An integrated nutrition and health program package on IYCN improves breastfeeding but not complementary feeding and nutritional status in rural northern India: A quasi-experimental randomized longitudinal study.

BACKGROUND: Undernutrition below two years of age remains a major public health problem in India. We conducted an evaluation of an integrated nutrition and health program that aimed to improve nutritional status of young children by improving breast and complementary feeding practices over that offered by the Government of India's standard nutrition and health care program. METHODS: In Uttar Pradesh state, through multi-stage cluster random sampling, 81 villages in an intervention district and 84 villages in a comparison district were selected. A cohort of 957 third trimester pregnant women identified during house-to-house surveys was enrolled and, following childbirth, mother-child dyads were followed every three months from birth to 18 months of age. The primary outcomes were improvements in weight-for-age and length-for-age z scores, with improved breastfeeding and complementary feeding practices as intermediate outcomes. FINDINGS: Optimal breastfeeding practices were higher among women in intervention than comparison areas, including initiating breastfeeding within one hour of delivery (17.4% vs. 2.7%, p<0.001), feeding colostrum (34.7% vs. 8.4%, p<0.001), avoiding pre-lacteals (19.6% vs. 2.1%, p<0.001) and exclusively breastfeeding up to 6 months (24.1% vs. 15.3%, p = 0.001). However, differences were few and mixed between study arms with respect to complementary feeding practices. The mean weight-for-age z-score was higher at 9 months (-2.1 vs. -2.4, p = 0.0026) and the prevalence of underweight status was lower at 12 months (58.5% vs. 69.3%, p = 0.047) among intervention children. The prevalence of stunting was similar between study arms at all ages. Coefficients to show the differences between the intervention and comparison districts (0.13 cm/mo) suggested significant faster linear growth among intervention district infants at earlier ages (0-5 months). INTERPRETATION: Mothers participating in the intervention district were more likely to follow optimal breast, although not complementary feeding practices. The program modestly improved linear growth in earlier age and weight gain in late infancy. Comprehensive nutrition and health interventions are complex; the implementation strategies need careful examination to improve feeding practices and thus impact growth. TRIAL REGISTRATION: The trial was registered with ClinicalTrials.gov, NCT00198835.

Clean cord care practices and neonatal mortality: evidence from rural Uttar Pradesh, India.

BACKGROUND: About a million newborns die each year in India, accounting for about a fourth of total global neonatal deaths. Infections are among the leading causes of neonatal mortality. Care practices immediately following delivery contribute to newborns' risk of infection and mortality. OBJECTIVES: This study examined the association between clean cord care practices and neonatal mortality in rural Uttar Pradesh, India. METHODS: The study used data from a household survey conducted to evaluate a community-based intervention program in two districts of Uttar Pradesh, India. Analysis included data from 5741 singleton live births delivered at home during 2005. The association between clean cord care (clean instrument used to cut cord, clean thread used to tie cord and antiseptics or nothing applied to the cord) and neonatal mortality was estimated using multivariate logistic regression models. RESULTS: Thirty per cent of the study mothers practiced clean cord care. Neonatal mortality rate was significantly lower among newborns exposed to clean cord care (36.5/1000 live births, 95% CI 28.0 to 46.8) than those who did not practice (53.0/1000 live births, 95% CI 46.1 to 60.6). Clean cord care was associated with 37% lower neonatal mortality (OR=0.63; 95% CI 0.46 to 0.87) after adjusting for mother's age, education, caste/tribe, religion, household wealth, newborn thermal care practice and care-seeking during the first week after birth and study arms. CONCLUSIONS: Promoting clean cord care practice among neonates in community-based maternal and newborn care programs has the potential to improve neonatal survival in rural India and similar other settings.

Utilization and perceptions of neonatal healthcare providers in rural Uttar Pradesh, India.

