Stillbirth undercount in the sample registration system and national family health survey, India.

Objective: To assess the extent of under-reporting of stillbirths in India by comparing stillbirth and neonatal mortality rates from two national data sources and to review possible reasons for undercounting of stillbirths. Methods: We extracted data on stillbirth and neonatal mortality rates from the annual reports for 2016-2020 of the sample registration system, the Indian government's main source of vital statistics. We compared the data with estimates of stillbirth and neonatal mortality rates from the fifth round of the Indian national family health survey covering events from 2016-2021. We reviewed the questionnaires and manuals from both surveys and compared the sample registration system's verbal autopsy tool with other international tools. Findings: The stillbirth rate for India from the national family health survey (9.7 stillbirths per 1000 births; 95% confidence interval: 9.2-10.1) was 2.6 times higher than the average rate reported in the sample registration system over 2016-2020 (3.8 stillbirths per 1000 births). However, neonatal mortality rates in the two data sources were similar. We identified issues with the definition of stillbirth, documentation of gestation period, and categorization of miscarriages and abortions that could result in undercounting stillbirths in the sample registration system. In the national family health survey only one adverse pregnancy outcome is documented, irrespective of the number of adverse pregnancy outcomes in the given period. Conclusion: For India to attain its 2030 target of single-digit stillbirth rate and to monitor actions to end preventable stillbirths, efforts are needed to improve the documentation of stillbirths in its data collection systems.

Domestic violence in Indian women: lessons from nearly 20 years of surveillance.

BACKGROUND: Prevalence of self-reported domestic violence against women in India is high. This paper investigates the national and sub-national trends in domestic violence in India to prioritise prevention activities and to highlight the limitations to data quality for surveillance in India. METHODS: Data were extracted from annual reports of National Crimes Record Bureau (NCRB) under four domestic violence crime-headings-cruelty by husband or his relatives, dowry death, abetment to suicide, and protection of women against domestic violence act. Rate for each crime is reported per 100,000 women aged 15-49 years, for India and its states from 2001 to 2018. Data on persons arrested and legal status of the cases were extracted. RESULTS: Rate of reported cases of cruelty by husband or relatives in India was 28.3 (95% CI 28.1-28.5) in 2018, an increase of 53% from 2001. State-level variations in this rate ranged from 0.5 (95% CI  - 0.05 to 1.5) to 113.7 (95% CI 111.6-115.8) in 2018. Rate of reported dowry deaths and abetment to suicide was 2.0 (95% CI 2.0-2.0) and 1.4 (95% CI 1.4-1.4) in 2018 for India, respectively. Overall, a few states accounted for the temporal variation in these rates, with the reporting stagnant in most states over these years. The NCRB reporting system resulted in underreporting for certain crime-headings. The mean number of people arrested for these crimes had decreased over the period. Only 6.8% of the cases completed trials, with offenders convicted only in 15.5% cases in 2018. The NCRB data are available in heavily tabulated format with limited usage for intervention planning. The non-availability of individual level data in public domain limits exploration of patterns in domestic violence that could better inform policy actions to address domestic violence. CONCLUSIONS: Urgent actions are needed to improve the robustness of NCRB data and the range of information available on domestic violence cases to utilise these data to effectively address domestic violence against women in India.

Administrative data deficiencies plague understanding of the magnitude of rape-related crimes in Indian women and girls.

BACKGROUND: This paper investigates trends in rape-related crimes against women and girls reported in the Indian administrative data from 2001 to 2018 to assess the burden of crime, describe sub-national variations, and highlight data gaps to address sexual violence effectively in India. METHODS: Data on five rape-related crimes were extracted from the annual reports of National Crimes Record Bureau (NCRB), and included assault with the intent to outrage modesty of woman, rape, insult to the modesty of women, attempt to commit rape, and murder with rape/gang-rape. Rates for all categories combined, and for each crime were estimated for women and girls for India and its states. Trends for type of offender for rape, mean number of people arrested, and legal status of the cases was also assessed. RESULTS: The rate of all rape-related crime increased from 11.6 in 2001 to 19.8 in 2018 per 100,000 women and girls. Most of the 70.7% increase in rate between 2001 and 2018 was post 2012 following a gang-rape and murder case in India's capital. The largest proportion of crimes was recorded as assault with the intent to outrage modesty of the woman, followed by rape. The cited offender in rape cases was for the majority a close known person (44·3%) or other known person (43·1%). By the end of 2018, only 9·6% of the cases had completed trials, with acquittals in 73% cases. CONCLUSIONS: The wide variations in the yearly crime rates at state-level highlighted significant issues in data quality including under-reporting, non-comparability, possible bias in data reporting in NCRB, definition of rape-related crime in India, and access in reporting of crimes. Addressing barriers to reporting, improving quality and scope of administrative data recorded on sexual violence is urgently needed for India to meet SDG targets of eliminating all forms of violence against women and girls.

