Predictors of contraceptive use among young married women in India: Does pregnancy history matter?

AIM: Contraceptive use and its correlates among young women continue to draw research attention due to its implication for fertility reduction, improved maternal and child health, and sexual and reproductive rights. This study explores the association between pregnancy history and contraceptive use among currently married young women (aged 15-24 years at childbirth) in India. METHOD: Data from the National Family Health Survey (2019-2021) was analyzed through STATA with a significance level of 5%. The births in the last 5 years preceding the survey to the women aged 15-24 years at childbirth (n = 127 954) were considered for analysis. Multinomial logistic regression was used to check the unadjusted and adjusted effects of the pregnancy history on contraceptive use. RESULTS: Young women with a history of mistimed pregnancy had significantly lower odds of using modern limiting methods of contraception (odds ratio [OR] = 0.90, confidence interval [CI] = 0.82-0.98), and those with a prior unwanted pregnancy were more likely to use modern limiting methods of contraception (OR = 1.75, CI = 1.57-1.95). CONCLUSION: Pregnancy history influences young married women's current contraceptive use in India. Family planning programs may use the contacts with antenatal, delivery, and post-delivery care system as an opportunity to identify women with an unwanted pregnancy, especially those educationally and economically weaker, for targeted information and service delivery. Better counseling of potential young contraceptive acceptors will ensure informed decision-making and increased use of modern spacing methods.

SS18-SSX Expression and Clinicopathologic Profiles in a Contemporary Cohort of Primary Paratesticular Synovial Sarcoma: A Series of Fourteen Patients.

Synovial sarcoma (SS) is a rare genitourinary malignancy with a specific SS18::SSX 1/2 gene fusion in majority of the instances. The paratesticular location of this neoplasm is extremely rare and only 4 cases are reported in the literature. Herein, we describe the clinicopathologic features and molecular profile of paratesticular SS in the largest case series to date and to the best of our knowledge, and the only series to use novel SS18-SSX antibody for immunohistochemistry. Clinicopathologic, immunohistochemical (IHC), molecular, treatment, and follow-up data of the patients were analyzed. There were 14 patients, ranging from 15 to 47 years (mean: 30 y). The tumor size ranged from 4​​​​​​ to 15 cm. The tumors were unilateral, solid, and homogeneous tan-white with monomorphic spindle cell histology. All 14 tumors expressed SS18-SSX and TLE1 IHC and harbored SS18 rearrangement. In addition, the tumor with multifocal SS18-SSX expression had lower break-apart signals in the FISH assay (38% of the tumor cells; range: 29% to 85%). Radical orchiectomy was performed in all 14 patients and adjuvant chemotherapy was administered in 9 patients. Follow-up was available in 9 patients. The follow-up duration ranged from 5 to 24 months (median=10 mo). Four patients died of metastatic disease (range: 5 to 16 mo) and 2 patients who are alive had metastatic disease at the last follow-up. Based on our experience with the largest series to date and aggregate of the published data, paratesticular SS has a poor prognosis despite aggressive therapy. Owing to its rarity, the differential diagnosis is wide and requires a systematic approach for ruling out key morphologic mimics aided with SS18-SSX IHC and molecular confirmation because this distinction carries important therapeutic and prognostic implications. Due to the excellent concordance of SS18-SSX IHC results with FISH results as observed in our study, we would like to suggest inclusion of SS18-SSX in the diagnostic immunohistochemistry panel of all spindle cell sarcomas where synovial sarcoma is considered as a morphologic differential. SS18-SSX-positive staining may be used as a surrogate for FISH assay in a resource-limited setting where molecular assay is not available. Furthermore, IHC has a fairly shorter turn-around-time, is less complex, and of low cost.

