Strengthening Fetal Heart Rate Monitoring during Labor with a Standard Handheld Doppler - Implementation Experience from India.

Background: India's neonatal and perinatal mortality is among the highest in the world. Intrapartum-related conditions contribute to a significant proportion of neonatal deaths and stillbirths. Fetal heart rate monitoring, a recommended norm to assess fetal well-bring, is not practiced as per standard guidelines in public health facilities. A standardized Doppler along with training on fetal heart rate monitoring was implemented across different levels of healthcare in three states. Methods: Facilities were selected purposively to implement the Doppler. Baseline data for 3 months were collected. Interviews of health providers and observation of labor were conducted quarterly. Data were analyzed through a comparison of baseline and intervention on a number of delivery and monitoring indicators. Results: Among 22,579 total deliveries, monitoring frequency increased along with increase in detection of abnormal fetal heart rate (FHR) while cesarean section and stillbirths reduced slightly. Cases never monitored reduced in the District Hospitals (7.98-2.07, P < 0.01) and in Community Health Centers (14.7-1.67, P < 0.001). Stillbirth rate reduced at the medical college (3.6-1.1, P < 0.001). Interviews with providers revealed acceptance of the device due to its reliable readings. Conclusion: The Doppler demonstrates acceptability and serves as a useful aid to improve intrapartum FHR monitoring.

Safe Delivery application with facilitation increases knowledge and confidence of obstetric and neonatal care among frontline health workers in India.

Background: Digital learning tools have proliferated among healthcare workers in India. Evidence of their effectiveness is however minimal. We sought to examine the impact of the Safe Delivery App (SDA) on knowledge and confidence among frontline health workers (HW) in India. We also studied whether facilitation to address technical challenges enhanced self-learning. Methods: Staff nurses and nurse-midwives from 30 facilities in two states were divided into control and intervention groups through randomization. Knowledge and confidence were assessed at baseline and after 6 months. Three rounds of facilitation addressing technical challenges in downloading and usage along with reminders about the next phase of learning were conducted in the intervention group. A user satisfaction scale along with qualitative interviews was conducted in the intervention group at the endline along with qualitative interviews on facilitation. Results: The knowledge and confidence of the healthcare workers significantly increased from the baseline to endline by 4 percentage points (P < 0.001). The participants who received facilitation had a higher mean score difference in knowledge and confidence compared to those who did not receive facilitation (P < 0.001). The participants were highly satisfied with the app and video was the most-watched feature. They reported a positive experience of the facilitation process. Conclusion: The effectiveness and acceptability of the SDA indicate the applicability of mHealth learning tools at the primary healthcare level. In a time of rapid digitalization of training, facilitation or supportive supervision needs further focus while on-ground digital training could be invested in to overcome digital illiteracy among healthcare workers.

A Novel Approach to Promote Evidence-Based Development of District Maternal and Newborn Health Plans in Two States in India.

Background: Maternal and child health implementation plan development in districts of India lacks systematic process and capacity resulting in suboptimal health improvements. There is ineffective and limited participation and lack of autonomy to effect changes in district priorities. Objectives: Primary objective was to demonstrate a systematic planning approach to develop evidence-based district implementation plans for mothers and children. Methods: A planning tool named RAASTA (RMNCH + A Action Agenda using Strategic Approach for evidence-based district work plans) adapted from WHO (World Health Organization) program review tools was used in the states of Uttarakhand and Jharkhand. The tool was implemented in the two states for the development of implementation plans in a 6-step process by prioritizing district health goals; reviewing maternal, neonatal, child, and family planning intervention coverage; and linking them with activity implementation status; assessing strengths, and weaknesses of previous implementation plans and developing solutions based on current gaps in intervention coverage's. Results: Tool was used for capacity building of 59 participants and also identification of prioritized activities based on their available data. Several newer activities were identified. The districts mainstreamed them as action plans, many of which were incorporated in the state Program Implementation Plan for budgetary provisions under state NHM (National Health Mission) funds. Conclusion: The use of a tool facilitated the systematic development of evidence-based district implementation plans.

Systems E-approach for women at risk (SEWA)-A digital health solution for detection of high-risk pregnancies.

