Mortality and recovery following moderate and severe acute malnutrition in children aged 6-18 months in rural Jharkhand and Odisha, eastern India: A cohort study.

BACKGROUND: Recent data suggest that case fatality from severe acute malnutrition (SAM) in India may be lower than the 10%-20% estimated by the World Health Organization (WHO). A contemporary quantification of mortality and recovery from acute malnutrition in Indian community settings is essential to inform policy regarding the benefits of scaling up prevention and treatment programmes. METHODS AND FINDINGS: We conducted a cohort study using data collected during a recently completed cluster-randomised controlled trial in 120 geographical clusters with a total population of 121,531 in rural Jharkhand and Odisha, eastern India. Children born between October 1, 2013, and February 10, 2015, and alive at 6 months of age were followed up at 9, 12, and 18 months. We measured the children's anthropometry and asked caregivers whether children had been referred to services for malnutrition in the past 3 months. We determined the incidence and prevalence of moderate acute malnutrition (MAM) and SAM, as well as mortality and recovery at each follow-up. We then used Cox-proportional models to estimate mortality hazard ratios (HRs) for MAM and SAM. In total, 2,869 children were eligible for follow-up at 6 months of age. We knew the vital status of 93% of children (2,669/2,869) at 18 months. There were 2,704 children-years of follow-up time. The incidence of MAM by weight-for-length z score (WLZ) and/or mid-upper arm circumference (MUAC) was 406 (1,098/2,704) per 1,000 children-years. The incidence of SAM by WLZ, MUAC, or oedema was 190 (513/2,704) per 1,000 children-years. There were 36 deaths: 12 among children with MAM and six among children with SAM. Case fatality rates were 1.1% (12/1,098) for MAM and 1.2% (6/513) for SAM. In total, 99% of all children with SAM at 6 months of age (227/230) were alive 3 months later, 40% (92/230) were still SAM, and 18% (41/230) had recovered (WLZ ≥ -2 standard deviation [SD]; MUAC ≥ 12.5; no oedema). The adjusted HRs using all anthropometric indicators were 1.43 (95% CI 0.53-3.87, p = 0.480) for MAM and 2.56 (95% CI 0.99-6.70, p = 0.052) for SAM. Both WLZ < -3 and MUAC ≥ 11.5 and < 12.5 were associated with increased mortality risk (HR: 3.33, 95% CI 1.23-8.99, p = 0.018 and HR: 3.87, 95% CI 1.63-9.18, p = 0.002, respectively). A key limitation of our analysis was missing WLZ or MUAC data at all time points for 2.5% of children, including for two of the 36 children who died. CONCLUSIONS: In rural eastern India, the incidence of acute malnutrition among children older than 6 months was high, but case fatality following SAM was 1.2%, much lower than the 10%-20% estimated by WHO. Case fatality rates below 6% have now been recorded in three other Indian studies. Community treatment using ready-to-use therapeutic food may not avert a substantial number of SAM-related deaths in children aged over 6 months, as mortality in this group is lower than expected. Our findings strengthen the case for prioritising prevention through known health, nutrition, and multisectoral interventions in the first 1,000 days of life, while ensuring access to treatment when prevention fails.

Putting women at the center: a review of Indian policy to address person-centered care in maternal and newborn health, family planning and abortion.

BACKGROUND: Person-centered care is a critical component of quality care, essential to enable treatment adherence, and maximize health outcomes. Improving the quality of health services is a key strategy to achieve the new global target of zero preventable maternal deaths by 2030. Recognizing this, the Government of India has in the last decade initiated a number of strategies to address quality of care in health and family welfare services. METHODS: We conducted a policy review of quality improvement strategies in India from 2005 to 15, covering three critical areas- maternal and newborn health, family planning, and abortion (MNHFP + A). Based on Walt and Gilson's policy triangle framework, we analyzed the extent to which policies incorporated person-centered care, while identifying unaddressed issues. Data was sourced from Government of India websites, scientific and grey literature databases. RESULTS: Twenty-two national policy documents, comprising two policy statements and 20 implementation guidelines of specific schemes were included in the review. Quality improvement strategies span infrastructure, commodities, human resources, competencies, and accountability that are driving quality assurance in MNHFP + A services. However, several implementation challenges have affected compliance with person-centered care, thereby affecting utilization and outcomes. CONCLUSION: Focus on person-centered care in Indian MNHFP + A policy has increased in recent years. Nevertheless, some aspects must still be strengthened, such as positive interpersonal behavior, information sharing and promptness of care. Implementation can be improved through better provider training, patient feedback and monitoring mechanisms. Moreover, unless persisting structural challenges are addressed implementation of person-centered care in facilities will not be effective.

