Blended Tele-mentoring Support for Strengthening Antenatal Care by Private Health care Facilities: FOGSI VISTRIT INITIATIVE.

Introduction: The objective of the present initiative was to build capacity of health care providers in private sector along with standardisation of care during antenatal period for common antenatal problems of GDM and iron deficiency anaemia in private sector. Methods: A pilot project for all levels of health care providers including doctors, nurses, counsellors and laboratory technicians of 34 private facilities in six districts of Jharkhand was planned. Training modules for GDM and anaemia based on government of India guidelines were developed. End line evaluation included data collection and descriptive analysis of quantitative data quality scores from assessment standards on GDM and anaemia in pregnancy. Results: Knowledge assessment of health care providers and doctors through baseline and end line knowledge assessment survey questionnaire showed that 100% health care providers who were trained scored 85% or more in knowledge assessment questionnaires as seen by baseline and end line questionnaire results. All project hospitals (n = 34) in Jharkhand achieved quality standards of care in intervention period for gestational diabetes mellitus and anaemia in pregnancy. They achieved total score more than 80% and exceeded target of 80% of the quality standards. Conclusion: A systematic strengthening of private health care facilities through a blended tele-mentoring and onsite support is possible. Supplementary Information: The online version contains supplementary material available at 10.1007/s13224-023-01866-5.

Real-world utilization pattern of dydrogesterone in 7287 Indian women with obstetric and gynecological conditions: data from multicentric, retrospective study.

Objective: Despite the literature on dydrogesterone, studies on dydrogesterone utilization patterns are largely lacking in Indian patients. Methods: This was a multi-center, retrospective, observational, cross-sectional, and descriptive study across 817 centers in India. Data of patients who received dydrogesterone in past and provided consent for future use of their medical record for research purpose was were retrieved and analyzed. Results: Data of 7287 subjects (aged 29.55±4.84 years) was analyzed. Threatened abortion was the most common indication for which the subjects received dydrogesterone (46.9%) followed by recurrent pregnancy loss. Polycystic ovary syndrome (PCOS), thyroid disorders and anemia were the most common comorbid conditions and prior pregnancy loss, advanced maternal age and obesity were the most common risk factors seen in subjects who received dydrogesterone. Total 27.5% of subjects received a loading dose of dydrogesterone, and majority (64%) received 40 mg as loading dose. 10 mg dose was used as maintenance or regular dose in 81.4% of the subjects. Twice daily (BID) was the most common dosing frequency (66.6%). The most common concomitant medications being taken by the subjects on dydrogesterone included folic acid (45.1%), iron supplements (30.3%) and calcium and vitamin D3 supplements (25.5%). Another progesterone preparation (oral, injection, vaginal, tubal) other than dydrogesterone was used concurrently in 7.8% of subjects. Conclusion: The study helped to identify the patient population that is benefitted by dydrogesterone and the preferred indications, risk factors, comorbid conditions and concomitant medication used in this patient population at real-life scenario.

Real-world utilization pattern of dydrogesterone in 7287 Indian women with obstetric and gynecological conditions: data from multicentric, retrospective study

Abstract Objective: Despite the literature on dydrogesterone, studies on dydrogesterone utilization patterns are largely lacking in Indian patients. Methods: This was a multi-center, retrospective, observational, cross-sectional, and descriptive study across 817 centers in India. Data of patients who received dydrogesterone in past and provided consent for future use of their medical record for research purpose was were retrieved and analyzed. Results: Data of 7287 subjects (aged 29.55±4.84 years) was analyzed. Threatened abortion was the most common indication for which the subjects received dydrogesterone (46.9%) followed by recurrent pregnancy loss. Polycystic ovary syndrome (PCOS), thyroid disorders and anemia were the most common comorbid conditions and prior pregnancy loss, advanced maternal age and obesity were the most common risk factors seen in subjects who received dydrogesterone. Total 27.5% of subjects received a loading dose of dydrogesterone, and majority (64%) received 40 mg as loading dose. 10 mg dose was used as maintenance or regular dose in 81.4% of the subjects. Twice daily (BID) was the most common dosing frequency (66.6%). The most common concomitant medications being taken by the subjects on dydrogesterone included folic acid (45.1%), iron supplements (30.3%) and calcium and vitamin D3 supplements (25.5%). Another progesterone preparation (oral, injection, vaginal, tubal) other than dydrogesterone was used concurrently in 7.8% of subjects. Conclusion: The study helped to identify the patient population that is benefitted by dydrogesterone and the preferred indications, risk factors, comorbid conditions and concomitant medication used in this patient population at real-life scenario.

Voices from Health Care Providers: Assessing the Impact of the Indian Assisted Reproductive Technology (Regulation) Act, 2021 on the Practice of IVF in India.

The regulatory vacuum in the field of ART in India was filled when in December 2021, the Assisted Reproductive Technology (Regulation) Act, 2021 (ART Act) (https://egazette.nic.in/WriteReadData/2021/232025.pdf) and the Surrogacy (Regulation) Act, 2021 (SR Act) were passed. We surveyed medical professionals to understand their knowledge, attitude and perception towards the Acts and to offer an initial, snapshot assessment of their impact on the medical community. The government has already signalled its intent to implement the Acts and has published several notifications/gazettes to clarify and amend the issues surrounding the Acts (https://artsurrogacy.gov.in/NationalArtSurrogacy/faces/HomePage.xhtml#). We hope that these responses will help to voice the thoughts, concerns and suggestions from of ART service providers for ART to further clarify and rationalise the laws. Infertility is already a much stigmatised problem which deserves to be a higher public health priority. While the laws are a welcome step, changes in both laws is are the need of the hour to make ART more accessible, available and affordable to the millions of couples who need these services and for the health care providers who to be able to deliver them.