Risk profile for drowning deaths in children in the Indian state of Bihar: results from a population-based study.

BACKGROUND: We report on incidence of drowning deaths and related contextual factors in children from a population-based study in the Indian state of Bihar which estimated the causes of death using verbal autopsy (VA). METHODS: Interviews were conducted for deaths in 1-14 years population that occurred from January 2012 to March 2014 in 109 689 households (87.1% participation) in 1017 clusters representative of the state. The Population Health Metrics Research Consortium shortened VA questionnaire was used for interview and cause of death was assigned using the SmartVA automated algorithm. The annualised unintentional drowning death incidence, activity prior to drowning, the body of water where drowning death had occurred and contextual information are reported. FINDINGS: The survey covered 224 077 children aged 1-14 years. Drowning deaths accounted for 7.2%, 12.5% and 5.8% of all deaths in 1-4, 5-9 and 10-14 years age groups, respectively. The adjusted incidence of drowning deaths was 14.3 (95% CI 14.0 to 14.7) per 100 000 children, with it being higher in urban (16.1, 95% CI 14.8 to 17.3) areas. Nearly half of the children drowned in a river (5.9, 95% CI 5.6 to 6.1) followed by in a pond (2.8, 95% CI 2.6 to 2.9). Drowning death incidence was the highest while playing (5.1, 95% CI 4.9 to 5.4) and bathing (4.0, 95% CI 3.8 to 4.2) with the former accounting for more deaths in 1-4 years age group. Sixty per cent of children were already dead when found. None of these deaths were reported to the civil registration system to obtain death certificate. INTERPRETATION: The findings from this large representative sample of children document the magnitude of and variations in unintentional drowning deaths in Bihar. Urgent targeted drowning interventions are needed to address the risk in children. Gross under-reporting of drowning deaths in children in India needs attention.

Identification of factors associated with stillbirth in the Indian state of Bihar using verbal autopsy: A population-based study.

BACKGROUND: India was estimated to have the largest numbers of stillbirths globally in 2015, and the Indian government has adopted a target of <10 stillbirths per 1,000 births by 2030 through the India Newborn Action Plan (INAP). The objective of this study was to use verbal autopsy interviews to examine factors associated with stillbirth in the Indian state of Bihar and make recommendations for the INAP to better inform the setting of priorities and actions to reduce stillbirths. METHODS AND FINDINGS: Verbal autopsy interviews were conducted for deaths including stillbirths that occurred from January 2011 to March 2014 in a sample of 109,689 households (87.1% participation) in 1,017 clusters representative of the state of Bihar. The Population Health Metrics Research Consortium shortened verbal autopsy questionnaire was used for each interview, and cause of death was assigned using the SmartVA automated algorithm. A stillbirth was defined as a foetal death with a gestation period of ≥28 weeks wherein the foetus did not show any sign of life. We report on the stillbirth epidemiology and present case studies from the qualitative data on the health provider interface that can be used to improve success of improved, skilled care at birth and delivery interventions. The annualised stillbirth incidence was 21.2 (95% CI 19.7 to 22.6) per 1,000 births, with it being higher in the rural areas. A total of 1,132 stillbirths were identified; 686 (62.2%) were boys, 327 (29.7%) were firstborn, and 760 (68.9%) were delivered at a health facility. Of all the stillbirths, 54.5% were estimated to be antepartum. Only 6,161 (55.9%) of the women reported at least 1 antenatal care visit, and 33% of the women reported not consuming the iron folic acid tablets during pregnancy. Significant differences were seen in delivery-related variables and associated maternal conditions based on the place of delivery and type of stillbirth. Only 6.1% of the women reported having undergone a test to rule out syphilis. For 34.2% of the stillbirths, the possible risk factor for stillbirth was unexplained. For the remaining 65.8% of the women who reported at least 1 complication during the last 3 months of pregnancy, maternal conditions including anaemia, fever during labour, and hypertension accounted for most of the complications. Of importance to note is that the maternal conditions overlapped quite significantly with the other possible underlying risk factors for stillbirth. Obstetrics complications and excessive bleeding during delivery contributed to nearly 30% of the cases as a possible risk factor for stillbirth, highlighting the need for better skilled care during delivery. Of the 5 major themes identified in open narratives, 3 were related to healthcare providers-lack of timely attention, poor skills (knowledge or implementation), and reluctance to deliver a dead baby. The case studies document the circumstances that highlight breakdowns in clinical care around the delivery or missed opportunities that can be used for improving the provision of quality skilled care. The main limitation of these data is that stillbirth is defined based on the gestation period and not based on birth weight; however, this is done in several studies from developing country settings in which birthweight is either not available or accurate. CONCLUSIONS: To our knowledge, this study is among the few large, population-based assessments of stillbirths using verbal autopsy at the state level in India. These findings provide detailed insight into investigating the possible risk factors for stillbirths, as well as insight into the ground-level changes that are needed within the health system to design and implement effective preventive and intervention policies to reduce the burden of stillbirths. As most of the stillbirths are preventable with high-quality, evidence-based interventions delivered before and during pregnancy and during labour and childbirth, it is imperative that with INAP in place, India aspires to document stillbirths in a systematic and standardised manner to bridge the knowledge gap for appropriate actions to reduce stillbirths. We have made several recommendations based on our study that could further strengthen the INAP approach to improve the quality and quantity of stillbirth data to avoid this needless loss of lives.