Preputial/penile skin flap, as a dorsal onlay or tubularized flap: a versatile substitute for complex anterior urethral stricture.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? For long complex anterior urethral stricture augmentation urethroplasty is considered the standard procedure but the best substitute material is still to be ascertained. Preputial/penile skin is a very good substitute especially when used as a dorsal onlay. It demonstrates exceptional functional and cosmetic results even in patients with unsuitable oral mucosa. OBJECTIVE: • To present our experience of single-stage reconstruction of urethral stricture with preputial/penile skin flap, as a dorsal onlay flap (DOF) where there is an adequate urethral plate and as a tubularized flap (TF) where there is a compromised urethral plate, in cases of complex anterior urethral strictures. MATERIALS AND METHODS: • We retrospectively reviewed 144 patients, who underwent single-stage repair of pendular /bulbar urethral strictures with preputial/penile flap as either a DOF or a TF, between January 2001 and December 2008. • Patients were divided into three groups: Group 1 consisted of patients who underwent transverse preputial DOF; Group 2 consisted of those who underwent tube urethroplasty; and Group 3 consisted of those patients who were circumcised and for whom the penile skin was used as a DOF (circumpenile flap). • Patients were followed up by physical examination, retrograde urethrography, uroflowmetry and post-void residual urine measurement. RESULTS: • The mean follow-up was 40.1 months (range 36-84 months). • The primary success rates at 1 year follow-up were 90, 85 and 93.3% for Groups1, 2 and 3, respectively, and at 3-years follow-up they were 85, 75 and 86.7%, respectively. • Half of the recurrences were successfully managed with a single visual internal urethrotomy or dilatation. • The secondary success rate was defined as recurrent stricture managed by a single endoscopic procedure and was 5, 10 and 6.8% in Groups 1, 2 and 3, respectively. The overall success rate was 90.85 and 93.3%, respectively. • A total of 75% of the patients in the study completed 60 months of follow-up with no additional recurrence. CONCLUSIONS: • A preputial/penile flap for complex anterior urethral stricture is a good treatment option, with results similar to other techniques, has acceptable donor site morbidity and is effective even in circumcised patients and for those patients with unsuitable oral mucosa. • A DOF is less likely to lead to diverticula formation and post-void dribbling. TFs have a higher failure rate than DOFs but, when combined judiciously with secondary endoscopic procedures, can provide good results.

Bone densitometric assessment and management of fracture risk in Indian men of prostate cancer on androgen deprivation therapy: Does practice pattern match the guidelines?

OBJECTIVE: Estimation of baseline bone mineral density (BMD) at the time of instituting androgen deprivation therapy (ADT) for metastatic prostate cancer is recommended by several specialty groups and expert panels. The present study was carried out to analyze the practice pattern of Indian urologists with regard to bone densitometric assessment and management of fracture risk in men of prostate cancer on ADT, and their degree of adherence to currently available guidelines. MATERIALS AND METHODS: Telephonic interviews of 108 qualified urologists, randomly selected from the member database of Urological Society of India was carried out with a predefined questionnaire. The responses were analyzed and compared with the available evidences and recommendations. RESULTS: Only 19.4% urologists routinely perform a baseline BMD before starting ADT. Although majority of them prescribe calcium and vitamin D supplementation, only few tell regarding fracture risk and life-style modification to their patients. While 59.6% of the respondents use Zoledronic acid (ZA) in their patients on ADT, half of them prescribe it without knowing the BMD status, which may lead to overuse of ZA. CONCLUSION: Majority of the urologists in India do not follow the guidelines for BMD measurement in prostate cancer. A baseline BMD may help in reducing the unnecessary use of ZA.

Reappraisal of HER2 Amplification in High-Grade Urothelial Carcinoma Based on 2018 ASCO/CAP Clinical Practice Guidelines.