BACKGROUND: High-risk pregnancy (HRP) puts current pregnancy at an increased risk of complications. In the absence of pre-existing HRP implementation model of the country, in collaboration with the Government of Himachal Pradesh, a new digital HRP model called the 'SEWA-A System E-approach for Women at risk' was developed. The current article demonstrates a model for the early identification and line listing of high-risk pregnant women (PW) with appropriate referrals and increased engagement with the healthcare workers using a digital tool in the form of the Android App. METHODS: SEWA was implemented as a pilot intervention in two community development blocks of the Chamba district. The key implementation steps included finalizing protocols for the identification of HRPs, defining processes and roles, mapping health facilities, setting up the communication loop, and developing of digital solutions. The digital app, used by the auxiliary nurse midwife (ANM) and program officers, tracked PW for a year from October 19 to October 20 and recorded the ANC visits, referrals, and birth outcomes. A qualitative assessment was conducted among the health workers to find out their level of acceptance. RESULTS: A total of 1,340 high-risk PW were identified. The intervention year saw a rise in the identification of HRP to 27.9% from 3.5% in the previous year. A total of 2,559 conditions were tagged to the identified 1,340 women categorized into current pregnancy (81%), previous pregnancy (16%), and any existing chronic illness (3%). A majority of the women who required urgent referrals were provided referrals. The application recorded 53% of the delivered HRP with a digital birth preparedness plan, prepared and shared with the PW and Accredited Social Health Activists (ASHA), by text message for compliance. CONCLUSION: The SEWA application is a feasible and sustainable solution to complement the competency of the care providers for early identification of the high-risk conditions and reduce the burden of preventable unprecedented deaths around the time of birth.

Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India.

OBJECTIVES: To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device. DESIGN: The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained. SETTING: Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall. PARTICIPANTS: Under-5 children presenting with ARI symptoms at the OPD. RESULTS: Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting. CONCLUSION: Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

Care Around Birth Approach: A Training, Mentoring, and Quality Improvement Model to Optimize Intrapartum and Immediate Postpartum Quality of Care in India.

BACKGROUND: With the highest risk of maternal and newborn mortality occurring during the period around birth, quality of care during the intrapartum and immediate postpartum periods is critical for maternal and neonatal survival. METHODS: The United States Agency for International Development's Scaling Up Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions project, also known as the Vriddhi project, collaborated with the national and 6 state governments to design and implement the Care Around Birth approach in 141 high caseload facilities across 26 high-priority districts of India from January 2016 to December 2017. The approach aimed to synergize evidence-based technical interventions with quality improvement (QI) processes, respectful maternity care, and health system strengthening efforts. The approach was designed using experiential training, mentoring, and a QI model. A baseline assessment measured the care ecosystem, staff competencies, and labor room practices. At endline, the approach was externally evaluated. RESULTS: Availability of logistics, recording and reporting formats, and display of protocols improved across the intervention facilities. At endline (October-December 2017), delivery and newborn trays were available in 98% of facilities compared to 66% and 55% during baseline (October-December 2015), respectively. Competency scores (> 80%) for essential newborn care and newborn resuscitation improved from 7% to 70% and from 5% to 82% among health care providers, respectively. The use of partograph in monitoring labor improved from 29% at the baseline to 61%; administration of oxytocin within 1 minute of delivery from 35% to 93%; newborns successfully resuscitated from 71% to 96%; and postnatal monitoring of mothers from 52% to 94%. CONCLUSION: The approach successfully demonstrated an operational design to improve the provision and experience of care during the intrapartum and immediate postpartum periods, thereby augmenting efforts aimed at ending preventable child and maternal deaths.

Putting the local back into planning-experiences and perceptions of state and district health functionaries of seven aspirational districts in India on an innovative planning capacity building approach.

District functionaries have ostensibly a major responsibility to develop evidence based plans. However, this responsibility is not commensurate with skills and expertise among functionaries in many Indian states. Vriddhi project-technical partner of the government, developed a planning tool for maternal and neonatal health programmes, called RMNCH + A Action Agenda using Strategic Approach (RAASTA), which was introduced in a workshop format in two states and attended by program officers. Qualitative feedback was obtained from selected participants to understand their experience of the workshop and of the planning tool. It emerged that previous planning process had little application of local evidence based solutions. Participants appreciated the alternative approach as RAASTA equipped them to use local evidence. Several action plans derived at the workshop were included in the state plan. At the same time, apprehension was expressed by participants about translating their learnings to practical application as planning was not a central priority in their scheme of duties and tasks. Enhanced support from states in refreshing district planners' skills would be an important step. One state government has scaled up the RAASTA tool while an electronic version is being developed for future use as it demonstrates great potential to equip and aid district officials in developing evidence based plans.