Factors influencing women's preference for health facility deliveries in Jharkhand state, India: a cross sectional analysis.

BACKGROUND: Expanding institutional deliveries is a policy priority to achieve MDG5. India adopted a policy to encourage facility births through a conditional cash incentive scheme, yet 28% of deliveries still occur at home. In this context, it is important to understand the care experience of women who have delivered at home, and also at health facilities, analyzing any differences, so that services can be improved to promote facility births. This study aims to understand women's experience of delivery care during home and facility births, and the factors that influence women's decisions regarding their next place of delivery. METHOD: A community-based cross-sectional survey was undertaken in a district of Jharkhand state in India. Interviews with 500 recently delivered women (210 delivered at facility and 290 delivered at home) included socio-demographic characteristics, experience of their recent delivery, and preference of future delivery site. Data analysis included frequencies, binary and multiple logistic regressions. RESULTS: There is no major difference in the experience of care between home and facility births, the only difference in care being with regard to pain relief through massage, injection and low cost of delivery for those having home births. 75% women wanted to deliver their next child at a facility, main reasons being availability of medicine (29.4%) and perceived health benefits for mother and baby (15%). Women with higher education (AOR = 1.67, 95% CI = 1.04-3.07), women who were above 25 years (AOR = 2.14, 95% CI = 1.26-3.64), who currently delivered at facility (AOR = 5.19, 95% CI = 2.97-9.08) and had health problem post-delivery (AOR = 1.85, 95% CI = 1.08-3.19) were significant predictors of future facility-based delivery. CONCLUSION: The predictors for facility deliveries include, availability of medicines and supplies, potential health benefits for the mother and newborn and the perception of good care from the providers. There is a growing preference for facility delivery particularly among women with higher age group, education, income and those who had antennal checkup. In order to uptake facility births, the quality improvement initiatives should regularly assess and address women's experiences of care.

Are village health sanitation and nutrition committees fulfilling their roles for decentralised health planning and action? A mixed methods study from rural eastern India.

BACKGROUND: In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community health forums, but there is little information about their composition, functioning and effectiveness. Our study examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of eastern India - West Singhbhum in Jharkhand and Kendujhar, in Odisha. METHODS: We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with purposively selected better and poorer performing committees, across the two states. We analysed the quantitative data using descriptive statistics and the qualitative data using a Framework approach. RESULTS: We found that VHSNCs comprised equitable representation from vulnerable groups when they were formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes. Less than 1 % members had received any training. Supervision of committees by district or block officials was rare. Their work focused largely on strengthening village sanitation, conducting health awareness activities, and supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers acted as conveners and record keepers. Links with the community involved awareness generation and community monitoring of VHSNC activities. Key challenges included irregular meetings, members' limited understanding of their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader health system. CONCLUSIONS: Our study suggests that VHSNCs perform few of their specified functions for decentralized planning and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need education, mobilisation and monitoring for formal links with the wider health system.

Out of pocket expenditure to deliver at public health facilities in India: a cross sectional analysis.

BACKGROUND: To expand access to safe deliveries, some developing countries have initiated demand-side financing schemes promoting institutional delivery. In the context of conditional cash incentive scheme and free maternity care in public health facilities in India, studies have highlighted high out of pocket expenditure (OOPE) of Indian families for delivery and maternity care. In this context the study assesses the components of OOPE that women incurred while accessing maternity care in public health facilities in Uttar Pradesh, India. It also assesses the determinants of OOPE and the level of maternal satisfaction while accessing care from these facilities. METHOD: It is a cross-sectional analysis of 558 recently delivered women who have delivered at four public health facilities in Uttar Pradesh, India. All OOPE related information was collected through interviews using structured pre-tested questionnaires. Frequencies, Mann-Whitney test and categorical regression were used for data reduction. RESULTS: The analysis showed that the median OOPE was INR 700 (US$ 11.48) which varied between INR 680 (US$ 11.15) for normal delivery and INR 970 (US$ 15.9) for complicated cases. Tips for getting services (consisting of gifts and tips for services) with a median value of INR 320 (US$ 5.25) contributed to the major share in OOPE. Women from households with income more than INR 4000 (US$ 65.57) per month, general castes, primi-gravida, complicated delivery and those not accompanied by community health workers incurred higher OOPE. The significant predictors for high OOPE were caste (General Vs. OBC, SC/ST), type of delivery (Complicated Vs. Normal), and presence of ASHA (No Vs. Yes). OOPE while accessing care for delivery was one among the least satisfactory items and 76 % women expressed their dissatisfaction. CONCLUSION: Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care.