OBJECTIVES: To examine and compare human epidermal growth factor receptor 2 (HER2) amplification status in high-grade urothelial carcinoma (HGUCa), using both 2013 and 2018 HER2 reporting guidelines for breast carcinoma from the American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP). METHODS: HER2 status by fluorescence in situ hybridization (FISH) assay in 78 cases of HGUCa was compared using 2013 and 2018 HER2 reporting guidelines. RESULTS: HER2 amplification was observed in 22 (28.2%) of 78 tumors, of which 17 were in group 1, 1 in group 2, and 2 each in groups 3 and 4 (FISH assay, 2018). The remaining 14 HER2-amplified tumors (FISH assay, 2013) became negative, falling into group 2 (FISH assay, 2018) and were either negative or equivocal on immunohistochemistry (IHC, 2018). All FISH-negative tumors (n = 37) using 2013 criteria remained negative (group 5, 2018). FISH-equivocal tumors (2013) were further categorized into HER2 amplified (n = 1) and HER2 negative (n = 4) (2018). Overall, 20 (25.6%) tumors had discordant HER2 FISH results (2018 vs 2013). CONCLUSIONS: Implementing 2018 guidelines, HER2 amplification decreased from 36 to 22 cases. The group with a HER2/CEP17 ratio of 2 or more and average HER2 copy number less than 4 (group 2) were predominantly negative by IHC, suggesting a biologically distinct group of HGUCa that is different from HER2-amplified tumors, which may not respond to HER2-targeted therapy.

p53 and p16ink4a As Predictive and Prognostic Biomarkers for Nodal metastasis and Survival in A Contemporary Cohort of Penile Squamous Cell Carcinoma.

BACKGROUND: Human papilloma virus (HPV) infection is implicated in a proportion of invasive squamous cell carcinoma of the penis (PC). A subset of PC involves dysregulation of the p53 pathway. HPV in situ hybridization (ISH) and p16ink4a positivity are surrogate markers for HPV infection, and p53 immunohistochemistry (IHC) denotes abnormality in the p53 pathway. There remains an ambiguity with regard to the contribution of both the pathways in the prognosis of PC. We sought to analyze the clinicopathologic characteristics of a cohort of Indian PC patients with respect to p16 ink4a and p53 expression. PATIENTS AND METHODS: A cohort of 123 PC patients was studied for p16ink4aand p53IHC and HPVISH. The results of these biomarkers were correlated with various clinicopathologic parameters. RESULTS: p16ink4a and HPV ISH were positive in 47% and 53% of the tumors, respectively. The proportion of warty, basaloid, or mixed warty-basaloid tumor subtypes showed significant p16ink4apositivity (P < .0001) compared to other subtypes. Twenty-eight patients were dual negative (p53- /p16ink4a-), 32 were dual positive (p53+/p16ink4a+), 38 were p53+/p16ink4a-, and 25 were p53-/p16ink4a +. In patients where p16ink4a was negative, a p53-positive phenotype had a higher propensity for lymph node metastases (OR, 5.42; 95% CI, 1.75-16.80; P = .003). Similarly, p53 positivity dictates nodal involvement in the p16ink4a-positive subset of tumors (OR, 5.00; 95% CI, 1.23-20.17; P = .024). On multivariate analyses, pathologic subtypes (warty, warty-basaloid, and basaloid) (P < .0001), p16ink4aexpression (P < .0001), and absence of nodal metastasis (P < .0001) were significant predictors of improved overall (OS) and cancer specific survival (CSS). In Kaplan-Meier analysis, the OS was significantly longer in patients with p16ink4a + tumors (P < .0001), as was the CSS (P < .0001). Patients with dual positive tumors had a significantly higher OS (P < .001) and CSS (P = .012), in the entire cohort. In the node positive patients, dual positivity was associated with significantly higher OS (P < .0001); however, the median CSS for p53+/p16ink4a+tumors were not significantly different compared to p53- /p16ink4a- tumors (P = .064), although there was a trend towards improved CSS. CONCLUSIONS: There is a strong concordance between p16ink4aIHC and HPV ISH results. p16ink4a status is an independent predictor of survival (OS and CSS) in our cohort of PCs. p53 is a predictor of nodal metastasis irrespective of p16 status. Dual positive tumors have a significantly better outcome in comparison to dual negative tumors.

Factors Associated with Disposable Menstrual Absorbent Use Among Young Women in India.