Intrapartum Fetal Heart Monitoring Practices in Selected Facilities in Aspirational Districts of Jharkhand, Odisha and Uttarakhand.

BACKGROUND: The risk of mortality for the mother and the newborn is aggravated during birth in low- and middle-income countries due to preventable causes, which can be addressed with increased quality of care practices. One such practice is intrapartum fetal heart rate (FHR) monitoring, which is crucial for the early detection of fetal ischemia, but is inadequately monitored in low- and middle-income countries. In India, there is currently a lack of sufficient data on FHR monitoring. METHODS: An assessment using facility records, interviews and observation was conducted in seven facilities providing tertiary, secondary or primary level care in aspirational districts of three states. The study sought to investigate the frequency of monitoring, devices used for monitoring and challenges in usage. RESULTS: FHR was not monitored as per standard protocol. Case sheets revealed 70% of labor was monitored at least once. Only 33% of observed cases were monitored every half hour during active labor, and none were monitored every 5 min during the second stage of labor. More time was observed for monitoring with a Doppler compared with a stethoscope, as providers reported fluctuation in readings. Reportedly, low audibility and a perceived need of expertise were associated with using a stethoscope. High case load and the time required for monitoring were reported as challenges in adhering to standard monitoring protocols. CONCLUSION: The introduction of a standardized device and a short refresher training on the World Health Organization and skilled birth attendant protocols for FHR monitoring will improve usage and compliance.

Experiences with use of a pulse oximeter multimodal device in outpatient management of children with Acute Respiratory Infection during Covid pandemic.

BACKGROUND: While Covid-19 infection rate in children is low, respiratory symptoms are a common mode of presentation which calls for better management of such symptoms. However, ARI case managemnet in primary health settings settings has challenges as health workers lack skills to count respiratory rate and check chest indrawing. To address this multimodal pulse oximeters have been introduced in health and wellness centres of seven states to ease the work of front line health workers. A study was undertaken to understand the usability of the multimodal pulse oximeter during Covid times. METHODS: A qualitative study was conducted with the aid of indepth interviews among a convenience sample of eleven health care workers from ten health and wellness centres. Interviews were conducted and recorded over phone, after obtaining consent. Transcribed interviews were coded and analysed on a qualitative analysis software. Content analysis was conducted. RESULTS: Total children screened during covid lockdown period (April 1-May 31) is 571, those diagnosed with pneumonia and severe pneumonia is 68 and 2. Health care workers were satisfied with pulse oximeter as it helped in timely diagnosis and treatment, and offered protection from possible infection as it mitigated the need for physical contact. CONCLUSION: The multimodal pulse oximeter is well accepted among providers as it is easy to use aiding in timely management of ARI in children. It has an added protection as it's use reduces the need for physical contact. It can be adopted in other HWC and primary health facilities.

Assessment of feasibility and acceptability of family-centered care implemented at a neonatal intensive care unit in India.