Determinants of women's satisfaction with maternal health care: a review of literature from developing countries.

BACKGROUND: Developing countries account for 99 percent of maternal deaths annually. While increasing service availability and maintaining acceptable quality standards, it is important to assess maternal satisfaction with care in order to make it more responsive and culturally acceptable, ultimately leading to enhanced utilization and improved outcomes. At a time when global efforts to reduce maternal mortality have been stepped up, maternal satisfaction and its determinants also need to be addressed by developing country governments. This review seeks to identify determinants of women's satisfaction with maternity care in developing countries. METHODS: The review followed the methodology of systematic reviews. Public health and social science databases were searched. English articles covering antenatal, intrapartum or postpartum care, for either home or institutional deliveries, reporting maternal satisfaction from developing countries (World Bank list) were included, with no year limit. Out of 154 shortlisted abstracts, 54 were included and 100 excluded. Studies were extracted onto structured formats and analyzed using the narrative synthesis approach. RESULTS: Determinants of maternal satisfaction covered all dimensions of care across structure, process and outcome. Structural elements included good physical environment, cleanliness, and availability of adequate human resources, medicines and supplies. Process determinants included interpersonal behavior, privacy, promptness, cognitive care, perceived provider competency and emotional support. Outcome related determinants were health status of the mother and newborn. Access, cost, socio-economic status and reproductive history also influenced perceived maternal satisfaction. Process of care dominated the determinants of maternal satisfaction in developing countries. Interpersonal behavior was the most widely reported determinant, with the largest body of evidence generated around provider behavior in terms of courtesy and non-abuse. Other aspects of interpersonal behavior included therapeutic communication, staff confidence and competence and encouragement to laboring women. CONCLUSIONS: Quality improvement efforts in developing countries could focus on strengthening the process of care. Special attention is needed to improve interpersonal behavior, as evidence from the review points to the importance women attach to being treated respectfully, irrespective of socio-cultural or economic context. Further research on maternal satisfaction is required on home deliveries and relative strength of various determinants in influencing maternal satisfaction.

Participatory women's groups and counselling through home visits to improve child growth in rural eastern India: protocol for a cluster randomised controlled trial.

BACKGROUND: Child stunting (low height-for-age) is a marker of chronic undernutrition and predicts children's subsequent physical and cognitive development. Around one third of the world's stunted children live in India. Our study aims to assess the impact, cost-effectiveness, and scalability of a community intervention with a government-proposed community-based worker to improve growth in children under two in rural India. METHODS: The study is a cluster randomised controlled trial in two rural districts of Jharkhand and Odisha (eastern India). The intervention tested involves a community-based worker carrying out two activities: (a) one home visit to all pregnant women in the third trimester, followed by subsequent monthly home visits to all infants aged 0-24 months to support appropriate feeding, infection control, and care-giving; (b) a monthly women's group meeting using participatory learning and action to catalyse individual and community action for maternal and child health and nutrition. Both intervention and control clusters also receive an intervention to strengthen Village Health Sanitation and Nutrition Committees. The unit of randomisation is a purposively selected cluster of approximately 1000 population. A total of 120 geographical clusters covering an estimated population of 121,531 were randomised to two trial arms: 60 clusters in the intervention arm receive home visits, group meetings, and support to Village Health Sanitation and Nutrition Committees; 60 clusters in the control arm receive support to Committees only. The study participants are pregnant women identified in the third trimester of pregnancy and their children (n = 2520). Mothers and their children are followed up at seven time points: during pregnancy, within 72 hours of delivery, and at 3, 6, 9, 12 and 18 months after birth. The trial's primary outcome is children's mean length-for-age Z scores at 18 months. Secondary outcomes include wasting and underweight at all time points, birth weight, growth velocity, feeding, infection control, and care-giving practices. Additional qualitative and quantitative data are collected for process and economic evaluations. DISCUSSION: This trial will contribute to evidence on effective strategies to improve children's growth in India. TRIAL REGISTRATION: ISRCTN register 51505201 ; Clinical Trials Registry of India number 2014/06/004664.