OBJECTIVE: To describe the utilization and perceptions of existing neonatal health services in rural Uttar Pradesh, India. DESIGN: A prospective observational study. SETTING: The study was located in Shivgarh, a rural block of Uttar Pradesh, India. PARTICIPANTS: One hundred and fifty-three households that utilized a healthcare provider for their sick neonates. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Perceived neonatal health improvement after utilization of neonatal health services; satisfaction with aspects of neonatal health services: 'overall care', 'interaction with provider', 'waiting time' and 'explanations of immediate care and follow-up care'. RESULTS: Unqualified allopathically oriented providers (UAOPs) were utilized by 110 households (71.8%), while qualified allopathically oriented providers (QAOPs) by 43 households (28.2%). The odds of perceived neonatal health improvement were significantly higher among households utilizing UAOPs (n = 88/110, 80.0%) than those using QAOPs (n = 23/43, 53.5%) [adjusted odds ratio (OR): 3.3, 95% confidence interval (CI): 1.5-7.5]. The median healthcare fee charged was higher for UAOPs (Rs. 25) than those for QAOPs (Rs. 1). Household satisfaction with 'overall care' of neonatal health service was significantly higher among households that utilized UAOPs compared with those that used QAOPs (OR: 2.4, 95% CI: 1.2-5.0). CONCLUSION: Households that utilized UAOPs reported better perceived neonatal health outcomes and higher satisfaction levels than those that used QAOPs, despite higher costs for the former. Future research should assess what dimensions of neonatal care are important to households and identify incentive structures that promote healthcare providers to deliver better perceived care in high-mortality settings such as rural Uttar Pradesh, India.

Neonatal health program management in a resource-constrained setting in rural Uttar Pradesh, India.

This analysis identifies salient features of team management that were critical to the efficiency of program implementation and the effectiveness of behavior change management to promote essential newborn care practices in Uttar Pradesh, India. In May 2003, the Johns Hopkins Bloomberg School of Public Health and King George Medical University initiated a cluster-randomized, controlled neonatal health research program. In less than 2 years, the trial demonstrated rapid adoption of several evidence-based newborn care practices and a substantial reduction in neonatal mortality in intervention clusters. Existing literature involving research program management in resource-constrained areas of developing countries is limited and fails to provide models for team organization and empowerment. The neonatal research project examined in this paper developed a unique management strategy that provides an effective blueprint for future projects. Transferable learning points from the project include emphasizing a common vision, utilizing a live-in field site office, prioritizing character and potential in the hiring process, implementing a learning-by-doing training program, creating tiers of staff recognition, encouraging staff autonomy, ensuring a broad staff knowledge base to seamlessly handle absences, and maintaining the flexibility to change partnerships or strategies.

NGO facilitation of a government community-based maternal and neonatal health programme in rural India: improvements in equity.

Socio-economic disparities in health have been well documented around the world. This study examines whether NGO facilitation of the government's community-based health programme improved the equity of maternal and newborn health in rural Uttar Pradesh, India. A quasi-experimental study design included one intervention district and one comparison district of rural Uttar Pradesh. A household survey conducted between January and June 2003 established baseline rates of programme coverage, maternal and newborn care practices, and health care utilization during 2001-02. An endline household survey was conducted after 30 months of programme implementation between January and March 2006 to measure the same indicators during 2004-05. The changes in the indicators from baseline to endline in the intervention and comparison districts were calculated by socio-economic quintiles, and concentration indices were constructed to measure the equity of programme indicators. The equity of programme coverage and antenatal and newborn care practices improved from baseline to endline in the intervention district while showing little change in the comparison district. Equity in health care utilization for mothers and newborns also showed some improvements in the intervention district, but notable socio-economic differentials remained, with the poor demonstrating less ability to access health services. NGO facilitation of government programmes is a feasible strategy to improve equity of maternal and neonatal health programmes. Improvements in equity were most pronounced for household practices, and inequities were still apparent in health care utilization. Furthermore, overall programme coverage remained low, limiting the ability to address equity. Programmes need to identify and address barriers to universal coverage and care utilization, particularly in the poorest segments of the population.