CONTEXT: Hygienic use of absorbent products during menstruation is a challenge for young women in India, especially among the underprivileged, who lack knowledge and access to resources. Reuse of menstrual absorbents can be unhygienic and result in adverse health and other outcomes. METHODS: Data from the 2015-2016 National Family Health Survey-4 for 233,606 menstruating women aged 15-24 were used to examine levels and correlates of exclusive use of disposable absorbents during menstruation. Bivariate and logistic regression analyses were conducted to identify disparities in exclusive use by such characteristics as caste, mass media exposure and interaction with health workers. RESULTS: Exclusive use of disposable absorbents was low among young women overall (37%), and varied substantially by caste and other characteristics. Compared with women from general castes, those from scheduled castes, scheduled tribes and other backward classes had reduced odds of exclusive disposable absorbent use (odds ratios, 0.8-0.9). Disposable absorbent use was negatively associated with lower levels of education and household wealth, and rural residence. Compared with women who reported daily media exposure, those exposed less frequently had reduced odds of disposable absorbent use (0.7-0.9). Among those who recently met with a health worker, odds of use were lower if menstrual hygiene had not been discussed (0.9). CONCLUSIONS: Promoting awareness of proper menstrual hygiene-through education, media campaigns and discussion with reproductive health workers-and targeted interventions to disseminate and subsidize the purchase of disposable sanitary napkins should be pursued to address health disparities.

RESUMEN Contexto: El uso higiénico de productos absorbentes durante la menstruación es un reto para las mujeres jóvenes en India, especialmente entre las carentes de privilegios que no tienen el conocimiento y el acceso a recursos. Reusar los productos absorbentes del flujo menstrual puede ser antihigiénico y derivar en resultados adversos para la salud y de otro tipo. Métodos: Se utilizaron datos correspondientes a los años 2015-2016 de la Encuesta Nacional de Salud Familiar 4 de 233,606 mujeres menstruantes en edades de 15 a 24 años, para examinar niveles y correlatos del uso exclusivo de productos absorbentes desechables durante la menstruación. Se condujeron análisis de regresión bivariada y logística para identificar las disparidades en el uso exclusivo por características tales como la casta, la exposición a medios masivos y la interacción con trabajadores sanitarios. Resultados: El uso exclusivo de productos absorbentes desechables fue bajo en mujeres jóvenes en general (37%) y varió sustancialmente en función de la casta y otras características. En comparación con mujeres de castas generales, aquellas pertenecientes a castas y tribus oficialmente reconocidas y otras clases en desventaja, tuvieron reducidas probabilidades de un uso exclusivo de productos absorbentes desechables (razón de probabilidades, 0.8-0.9). El uso de productos absorbentes desechables se asoció negativamente con más bajos niveles educativos y de riqueza familiar, así como con el hecho de residir en zonas rurales. En comparación con las mujeres que reportaron tener exposición diaria a los medios, aquellas con una exposición menos frecuente tuvieron probabilidades reducidas de usar productos absorbentes desechables (0.7-0.9). Entre aquellas que tuvieron contacto reciente con un trabajador sanitario las probabilidades de uso exclusivo fueron menores si la higiene menstrual no había sido abordada durante la consulta (0.9). Conclusiones: Debe procurarse la promoción de la conciencia acerca de una apropiada higiene menstrual -a través de la educación, las campañas de medios y las conversaciones con trabajadores de la salud reproductiva- así como las intervenciones para diseminar y subsidiar la compra de toallas sanitarias desechables con el fin de hacer frente a las disparidades en salud.