"Neither we are satisfied nor they"-users and provider's perspective: a qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India.

BACKGROUND: Quality of care provided during childbirth is a critical determinant of preventing maternal mortality and morbidity. In the studies available, quality has been assessed either from the users' perspective or the providers'. The current study tries to bring both perspectives together to identify common key focus areas for quality improvement. This study aims to assess the users' (recently delivered women) and care providers' perceptions of care to understand the common challenges affecting provision of quality maternity care in public health facilities in India. METHODS: A qualitative design comprising of in-depth interviews of 24 recently delivered women from secondary care facilities and 16 health care providers in Uttar Pradesh, India. The data were analysed thematically to assess users' and providers' perspectives on the common themes. RESULTS: The common challenges experienced regarding provision of care were inadequate physical infrastructure, irregular supply of water, electricity, shortage of medicines, supplies, and gynaecologist and anaesthetist to manage complications, difficulty in maintaining privacy and lack of skill for post-delivery counselling. However, physical access, cleanliness, interpersonal behaviour, information sharing and out-of-pocket expenditure were concerns for only users. Similarly, providers raised poor management of referral cases, shortage of staff, non-functioning of blood bank, lack of incentives for work as their concerns. DISCUSSION: The study identified the common themes of care from both the perspectives, which have been foundrelevant in terms of challenges identified in many developing countries including India. The study framework identified new themes like management of emergencies in complicated cases, privacy and cost of care which both the group felt is relevant in the context of providing quality care during childbirth in low resource setting. The key challenges identified by both the groups can be prioritized, when developing quality improvement program in the health facilities. The identified components of care can match the supply with the demand for care and make the services truly responsive to user needs. CONCLUSION: The study highlights infrastructure, human resources, supplies and medicine as priority areas of quality improvement in the facility as perceived by both users and providers, nevertheless the interpersonal aspect of care primarily reported by the users must also not be ignored.

Developing a framework to review near-miss maternal morbidity in India: a structured review and key stakeholder analysis.

BACKGROUND: In India there is a thrust towards promoting institutional delivery, resulting in problems of overcrowding and compromise to quality of care. Review of near-miss obstetric events has been suggested to be useful to investigate health system functioning, complementing maternal death reviews. The aim of this project was to identify the key elements required for a near-miss review programme for India. METHODS: A structured review was conducted to identify methods used in assessing near-miss cases. The findings of the structured review were used to develop a suggested framework for conducting near-miss reviews in India. A pool of experts in near-miss review methods in low and middle income countries (LMICs) was identified for vetting the framework developed. Opinions were sought about the feasibility of implementing near-miss reviews in India, the processes to be followed, factors that made implementation successful and the associated challenges. A draft of the framework was revised based on the experts' opinions. RESULTS: Five broad methods of near-miss case review/audit were identified: Facility-based near-miss case review, confidential enquiries, criterion-based clinical audit, structured case review (South African Model) and home-based interviews. The opinion of the 11 stakeholders highlighted that the methods that a facility adopts should depend on the type and number of cases the facility handles, availability and maintenance of a good documentation system, and local leadership and commitment of staff. A proposed framework for conducting near-miss reviews was developed that included a combination of criterion-based clinical audit and near-miss review methods. CONCLUSION: The approach allowed for development of a framework for researchers and planners seeking to improve quality of maternal care not only at the facility level but also beyond, encompassing community health workers and referral. Further work is needed to evaluate the implementation of this framework to determine its efficacy in improving the quality of care and hence maternal and perinatal morbidity and mortality.

"Just as curry is needed to eat rice, antibiotics are needed to cure fever"-a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India.