Fracture Strength of Tooth Roots Following Canal Preparation by Three Rotary File Systems: An In Vitro Study.

BACKGROUND: Since the beginning of modern endodontics, there have been many concepts, strategies, and techniques for root canal preparation. A mind-boggling variety of files have developed for negotiating and shaping them throughout the years. Today's most secure, most effective, and simplest file system combines the most reliable design elements of the past with the latest technological advances to create the most effective file system. So, the need for the study is to evaluate the fracture strength of tooth roots following canal preparation by three rotary file systems: ProTaper Universal file system (Dentsply, USA), ProTaper Next file system (Dentsply Sirona USA), and Neolix A1 nickel-titanium (NiTi) file system (Orikam Healthcare India Pvt Ltd., New Delhi, India). METHOD: Ninety human mandibular molars were selected for the study. Inclusion criteria include human mandibular first and second molars and teeth removed for routine clinical reasons, and intact apices were selected, excluding cases with root surface caries, root surface fissures, teeth with immature root apex, mesial canal fusion, extremely short roots, thin roots, or curved roots. All teeth were preserved in a solution of 10% neutral buffered formalin for two weeks and then transferred to distilled water for examination. The teeth were randomly divided into three groups. Access cavities were created, and working lengths were determined. Groups 1, 2, and 3 underwent shaping using ProTaper Universal, ProTaper Next, and Neolix A1 (NiTi) file systems, respectively, following guidelines. Canals were irrigated with sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA) and were obturated up to the mid-root region with AH Plus sealer. To facilitate fracture testing, obturation was performed to distribute the load from the spreader to the canal wall. The EndoSequence and Quick-Fill obturation system were utilized to fill the apical half of the canal with gutta-percha material. After obturation, the distal root of each tooth was cut, while the mesial root was securely positioned in a putty material. A universal testing machine was employed for the fracture tests, operating at a cross-head speed of 1 mm/min. The machine was equipped with a D11 hand spreader tip, which was inserted into the root canal to make contact with the gutta-percha. Gradual force was applied to the root canal until a fracture occurred, at which point the force application was stopped. The amount of force required to cause the fracture was measured in newtons. Data were collected and recorded using IBM SPSS Statistics for Windows, Version 17.0 (Released 2008; IBM Corp., Armonk, New York, United States) and then transferred to Microsoft Excel for analysis. Descriptive statistics, mean, and standard deviation were used for continuous data. The fracture resistance of dental roots treated with three types of files was compared using a one-way ANOVA. Graphs were generated using Excel and Word. A significance level of p<0.01 was chosen. RESULT: ANOVA indicated significant differences in mean fracture resistance: Neolix A1 (NiTi) (95.3 N) > NEXT (91.0 N) > universal (86.6 N), with a p-value of 0.004 (<0.001), confirming statistical significance. CONCLUSION: The study concludes that the canal instrumented with Neolix A1 (NiTi) exhibits higher fracture resistance after canal instrumentation compared to ProTaper Next and ProTaper Universal.

Sociodemographic characteristics of women who died by suicide in India from 2014 to 2020: findings from surveillance data.