RÉSUMÉ Contexte: L'utilisation hygiénique de produits absorbants pendant la menstruation pose un défi aux jeunes femmes d'Inde, en particulier celles défavorisées, qui manquent d'information et d'accès aux ressources. La réutilisation d'absorbants menstruels peut être contraire à l'hygiène et donner lieu à des résultats de santé et autres défavorables. Méthodes: Les données de l'Enquête nationale 2015-2016 sur la santé familiale-4 relatives à 233 606 femmes réglées âgées de 15 à 24 ans ont servi à examiner les niveaux et les corrélats de l'utilisation exclusive d'absorbants jetables pendant la menstruation. Les disparités en ont été identifiées par analyses de régression logistique et bivariée en fonction de caractéristiques telles que la caste, l'exposition aux médias et l'interaction avec les agents de santé. Résultats: L'utilisation exclusive d'absorbants jetables s'est révélée faible parmi les jeunes femmes dans leur ensemble (37%), avec une variation nette suivant la caste et d'autres caractéristiques. Par rapport aux femmes des castes générales, celles des castes et tribus répertoriées et des autres classes inférieures présentaient une probabilité réduite d'utilisation exclusive d'absorbants jetables (RC, 0,8-0,9). L'utilisation d'absorbants jetables était associée négativement aux niveaux d'éducation et de richesse du ménage inférieurs, ainsi qu'à la résidence en milieu rural. Par rapport aux femmes ayant fait état d'une exposition journalière aux médias, celles qui y étaient exposées moins fréquemment étaient moins susceptibles d'utiliser des produits absorbants jetables (0,7-0,9). Parmi celles qui s'étaient entretenues récemment avec un agent de santé, la probabilité d'utilisation était moindre si la question de l'hygiène menstruelle n'avait pas été abordée (0,9). Conclusions: La promotion de la sensibilisation à une bonne hygiène menstruelle ­ par l'éducation, les campagnes médiatiques et la discussion avec les agents de santé reproductive ­ et des interventions de dissémination et de subvention de l'achat de serviettes hygiéniques jetables doivent être poursuivies pour éliminer les disparités sanitaires.

Providing quality abortion care: Findings from a study of six states in India.

OBJECTIVE: Although abortion has been legal in India since 1971, but very little research has been done so far on the issue of the quality of abortion services. To fill this gap, this paper examines whether the quality of abortion services provided in the country is in line with the WHO's recommendations. STUDY DESIGN: We analyse a cross-sectional health facilities survey conducted in six Indian states, representing different sociocultural and geographical regions, as part of a study done in 2015. MAIN OUTCOME MEASURES: Percentage of facilities offering different abortion methods, type of anaesthesia given, audio-visual privacy level, compliance with the law by obtaining woman's consent only, imposing the requirement of adopting a contraceptive method as a precondition to receive abortion. RESULTS: Except for the state of Madhya Pradesh, fewer than half of the facilities in the other states offer safe abortion services. Fewer than half of the facilities offer the WHO recommended manual vacuum aspiration method. Only 6-26% facilities across the states seek the woman's consent alone for providing abortion. About 8-26% facilities across the states also require that women adopt some method of contraception before receiving abortion. CONCLUSION: To provide comprehensive quality abortion care, India needs to expand the provider base by including doctors from the Ayurveda, Unani, Siddha, and Homeopathy streams as also nurses and auxiliary midwives after providing them necessary skills. Medical and nursing colleges and training institutions should expand their curriculum by offering an in-service short-term training on vacuum aspiration (VA) and medical methods of abortion.

Provision of medical methods of abortion in facilities in India in 2015: A six state comparison.

Medical methods of abortion, MMA, has been legal in India since 2002. Guidelines stipulate that it should be administered by a provider or acquired via prescription. 1.2 million women having abortions in India use MMA acquired from health facilities [Singh, S., Shekhar, C., Acharya, R., Moore, A. M., Stillman, M., Pradhan, M. R., … Browne, A. (2018). The incidence of abortion and unintended pregnancy in India, 2015. The Lancet Global Health, 6(1), e111-e120. doi: 10.1016/S2214-109X(17)30453-9 ]. We undertook a study of abortion in Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh in 2015 to better understand under what conditions and how MMA is being administered in facilities. The majority of facilities that provide MMA are in the private sector and located in urban areas. Most facilities offer MMA both at the facility and as a prescription, although some facilities only offer MMA as a prescription. A high proportion of facilities report that women typically take the medication at home. (Re)training providers in MMA protocols and counselling, increasing the number of facilities offering MMA, and stocking of the drugs would help improve women's access to MMA and the information they need to be able to use this method safely. Key Messages: In the six states in our sample, Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh, 8% of abortions in 2015 were done using medical methods of abortion (MMA) acquired from health facilities. The majority of facilities that provide MMA in the six states are in the private sector and are located in urban areas. Health facilities in Madhya Pradesh and Tamil Nadu are comparatively better in their provision of MMA with Assam, Bihar, Gujarat and Uttar Pradesh demonstrating poorer provision of MMA. There are many opportunities for improvement in the practices of MMA provision through improved training of providers, accessibility to the medications and better support of women using MMA.