BACKGROUND: A family-centered care (FCC) parent participation program that ensures an infant is not separated from parents against their will was developed for the caring of their small or sick newborn at a neonatal intensive care unit (NICU) in Delhi, India. Healthcare provider sensitization training directed at psychosocial and tangible support and an audio-visual training tool for parent-attendants were developed that included: 1) handwashing, infection prevention, protocol for entry; 2) developmentally supportive care, breastfeeding, expression of breastmilk and assisted feeding; 3) kangaroo mother care; and 4) preparation for discharge and care at home. The study aimed to examine the feasibility and acceptability of the FCC model in a NICU in India. METHODS: A prospective cohort design collected quantitative data on each parent-attendant/infant dyad at enrollment, during the NICU stay, and at discharge. Feasibility of the FCC program was measured by assessing the participation of parent-attendants and healthcare providers, and whether training components were implemented as intended. Acceptability was measured by the proportion of parent-attendants who participated in the trainings and their ability to accurately complete program activities. RESULTS: Of 395 NICU admissions during the study period, eligible participants included 333 parent-attendant/infant dyads, 24 doctors, and 21 nurses. Of the 1242 planned parent-attendant training sessions, 939 (75.6%) were held, indicating that program fidelity was high, and the majority of trainings were implemented as intended. While 50% of parent-attendants completed all 4 FCC training sessions, 95% completed sessions 1 and 2; 60% of the total participating parent-attendants completed session 3, and 75% completed session 4. Compliance rates were over 96% for 5 of 10 FCC parent-attendant activities, and 60 to 78% for the remaining 5 activities. CONCLUSIONS: FCC was feasible to implement in this setting and was acceptable to participating parent-attendants and healthcare providers. Parents participated in trainings conducted by NICU providers and engaged in essential care to their infants in the NICU. A standard care approach and behavior norms for healthcare providers directed psychosocial and tangible support to parent-attendants so that a child is not separated from his or her parents against their will while receiving advanced care in the NICU.

Measuring accuracy of plethysmography based respiratory rate measurement using pulse oximeter at a tertiary hospital in India.

BACKGROUND: Childhood pneumonia continues to be a major infectious killer in India. WHO recommended respiratory rate and oxygen saturation (SpO2) measurements are not well implemented in Indian public health outpatient facilities with the result that treatment decision-making rely on subjective assessments from variably trained and supervised healthcare providers. The introduction of a multi-modal pulse oximeter (POx) that gives reliable measurements would mitigate incorrect diagnosis. In light of future potential use of pulse oximeter in peripheral health centres, it becomes important to measure accuracy of respiratory rate and oxygen saturation of such an instrument. The current study measures accuracy of plethysmography based respiratory rate (RR) using a pulse oximeter (Masimo Rad-G) by comparing it with a gold standard (pediatrician) measurement. STUDY DESIGN: A cross sectional study was conducted in the OPD and emergency ward of Kalawati Saran Children's Hospital over a 2 week period wherein a convenience sample of 97 children (2 to 59 months) were assessed by a pediatrician as part of routine assessment alongside independent measure by a consultant using pulse oximeter. The level of agreement between plethymography based RR and pediatrician measure was analyzed along with sensitivity and specificity of fast breathing of plethymography based RR measure. RESULTS: Both methods of measurement show strong association (97%, p < 0.001) and observed values, falling on line of unity, obtained either from pulse oximeter or by pediatrician are very close to each other. Fast breathing measured by POx has a sensitivity of 95% and specificity of nearly 94%. CONCLUSION: The current study provides evidence of the accuracy of a plethysmography based RR using a pulse oximeter which can potentially be of use in planning of pneumonia management in public health facilities.

Strengthening the Use of Partograph in High Caseload Public Health Facilities in India through an Integrated Quality Improvement Approach.

BACKGROUND: The effective implementation of evidence-based practices including the use of partograph to improve maternal and newborn outcomes is critical on account of increased institutional delivery. However, despite clear guidelines, partograph use in India is not widely practiced. MATERIALS AND METHODS: Quality improvement (QI) efforts along with training and mentoring were operationalized in a total of 141 facilities across 26 high priority districts of India. Assessments were conducted across baseline, intervention period, and end line. These included reviewing the availability of partograph and staff competency in filling them at baseline and end line, as well as reviewing monthly data for use and completeness of filling. The monthly data were tabulated quarter wise to study trends. Competency scores were tabulated to show the difference across assessments. RESULTS: An overall upward trend from 29% to 61% was seen in the practice of partograph use. Simultaneously, completeness in filling up the partograph increased from 32% to 81%. Staff competency in filling partograph improved considerably: proportion of staff scoring low decreased over the intervention period from 63% to 2.5% (P < 0.0001), and the proportion scoring high increased from 13% to 72% (P < 0.0001) from baseline to end line. CONCLUSION: The integrated approach of training, mentoring, and QI can be used in similar settings to strengthen partograph use.

Acceptability of a family-centered newborn care model among providers and receivers of care in a Public Health Setting: a qualitative study from India.