BACKGROUND: Women in India have twice the suicide death rate (SDR) compared with the global average for women. The aim of this study is to present a systematic understanding of sociodemographic risk factors, reasons for suicide deaths, and methods of suicide among women in India at the state level over time. METHODS: Administrative data on suicide deaths among women by education level, marital status, and occupation, and reason for and method of suicide were extracted from the National Crimes Record Bureau reports for years 2014 to 2020. We extrapolated SDR at the population level for Indian women by education, marital status, and occupation to understand the sociodemography of these suicide deaths for India and its states. We reported the reasons for and methods of suicide deaths among Indian women at the state level over this period. FINDINGS: SDR was higher among women with education of class 6 or more (10·2; 95% CI 10·1-10·4) than those with no education (3·8; 3·7-3·9) or education until class 5 (5·4; 5·2-5·5) in India in 2020, with similar patterns in most states. SDR declined between 2014 and 2020 for women with education until class 5. Women currently married accounted for 28 085 (63·1%) of 44 498 suicide deaths in India, 8336 (56·2%) of 14 840 in less developed states, and 19 661 (66·9%) of 29 407 in more developed states in 2020. For India, women currently married had a significantly higher SDR (8·1; 8·0-8·2) than those never married in 2014. However, women who never married had a significantly higher SDR (8·4; 8·2-8·5) in 2020 than those who were currently married. Many individual states in 2020 had similar SDR for women who never married and those who are currently married. Housewife as an occupation accounted for 50% or more of suicide deaths from 2014 to 2020 in India and its states. Family problems was the most common reason for suicide from 2014 to 2020, accounting for 16 140 (36·3%) of 44 498 suicide deaths in India, 5268 (35·5%) of 14 840 in less developed states, and 10 803 (36·7%) of 29 407 in more developed states in 2020. Hanging was the leading mean of suicide from 2014 to 2020. Insecticide or poison consumption was the second leading cause of suicide, accounting for 2228 (15·0%) of all 14 840 suicide deaths in less developed states and 5753 (19·6%) of 29 407 in more developed states, with a near 70·0% increase in the use of this method from 2014 to 2020. INTERPRETATION: The higher SDR among women who have received an education, similar SDR between women currently married and never married, and variations in the reasons for and means of suicide at the state level highlight the need to incorporate sociological insights into how the external social environment can matter for women to better understand the complexity of suicide and determine how to effectively intervene. FUNDING: Bill & Melinda Gates Foundation.

Implications of the availability and distribution of birth weight on addressing neonatal mortality: population-based assessment from Bihar state of India.

OBJECTIVE: A large proportion of neonatal deaths in India are attributable to low birth weight (LBW). We report population-based distribution and determinants of birth weight in Bihar state, and on the perceptions about birth weight among carers. DESIGN: A cross-sectional household survey in a state representative sample of 6007 live births born in 2018-2019. Mothers provided detailed interviews on sociodemographic characteristics and birth weight, and their perceptions on LBW (birth weight <2500 g). We report on birth weight availability, LBW prevalence, neonatal mortality rate (NMR) by birth weight and perceptions of mothers on LBW implications. SETTING: Bihar state, India. PARTICIPANTS: Women with live birth between October 2018 and September 2019. RESULTS: A total of 5021 (83.5%) live births participated, and 3939 (78.4%) were weighed at birth. LBW prevalence among those with available birth weight was 18.4% (95% CI 17.1 to 19.7). Majority (87.5%) of the live births born at home were not weighed at birth. LBW prevalence decreased and birth weight ≥2500 g increased significantly with increasing wealth index quartile. NMR was significantly higher in live births weighing <1500 g (11.3%; 95% CI 5.1 to 23.1) and 1500-1999 g (8.0%; 95% CI 4.6 to 13.6) than those weighing ≥2500 g (1.3%, 95% CI 0.9 to 1.7). Assuming proportional correspondence of LBW and NMR in live births with and without birth weight, the estimated LBW among those without birth weight was 35.5% (95% CI 33.0 to 38.0) and among all live births irrespective of birth weight availability was 23.0% (95% CI 21.9 to 24.2). 70% of mothers considered LBW to be a sign of sickness, 59.5% perceived it as a risk of developing other illnesses and 8.6% as having an increased probability of death. CONCLUSIONS: Missing birth weight is substantially compromising the planning of interventions to address LBW at the population-level. Variations of LBW by place of delivery and sociodemographic indicators, and the perceptions of carers about LBW can facilitate appropriate actions to address LBW and the associated neonatal mortality.