OBJECTIVES: To understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West Bengal in India. DESIGN: Qualitative study using focus group discussions and in-depth interviews. SETTING: Two contrasting village clusters in South 24 Parganas district, West Bengal, India. Fieldwork was conducted between November 2019 and January 2020. PARTICIPANTS: 98 adult community members (42 men and 56 women) were selected purposively for 8 focus group discussions. In-depth interviews were conducted with 16 community key informants (7 teachers, 4 elected village representatives, 2 doctors and 3 social workers) and 14 community health workers. RESULTS: Significant themes at the individual level included sociodemographics (age, gender, education), cognitive factors (knowledge and perceptions of modern antibiotics within non-biomedical belief systems), affective influences (emotive interpretations of appropriate medicine consumption) and economic constraints (affordability of antibiotic courses and overall costs of care). Antibiotics were viewed as essential fever remedies, akin to antipyretics, with decisions to halt mid-course influenced by non-biomedical beliefs associating prolonged use with toxicity. Themes at the community and health system levels included the health stewardship roles of village leaders and knowledge brokering by informal providers, pharmacists and public sector accredited social health activists. However, these community resources lacked sufficient knowledge to address people's doubts and concerns. Qualified doctors were physically and socially inaccessible, creating a barrier to seeking their expertise. CONCLUSIONS: The interplay of sociodemographic, cognitive and affective factors, and economic constraints at the individual level, underscores the complexity of antibiotic usage. Additionally, community leaders and health workers emerge as crucial players, yet their knowledge gaps and lack of empowerment pose challenges in addressing public concerns. This comprehensive analysis highlights the need for targeted interventions that address both individual beliefs and community health dynamics to promote judicious antibiotic use.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review.

INTRODUCTION: Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms. METHODS: Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms. CONCLUSION: Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Community engagement to support COVID-19 vaccine uptake: a living systematic review protocol.

INTRODUCTION: Widespread vaccination against COVID-19 is one of the most effective ways to control, and ideally, end the global COVID-19 pandemic. Vaccine hesitancy and vaccine rates vary widely across countries and populations and are influenced by complex sociocultural, political, economic and psychological factors. Community engagement is an integral strategy within immunisation campaigns and has been shown to improve vaccine acceptance. As evidence on community engagement to support COVID-19 vaccine uptake is emerging and constantly changing, research that lessens the knowledge-to-practice gap by providing regular and up-to-date evidence on current best-practice is essential. METHODS AND ANALYSIS: A living systematic review will be conducted which includes an initial systematic review and bimonthly review updates. Searching and screening for the review and subsequent updates will be done in four streams: a systematic search of six databases, grey literature review, preprint review and citizen sourcing. The screening will be done by a minimum of two reviewers at title/abstract and full-text in Covidence, a systematic review management software. Data will be extracted across predefined fields in an excel spreadsheet that includes information about article characteristics, context and population, community engagement approaches, and outcomes. Synthesis will occur using the convergent integrated approach. We will explore the potential to quantitatively synthesise primary outcomes depending on heterogeneity of the studies. ETHICS AND DISSEMINATION: The initial review and subsequent bimonthly searches and their results will be disseminated transparently via open-access methods. Quarterly briefs will be shared on the reviews' social media platforms and across other interested networks and repositories. A dedicated web link will be created on the Community Health-Community of Practice site for sharing findings and obtaining feedback. A mailing list will be developed and interested parties can subscribe for updates. PROSPERO REGISTRATION NUMBER: CRD42022301996.

"There Is No Link Between Resource Allocation and Use of Local Data": A Qualitative Study of District-Based Health Decision-Making in West Bengal, India.

BACKGROUND: Effective coordination among multiple departments, including data-sharing, is needed for sound decision-making for health services. India has a district planning process involving departments for local resource-allocation based on shared data. This study assesses the decision-making process at the district level, with a focus on the extent of local data-use for resource allocation for maternal and child health. METHODS: Direct observations of key decision-making meetings and qualitative interviews with key informants were conducted in two districts in the State of West Bengal, India. Content analysis of the data maintained within the district health system was done to understand the types of data available and sharing mechanisms. This information was triangulated thematically based on WHO health system blocks. RESULTS: There was no structured decision-making process and only limited inter-departmental data-sharing. Data on all 21 issues discussed in the district decision-making meetings observed were available within the information systems. Yet indicators for only nine issues-such as institutional delivery and immunisation services were discussed. Discussions about infrastructure and supplies were not supported by data, and planning targets were not linked to health outcomes. CONCLUSION: Existing local data is highly under-used for decision-making at the district level. There is strong potential for better interaction between departments and better use of data for priority-setting, planning and follow-up.

Community engagement for COVID-19 prevention and control: a rapid evidence synthesis.

