical significant difference between white tea mouthrinse group and placebo group, chlorhexidine group and placebo group and also chlorhexidine group and white tea mouthrinse group. However, chlohexidine showed superior antiplaque activity. In vitro test, white tea showed effective inhibition against all three bacterial strains Pi, Pg, and Aa at 1% concentration. CONCLUSION: White tea mouthrinse potently inhibits plaque formation although not as comparable to chlorhexidine mouthrinse. Hence, for those preferring herbal products, white tea mouthrinse is a good option.

Using a structured questionnaire improves seizure description by medical students.

OBJECTIVE: The purpose of this study was to evaluate a structured questionnaire for improving a medical students' ability to identify, describe and interpret a witnessed seizure. METHODS: Ninety two 3rd year medical students, blinded to seizure diagnosis, viewed videos of a primary generalized seizure and a complex partial seizure. Students next completed an unstructured questionnaire that asked the students to describe the seizure video recordings. The students then completed a structured questionnaire that asked the student to respond to 17 questions regarding specific features occurring during the seizures. We determined the number and types of correct responses for each questionnaire. RESULTS: Overall, the structured questionnaire was more effective in eliciting an average of 9.25 correct responses compared to the unstructured questionnaire eliciting an average of 5.30 correct responses (p < 0.001). Additionally, 10 of the 17 seizure features were identified more effectively with the structured questionnaire. Potentially confounding factors, prior knowledge of someone with epilepsy or a prior experience of viewing a seizure, did not predict the student's ability to correctly identify any of the 17 features. CONCLUSIONS: A structured questionnaire significantly improves a medical student's ability to provide an accurate clinical description of primary generalized and complex partial witnessed seizures. Our analysis identified the 10 specific features improved by using the structured questionnaire.

Neurosarcoidosis with necrotising sarcoid granulomatosis mimicking meningiomatosis cerebri: case report and literature search.

A 52-year-old woman presented with headaches, difficulty with word finding and left eye blindness. MRI showed enhancing frontal dural-based masses suggestive of meningiomatosis. Biopsy and debulking revealed necrotising granulomas, without discernible micro-organisms or neoplasia; a thorough clinical work-up was negative for infection and vasculitis. A CT scan showed mild bilateral hilar lymphadenopathy, a tiny pulmonary nodule and cirrhotic liver. Her subsequent alteration of mental status was attributed to hepatic encephalopathy based upon elevated aminotransferase and ammonia levels, biopsy evidence of hepatoportal sclerosis with rare granulomas and response to lactulose. A diagnosis of neurosarcoidosis of the necrotising sarcoid granulomatosis variant (NS-NSG) with atypical systemic involvement was made. This is the fifth case report of NS-NSG clinically mimicking a neoplasm and histologically mimicking a mycobacterial infection. NS-NSG can have an atypical clinical picture including intracranial masses; a thorough work-up to exclude infectious and other non-infectious aetiologies is a prerequisite to its diagnosis.

Wilson's Disease : A Case Report.

Wilson's disease is a rare metabolic disorder involving copper metabolism may present with hepatic, neurological and psychiatric manifestations. We present a case of Wilson's disease with behavioral symptoms, which responded to risperidone.