India's disability estimates: Limitations and way forward.

BACKGROUND: With India preparing for the next decennial Census in 2021, we compared the disability estimates and data collection methodology between the Census 2011 and the most recent population-level survey for India and its states, to highlight the issues to be addressed to improve robustness of the disability estimates in the upcoming Census. METHODS: Data from the Census 2011 and from two complementary nationally representative household surveys that covered all Indian states with the same methodology and survey instruments-the District-Level Household Survey-4 (DLHS-4, 2012-2013) and the Annual Health Surveys (AHS three rounds, 2010-11, 2011-12 and 2012-13) were used. Data from DLHS-4 and AHS 2012-13 round were pooled to generate estimates for the year 2012-13. Data collection methodology between the sources was compared, including the review of definitions of each type of disability. The overall, mental, visual, hearing, speech, and movement disability rate (DR) per 100,000 population were compared between the sources for India and for each state, and the percent difference in the respective rates was calculated. We explored the reliability of these estimates comparing yearly data from the AHS for three successive rounds. RESULTS: Survey data were collected through proxy reporting, however, it is not entirely clear whether the data were proxy- or self-reported or a mix of both in the Census. The overall DR was 25.1% higher in the Census (2,242; 95% CI 2,241-2,243) than the survey (1,791; 95% CI 1,786-1,797) per 100,000 population, with the state-level difference ranging from -64% in Tamil Nadu to 107% in Sikkim state. Despite both sources using nearly similar definitions for overall disability and disability by type, the difference in DR was 125.5%, 54.2%, -25.7%, -19.7%, and 21.9% for hearing, speech, mental, movement, and visual DR, respectively. At the state-level, the difference in disability-specific estimates ranged from -84% to 450%. The extent of variations in the disability-specific estimates in AHS successive rounds ranged from -25% to 929% at the state-level. CONCLUSIONS: There is momentum globally towards building disability measurement that is consistent with the data required for monitoring of the Sustainable Development Goals to ensure robust estimation of disability. The current estimates from the Census and surveys seem much lower than would be expected at the population level. We make recommendations that India needs to take serious note of in order to improve the validity and reliability of India's disability estimates.

Mortality due to snakebite and other venomous animals in the Indian state of Bihar: Findings from a representative mortality study.

BACKGROUND: Animal bites and stings contribute significantly to mortality in certain parts of the world. India accounts for the highest number of snakebites and related mortality globally. We report on mortality due to bite or sting of a venomous animal from a population-based study in the Indian state of Bihar which estimated the causes of death using verbal autopsy. METHODOLOGY/PRINCIPAL FINDINGS: Interviews were conducted for all deaths that occurred from January 2012 to March 2014 in 109,689 households (87.1% participation) covering 627,658 population in 1,017 clusters representative of the state using the Population Health Metrics Research Consortium shortened verbal autopsy questionnaire. Cause of death was assigned using the SmartVA automated algorithm. The annualized mortality rate per 100,000 population due to snakebite, scorpion sting and other animals adjusted for age, sex and urban-rural population distribution of the state; and detailed contextual information on snakebites are reported. Deaths due to bite/sting of a venomous animal accounted for 10.7% of all deaths due to unintentional injuries, with an adjusted mortality rate of 6.2 (95% CI 6.0-6.3) per 100,000 population. The adjusted snakebite mortality rate was 4.4 (95% CI 4.3-4.6) which was significantly higher in the rural areas (4.8, 95% CI 4.7-5.0) and in females (5.5, 95% CI 5.3-5.7). Snakebites accounted for 7.6% of all unintentional injury deaths across all ages but for 33.3% of the deaths in 10-14 years age group. A similar proportion of snakebite deaths occurred while sleeping (30.2%), playing (30.2%) and during field/outdoor activities (27.9%). In these cases, 8.2% people were already dead when found, 34.7% had died before treatment could be provided, and 28 (57.1%) had died post treatment among whom 46.4% had sought treatment at a health facility, 25% with a traditional healer, and the rest from both. Death before reaching a health provider, non-availability of medicines or doctor, referral patterns, and sex-differentials in the context of snakebite deaths are reported. None of the verbatim specifically mentioned anti-venom being used for treatment. The adjusted mortality rate for scorpion sting was 0.9 (95% CI 0.8-0.9). CONCLUSIONS: The findings from this large representative sample documents the magnitude of snakebite mortality in Bihar and highlight the circumstances surrounding the snakebite events that could facilitate prevention and intervention opportunities.