INTRODUCTION: Community engagement has been considered a fundamental component of past outbreaks, such as Ebola. However, there is concern over the lack of involvement of communities and 'bottom-up' approaches used within COVID-19 responses thus far. Identifying how community engagement approaches have been used in past epidemics may support more robust implementation within the COVID-19 response. METHODOLOGY: A rapid evidence review was conducted to identify how community engagement is used for infectious disease prevention and control during epidemics. Three databases were searched in addition to extensive snowballing for grey literature. Previous epidemics were limited to Ebola, Zika, SARS, Middle East respiratory syndromeand H1N1 since 2000. No restrictions were applied to study design or language. RESULTS: From 1112 references identified, 32 articles met our inclusion criteria, which detail 37 initiatives. Six main community engagement actors were identified: local leaders, community and faith-based organisations, community groups, health facility committees, individuals and key stakeholders. These worked on different functions: designing and planning, community entry and trust building, social and behaviour change communication, risk communication, surveillance and tracing, and logistics and administration. CONCLUSION: COVID-19's global presence and social transmission pathways require social and community responses. This may be particularly important to reach marginalised populations and to support equity-informed responses. Aligning previous community engagement experience with current COVID-19 community-based strategy recommendations highlights how communities can play important and active roles in prevention and control. Countries worldwide are encouraged to assess existing community engagement structures and use community engagement approaches to support contextually specific, acceptable and appropriate COVID-19 prevention and control measures.

Learning for Universal Health Coverage.

The journey to universal health coverage (UHC) is full of challenges, which to a great extent are specific to each country. 'Learning for UHC' is a central component of countries' health system strengthening agendas. Our group has been engaged for a decade in facilitating collective learning for UHC through a range of modalities at global, regional and national levels. We present some of our experience and draw lessons for countries and international actors interested in strengthening national systemic learning capacities for UHC. The main lesson is that with appropriate collective intelligence processes, digital tools and facilitation capacities, countries and international agencies can mobilise the many actors with knowledge relevant to the design, implementation and evaluation of UHC policies. However, really building learning health systems will take more time and commitment. Each country will have to invest substantively in developing its specific learning systemic capacities, with an active programme of work addressing supportive leadership, organisational culture and knowledge management processes.

Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India.

BACKGROUND: Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. METHODS: Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women's experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages-admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. RESULTS: Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care 'structure' and 'process'. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. CONCLUSIONS: The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.

Do women's perspectives of quality of care during childbirth match with those of providers? A qualitative study in Uttar Pradesh, India.

BACKGROUND: Persistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions. OBJECTIVE: This study aimed to examine pregnant women's expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider's perceptions of the same, as well as the barriers that limit their ability to provide high-quality care. METHODS: A qualitative descriptive analysis was conducted on data from two studies - focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women's experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016-17) to understand provision of person-centred care. Provider perspectives were matched with themes of women's perspectives on quality of childbirth care in facilities. RESULTS: Major themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries. CONCLUSIONS: This study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers' perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.

Advancing a conceptual model to improve maternal health quality: The Person-Centered Care Framework for Reproductive Health Equity.

Background: Globally, substantial health inequities exist with regard to maternal, newborn and reproductive health. Lack of access to good quality care-across its many dimensions-is a key factor driving these inequities. Significant global efforts have been made towards improving the quality of care within facilities for maternal and reproductive health. However, one critically overlooked aspect of quality improvement activities is person-centered care. Main body: The objective of this paper is to review existing literature and theories related to person-centered reproductive health care to develop a framework for improving the quality of reproductive health, particularly in low and middle-income countries. This paper proposes the Person-Centered Care Framework for Reproductive Health Equity, which describes three levels of interdependent contexts for women's reproductive health: societal and community determinants of health equity, women's health-seeking behaviors, and the quality of care within the walls of the facility. It lays out eight domains of person-centered care for maternal and reproductive health. Conclusions: Person-centered care has been shown to improve outcomes; yet, there is no consensus on definitions and measures in the area of women's reproductive health care. The proposed Framework reviews essential aspects of person-centered reproductive health care.

Effect of participatory women's groups and counselling through home visits on children's linear growth in rural eastern India (CARING trial): a cluster-randomised controlled trial.

