Socioeconomic and geographic inequalities in antenatal and postnatal care components in India, 2016-2021.

Despite the well-known importance of high-quality care before and after delivery, not every mother and newborn in India receive appropriate antenatal and postnatal care (ANC/PNC). Using India's National Family Health Surveys (2015-2016 and 2019-2021), we quantified the socioeconomic and geographic inequalities in the utilization of ANC/PNC among women aged 15-49 years and their newborns (N = 161,225 in 2016; N = 150,611 in 2021). For each of the eighteen ANC/PNC components, we assessed absolute and relative inequalities by household wealth (poorest vs. richest), maternal education (no education vs. higher than secondary), and type of place of residence (rural vs. urban) and evaluated state-level heterogeneity. In 2021, the national prevalence of ANC/PNC components ranged from 19.8% for 8 + ANC visits to 91.6% for maternal weight measurement. Absolute inequalities were greatest for ultrasound test (33.3%-points by wealth, 30.3%-points by education) and 8 + ANC visits (13.2%-points by residence). Relative inequalities were greatest for 8 + ANC visits (1.8 ~ 4.4 times). All inequalities declined over time. State-specific estimates were overall consistent with national results. Socioeconomic and geographic inequalities in ANC/PNC varied significantly across components and by states. To optimize maternal and newborn health in India, future interventions should aim to achieve universal coverage of all ANC/PNC components.

Women's empowerment and child anthropometric failures across 28 sub-Saharan African countries: A cross-level interaction by Gender Inequality Index.

Background: Child undernutrition remains a major global health issue, particularly in sub-Saharan Africa (SSA). Given the important role mothers play in early childhood health and development, we examined how individual-level women's empowerment and country-level Gender Inequality Index (GII) are jointly related with child undernutrition in SSA. Methods: We pooled recent Demographic and Health Surveys from 28 SSA countries. For 137,699 children <5 years old, undernutrition was defined using anthropometric failures (stunting, underweight, wasting). Women's empowerment was assessed using three domains of Survey-based Women's EmPowERment (SWPER) index: attitude to violence, social independence, and decision-making; and country-level gender inequality was measured using GII from United Nations Development Programme. Three-level logistic regression was conducted to examine the joint associations of SWPER and GII as well as their interactions with child anthropometric failures, after adjusting for sociodemographic covariates. Results: Overall, 32.85% of children were stunted, 17.63% were underweight, and 6.68% had wasting. Children of mothers with low-level of empowerment for all domains of SWPER had higher odds of stunting (attitude to violence: OR=1.15; 95% CI, 1.11-1.19; social independence: OR=1.21; 95% CI, 1.17-1.25; decision-making: OR=1.16; 95% CI, 1.12-1.20), and consistent results were found for underweight and wasting. Independent of women's empowerment, country-level GII increased the probability of underweight (ranging ORs=1.46; 95% CI, 1.15-1.85 to 1.50; 95% CI, 1.18-1.90) and wasting (ranging ORs=1.56; 95% CI, 1.24-1.97 to 1.61; 95% CI, 1.27-2.03). Significant interaction was found between women's empowerment and country-level GII for stunting and underweight (p<0.05). Conclusions: In SSA countries with greater gender inequality, improving women's social independence and decision-making power in particular can reduce their children's risk of anthropometric failures. Policies and interventions targeted at strengthening women's empowerment should consider the degree of gender inequality in each country.

Progress on Sustainable Development Goal indicators in 707 districts of India: a quantitative mid-line assessment using the National Family Health Surveys, 2016 and 2021.

Background: India has committed itself to accomplishing the Sustainable Development Goals (SDGs) by 2030. Meeting these goals would require prioritizing and targeting specific areas within India. We provide a mid-line assessment of the progress across 707 districts of India for 33 SDG indicators related to health and social determinants of health. Methods: We used data collected on children and adults from two rounds of the National Family Health Survey (NFHS) conducted in 2016 and 2021. We identified 33 indicators that cover 9 of the 17 official SDGs. We used the goals and targets outlined by the Global Indicator Framework, Government of India and World Health Organization (WHO) to determine SDG targets to be met by 2030. Using precision-weighted multilevel models, we estimated district mean for 2016 and 2021, and using these values, computed the Annual Absolute Change (AAC) for each indicator. Using the AAC and targets, we classified India and each district as: Achieved-I, Achieved-II, On-Target and Off-Target. Further, when a district was Off-Target on a given indicator, we further identified the calendar year in which the target will be met post-2030. Findings: India is not On-Target for 19 of the 33 SDGs indicators. The critical Off-Target indicators include Access to Basic Services, Wasting and Overweight Children, Anaemia, Child Marriage, Partner Violence, Tobacco Use, and Modern Contraceptive Use. For these indicators, more than 75% of the districts were Off-Target. Because of a worsening trend observed between 2016 and 2021, and assuming no course correction occurs, many districts will never meet the targets on the SDGs even well after 2030. These Off-Target districts are concentrated in the states of Madhya Pradesh, Chhattisgarh, Jharkhand, Bihar, and Odisha. Finally, it does not appear that Aspirational Districts, on average, are performing better in meeting the SDG targets than other districts on majority of the indicators. Interpretation: A mid-line assessment of districts' progress on SDGs suggests an urgent need to increase the pace and momentum on four SDG goals: No Poverty (SDG 1), Zero Hunger (SDG 2), Good Health and Well-Being (SDG 3) and Gender Equality (SDG 5). Developing a strategic roadmap at this time will help India ensure success with regards to meeting the SDGs. India's emergence and sustenance as a leading economic power depends on meeting some of the more basic health and social determinants of health-related SDGs in an immediate and equitable manner. Funding: This work was funded by the Bill and Melinda Gates Foundation, INV-002992.