BACKGROUND: Family-centered care (FCC), based on collaborative participation of the family along with a team of health care providers, is found to increase the well-being of sick infants in neonatal critical care units. Over the last 4 years, the neonatal unit of Dr. Ram Manohar Lohia Hospital in Delhi has innovated and developed an implementation framework for FCC. This qualitative study assessed the acceptability of family-centered care among providers and family members of neonates to identify gaps and challenges in implementation. METHODS: In-depth interviews were conducted among a purposive sample of twelve family members of admitted neonates and six providers to examine their perceptions and experiences regarding FCC. RESULTS: Family members and providers expressed a positive perception and acceptance of FCC based on the competencies and knowledge acquired by parents and other caregivers of essential newborn care. Family members reported being satisfied with the overall health care experience due to the transparency of care and allowing them to be by their baby's bedside. Limitations in the infrastructure or lack of facilities at the public hospital did not seem to dilute these positive perceptions. Providers also perceived FCC as a good practice to be continued in spite of concerns around sharing of nursery space with parents, the need for constant vigilance of parents' practices in handling of their newborns, and the need for separate, designated nursing staff for FCC. CONCLUSION: Both providers and receivers of neonatal care found FCC to be an acceptable form of care. Providers identified challenges and suggested possible solutions, such as need of periodic provider sensitization on FCC, improved staff organization, and provision of mother-friendly facilities to enable her to provide around-the-clock care by her baby's bedside. Overcoming these challenges would allow for better integration of FCC within general clinical care in neonatal care units.

Quality Improvement Approaches Associated with Quality of Childbirth Care Practices in Six Indian States.

OBJECTIVE: To compare the impact of quality improvement (QI) approaches and other health system factors (level of health facility, cadre of staff conducting the delivery, years of experience of staff conducting the delivery, and time of day) on the quality of six elements of delivery and postpartum/postnatal care. DESIGN: Cross-sectional study using external observers. SETTING: 12 public health facilities in 6 states in India during November 2014. PARTICIPANTS/PATIENTS: 461 deliveries in above facilities. INTERVENTION: Facilities were chosen based on having received one day of QI training and at least six monthly QI coaching visits. MAIN OUTCOME MEASURE(S): (i) Administration of oxytocin within one minute following delivery, (ii) immediate drying and wrapping of the newborn, (iii) use of sterile cord clamps, (iv) breastfeeding within one hour of birth, (v) mothers' condition assessed between 0 and 30 minute after delivery, and (vi) vitamin K given to infants within 6 hour of birth. RESULTS: On multivariate analysis, facilities using QI approaches with deliberate aims to address the processes of interest were more likely to dry and wrap infants (OR 2.6, 95% CI: 2.1, 6.6), initiate early breastfeeding (OR 3.6, 95% CI: 2.1, 6.2) and conduct post-partum vitals monitoring (OR 2.7, 95% CI: 1.7, 4.2). The other health system factors had mixed effects. CONCLUSIONS: Facilities using QI approaches to ensure all women and babies receive specific elements of care provide that element of care to a greater proportion than facilities not using QI approaches for that element of care.

How female community health workers navigate work challenges and why there are still gaps in their performance: a look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework.

BACKGROUND: Accredited Social Health Activists (ASHAs) are community health workers tasked to deliver health prevention in communities and link them with the health care sector. This paper examines the social, cultural, and institutional influences that either facilitate or impede ASHAs' abilities to deliver services effectively through the lens of the reciprocal determinism framework of social cognitive theory. METHODS: We conducted 98 semi-structured, in-depth interviews with ASHAs (n = 49) and their family members (n = 49) in Gurdaspur and Mewat districts. Data were analyzed by comparing and contrasting codes leading to the identification of patterns which were explained with the help of a theoretical framework. RESULTS: We found that while the work of ASHAs led to some positive health changes in the community, thus providing them with a sense of self-worth and motivation, community norms and beliefs as well as health system attitudes and practices limited their capacity as community health workers. CONCLUSION: We outline potential mechanisms for improving ASHA capacity such as improved sensitization about religious, cultural, and gender norms; enhanced communication skills; and sensitization and advocating their work with health and state officials.

Evaluation of a quality improvement intervention for obstetric and neonatal care in selected public health facilities across six states of India.