The incidence of abortion and unintended pregnancy in India, 2015.

BACKGROUND: Reliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015. METHODS: National abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015-16 National Family Health Survey-4. FINDINGS: We estimate that 15·6 million abortions (14·1 million-17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2-52·1) per 1000 women aged 15-49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15-49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15-49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended. INTERPRETATION: Health facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy. FUNDING: Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.

Cytomorphologic and Immunophenotypic Profile of a Cohort of Small Cell Carcinoma of the Urinary Bladder.

BACKGROUND: The incidence of primary small cell carcinoma (SCC) of the urinary bladder is extremely rare. We sought to analyze the cytologic and immunophenotypic features of SCC of the urinary bladder in urine and reassert the importance of cytologic examination of urine specimens for diagnosis of this tumor. METHODS: We studied the clinical and cytomorphologic features in the presurgical urine specimens (4 voided urine and 2 bladder-washing specimens) of histopathologically and immunohistochemically proven cases of SCC of the urinary bladder. RESULTS: There were 6 cases, all males, with an age range of 61-81 years. On cytologic and histopathologic examination, typical SCC morphology was present in all cases. On immunohistochemistry, synaptophysin and CD56 were positive in all 6 cases, while chromogranin was positive in only 3. The Ki-67 labeling index ranged from 30 to 100%. CONCLUSIONS: SCC should be kept in the differential diagnosis, when high-grade urothelial carcinoma is suspected in a urine cytology specimen, as this distinction has important therapeutic and prognostic implications. Therefore, a careful observation and, if required, the use of an appropriate immunocytochemical panel on the presurgical urine specimens can lead to a correct diagnosis.

India's progress towards the Millennium Development Goals 4 and 5 on infant and maternal mortality.

BACKGROUND: India is in a race against time to achieve the Millennium Development Goals (MDGs) 4 and 5, to reduce Infant Mortality Rate (IMR) to '28' and Maternal Mortality Ratio (MMR) to '109', by 2015. This study estimates the percent net contribution of the states and the periods in shaping India's IMR/MMR, and predicts future levels. METHODS: A standardized decomposition technique was used to estimate each state's and period's percent share in shaping India's decline in IMR/MMR between two time points. Linear and exponential regression curves were fitted for IMR/MMR values of the past two decades to predict IMR/MMR levels for 2015 for India and for the 15 most populous states. RESULTS: Due to favourable maternal mortality reduction efforts in Bihar/Jharkhand (19%) and Madhya Pradesh/Chhattisgarh (11%), Uttar Pradesh (33%) - India is predicted to attain the MDG-5 target by 2016, assuming the pace of decline observed in MMR during 1997-2009 continues to follow a linear-trend, while the wait may continue until 2023-2024 if the decline follows an exponential- trend. Attaining MDG-4 may take until 2023-2024, due to low acceleration in IMR drop in Bihar/ Jharkhand, Uttar Pradesh/Uttarakhand and Rajasthan. The maximum decline in MMR during 2004-2009 coincided with the launch and uptake of the National Rural Health Mission (NRHM). CONCLUSIONS: Even though India as a nation is not predicted to attain all the MDG 4 and 5 targets, at least four of its 15 most populous states are predicted to do so. In the past two decades, MMR reduction efforts were more effective than IMR reduction efforts.