BACKGROUND: Around 30% of the world's stunted children live in India. The Government of India has proposed a new cadre of community-based workers to improve nutrition in 200 districts. We aimed to find out the effect of such a worker carrying out home visits and participatory group meetings on children's linear growth. METHODS: We did a cluster-randomised controlled trial in two adjoining districts of Jharkhand and Odisha, India. 120 clusters (around 1000 people each) were randomly allocated to intervention or control using a lottery. Randomisation took place in July, 2013, and was stratified by district and number of hamlets per cluster (0, 1-2, or ≥3), resulting in six strata. In each intervention cluster, a worker carried out one home visit in the third trimester of pregnancy, monthly visits to children younger than 2 years to support feeding, hygiene, care, and stimulation, as well as monthly women's group meetings to promote individual and community action for nutrition. Participants were pregnant women identified and recruited in the study clusters and their children. We excluded stillbirths and neonatal deaths, infants whose mothers died, those with congenital abnormalities, multiple births, and mother and infant pairs who migrated out of the study area permanently during the trial period. Data collectors visited each woman in pregnancy, within 72 h of her baby's birth, and at 3, 6, 9, 12, and 18 months after birth. The primary outcome was children's length-for-age Z score at 18 months of age. Analyses were by intention to treat. Due to the nature of the intervention, participants and the intervention team were not masked to allocation. Data collectors and the data manager were masked to allocation. The trial is registered as ISCRTN (51505201) and with the Clinical Trials Registry of India (number 2014/06/004664). RESULTS: Between Oct 1, 2013, and Dec 31, 2015, we recruited 5781 pregnant women. 3001 infants were born to pregnant women recruited between Oct 1, 2013, and Feb 10, 2015, and were therefore eligible for follow-up (1460 assigned to intervention; 1541 assigned to control). Three groups of children could not be included in the final analysis: 147 migrated out of the study area (67 in intervention clusters; 80 in control clusters), 77 died after the neonatal period and before 18 months (31 in intervention clusters; 46 in control clusters), and seven had implausible length-for-age Z scores (<-5 SD; one in intervention cluster; six in control clusters). We measured 1253 (92%) of 1362 eligible children at 18 months in intervention clusters, and 1308 (92%) of 1415 eligible children in control clusters. Mean length-for-age Z score at 18 months was -2·31 (SD 1·12) in intervention clusters and -2·40 (SD 1·10) in control clusters (adjusted difference 0·107, 95% CI -0·011 to 0·226, p=0·08). The intervention did not significantly affect exclusive breastfeeding, timely introduction of complementary foods, morbidity, appropriate home care or care-seeking during childhood illnesses. In intervention clusters, more pregnant women and children attained minimum dietary diversity (adjusted odds ratio [aOR] for women 1·39, 95% CI 1·03-1·90; for children 1·47, 1·07-2·02), more mothers washed their hands before feeding children (5·23, 2·61-10·5), fewer children were underweight at 18 months (0·81, 0·66-0·99), and fewer infants died (0·63, 0·39-1·00). INTERPRETATION: Introduction of a new worker in areas with a high burden of undernutrition in rural eastern India did not significantly increase children's length. However, certain secondary outcomes such as self-reported dietary diversity and handwashing, as well as infant survival were improved. The interventions tested in this trial can be further optimised for use at scale, but substantial improvements in growth will require investment in nutrition-sensitive interventions, including clean water, sanitation, family planning, girls' education, and social safety nets. FUNDING: UK Medical Research Council, Wellcome Trust, UK Department for International Development (DFID).

Linkages between public and non-government sectors in healthcare: A case study from Uttar Pradesh, India.

Effective utilisation of collaborative non-governmental organisation (NGO)-public health system linkages in pluralistic health systems of developing countries can substantially improve equity and quality of services. This study explores level and types of linkages between public health sector and NGOs in Uttar Pradesh (UP), an underprivileged state of India, using a social science model for the first time. It also identifies gaps and challenges for effective linkage. Two NGOs were selected as case studies. Data collection included semi-structured in-depth interviews with senior staff and review of records and reporting formats. Formal linkages of NGOs with the public health system related to registration, participation in district level meetings, workforce linkages and sharing information on government-supported programmes. Challenges included limited data sharing, participation in planning and limited monitoring of regulatory compliances. Linkage between public health system and NGOs in UP was moderate, marked by frequent interaction and some reciprocity in information and resource flows, but weak participation in policy and planning. The type of linkage could be described as 'complementarity', entailing information and resource sharing but not joint action. Stronger linkage is required for sustained and systematic collaboration, with joint planning, implementation and evaluation.