BACKGROUND: While increase in the number of women delivering in health facilities has been rapid, the quality of obstetric and neonatal care continues to be poor in India, contributing to high maternal and neonatal mortality. METHODS: The USAID ASSIST Project supported health workers in 125 public health facilities (delivering approximately 180,000 babies per year) across six states to use quality improvement (QI) approaches to provide better care to women and babies before, during and immediately after delivery. As part of this intervention, each month, health workers recorded data related to nine elements of routine care alongside data on perinatal mortality. We aggregated facility level data and conducted segmented regression to analyse the effect of the intervention over time. RESULTS: Care improved to 90-99% significantly (p < 0.001) for eight of the nine process elements. A significant (p < 0.001) positive change of 30-70% points was observed during post intervention for all the indicators and 3-17% points month-to-month progress shown from the segmented results. Perinatal mortality declined from 26.7 to 22.9 deaths/1000 live births (p < 0.01) over time, however, it is not clear that the intervention had any significant effect on it. CONCLUSION: These results demonstrate the effectiveness of QI approaches in improving provision of routine care, yet these approaches are underused in the Indian health system. We discuss the implications of this for policy makers.

The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India.

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household's financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.

HIV testing among pregnant wives of migrant men in a rural district of India: urgent call for scale up.

In India, despite the fact that more pregnant women are being tested for HIV under the purview of the Prevention of Parent-to-Child HIV Transmission program, official figures indicate low rates of HIV testing, evidencing missed opportunities for HIV prevention. The present study examined the prevalence of HIV testing and the barriers to testing among pregnant women, whose vulnerability to HIV is enhanced by their spouses' risky behaviors. A cross-sectional study was conducted from November 2010 to January 2011 among 357 women who had given birth in the last two years in a district in Orissa. Only one-third of women had been tested for HIV during pregnancy. Women with more than six years of education (OR: 2.39, 95% CI: 1.06-5.39), having knowledge of sexually transmitted infections (OR: 12.37, 95% CI: 5.55-27.58), having discussions with spouses about HIV (OR: 3.56, 95% CI: 1.61-7.86), and seeking antenatal care in government district hospitals and private clinics as opposed to peripheral community health centers, were more likely to receive HIV testing during pregnancy. The findings point to the need to widen HIV testing to community-based services, increase coverage of HIV/sexually transmitted infection awareness and prevention programs, and encourage spousal communication through quality counseling.

Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India.

BACKGROUND: Data on mental health among injecting drug users in South Asia is scarce yet poor mental health among users has significant implications for the success of HIV prevention and treatment programmes. A cohort of 449 injecting drug users in Delhi was examined on the following issues (1) examine trends in suicidal ideation, suicide plan and suicidal attempts over a 12-month period, (2) examine association between injecting practices (receive and give used syringes) and suicidal ideation over a 12 month study period. METHODS: An observational study was conducted providing phased interventions with follow up interviews every 3 months to 449 injecting drug users (IDUs), from August 2004 to November 2005. The study was conducted in Yamuna Bazaar, a known hub of drug peddling in Delhi. Interventions included nutrition, basic medical services, needle exchange, health education, HIV voluntary counseling and testing, STI diagnosis and treatment, oral buprenorphine substitution, and detoxification, each introduced sequentially. RESULTS: Suicidal ideation and suicide attempts, did not significantly change over 12 months of observation, while suicide plans actually increased over the time period. Keeping other factors constant, IDUs with suicidal ideation reported more giving and receiving of used syringes in the recent past. CONCLUSIONS: Mental health services are warranted within harm reduction programmes. Special attention must be paid to suicidal IDUs given their higher risk behaviours for acquiring HIV and other blood borne infections. IDU intervention programmes should assess and address suicide risk through brief screening and enhanced counseling.

The impact of human rights violations and perceptions of discrimination on health service utilization among injection drug users in Delhi, India.

The study was conducted from August to December 2007, in two urban, poor neighborhoods in Delhi. A respondent-driven sampling was used to recruit 343 injection drug users who were interviewed with a survey questionnaire that included items of human rights abuses, health service utilization, and sociodemographic characteristics. Multivariate logistic regression with backward selection of variables was conducted with the three outcome variables-service utilization in general care sector, harm reduction, and drug user treatment. Findings suggest advocating for human rights and securing standards of care in improving health care use and future research on documenting human rights abuses occur in health care settings. The study's limitations are noted.