Indian Academy of Pediatrics Position Paper on Nurturing Care for Early Childhood Development.

Early childhood development (ECD) refers to the physical, motor, socio-emotional, cognitive, and linguistic development of a young child. The 'Countdown to 2030' global distribution of 'children at risk of poor development' indicates the need for urgent action and investment in ECD. Nurturing care enhances ECD, even in the presence of adversities. Strategic actions should exist at multiple levels: the family, community, health care providers and government. Previously, child health related policies and programs of the Government of India functioned in isolation, but have recently started demonstrating multi-sectoral collaboration. Nonetheless, the status of ECD in India is far from optimal. There is strong evidence that parenting programs improve outcomes related to ECD. This is dependent on key programmatic areas (timing, duration, frequency, intensity, modality, content, etc.), in addition to political will, funding, partnership, and plans for scaling up. Each country must implement its unique ECD program that is need-based and customized to their stakeholder community. Barriers like inadequate sensitization of the community and low competency of health care providers need to be overcome. IAP firmly believes that responsive parenting interventions revolving around nurturing care should be incorporated in office practice. This paper outlines IAP's position on ECD, and its recommendations for pediatricians and policy makers. It also presents the roadmap in partnership with other stakeholders in maternal, neonatal, and child health; Federation of Obstetric and Gynaecological Societies of India (FOGSI), National Neonatology Forum (NNF), World Health Organization (WHO), and United Nation Children Fund (UNICEF).

Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology.

In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross-country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers' advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy.

Updated status of assisted reproductive technology activities in the Asia-Oceania region.

AIM: To report on a descriptive survey on the availability, regulation and funding issues of assisted reproductive technology (ART) activities in member countries of the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG). METHODS: A survey questionnaire was initially sent out to representatives of the 28 member national societies of AOFOG in 2015, and final verification and compilation of data were completed in November 2017. RESULTS: A response was received from 24 countries. Artificial insemination and in vitro fertilization treatments were available in 23 and 22 of them respectively. Of the 23 responding countries where ART activities were carried out, these were governed by legislation or national regulations in 12 of them, and 15 had a national registry, to which reporting was compulsory in 11 of them. Only Australia, Nepal, New Zealand and Saudi Arabia allowed ART treatment for both single men and women, while only Australia and New Zealand allowed ART treatment for homosexual couples. In Vietnam, ART treatment was allowed only for single women (but not men) from the same country. In Israel, only single or homosexual women but not men were allowed to receive ART treatment. Government subsidy was available for artificial insemination and in vitro fertilization treatments in 10 and 9 responding countries respectively. Compensation to gamete donors and surrogate mothers were allowed in some countries, mostly on the basis of covering the medical treatment cost and compensation for leave from work. CONCLUSION: There is great diversity in the availability of various forms of ART treatments, their regulations and data-monitoring mechanisms, as well as funding issues, among Asian-Oceanic countries. Availability of ART activities involving donor gametes or surrogacy, or those for nonheterosexual unions, is still limited in this region.

Achievements of the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences in South-Southeast Asia.

Since 2008, the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences has contributed to ensuring the substitution of sharp curettage by manual vacuum aspiration (MVA) and medical abortion in selected hospitals in participating countries of South-Southeast Asia. This initiative facilitated the registration of misoprostol in Pakistan and Bangladesh, and the approval of mifepristone for "menstrual regulation" in Bangladesh. The Pakistan Nursing Council agreed to include MVA and medical abortion in the midwifery curriculum. The Bangladesh Government has approved the training of nurses and paramedics in the use of MVA to treat incomplete abortion in selected cases. The Sri Lanka College of Obstetricians and Gynaecologists, in collaboration with partners, has presented a draft petition to the relevant authorities appealing for them to liberalize the abortion law in cases of rape and incest or when lethal congenital abnormalities are present. Significantly, the initiative has introduced or strengthened the provision of postabortion contraception.

Feasibility of expanding the medication abortion provider base in India to include ayurvedic physicians and nurses.

CONTEXT: The availability of trained abortion providers is limited in India. Allowing ayurvedic physicians and nurses to perform medication abortions may improve women's access to the procedure, but it is unclear whether these clinicians can provide these services safely and effectively. METHODS: Allopathic physicians, ayurvedic physicians and nurses (10 of each), none of whom had experience in abortion provision, were trained to perform medication abortions. In 2008-2010, these providers performed medication abortions in five clinics in Bihar and Jharkhand for 1,225 women with a pregnancy of up to eight weeks' gestation. A two-sided equivalence design was used to test whether providers' assessments of client eligibility and completeness of abortion matched those of an experienced physician "verifier," and whether medication abortions performed by nurses and ayurvedic physicians were as safe and effective as those done by allopathic physicians. RESULTS: Failure rates were low (5-6%), and those for nurses and ayurvedic physicians were statistically equivalent to those for allopathic physicians. Provider assessments of client eligibility and completeness of abortion differed from those of the verifier in only a small proportion of cases (3-4% for eligibility and 4-5% for completeness); these proportions, and rates of loss to follow-up, were statistically equivalent among provider types. No serious complications were observed, and services by all three groups of providers were acceptable to women. CONCLUSION: Findings support amending existing laws to improve women's access to medication abortion by expanding the provider base to include ayurvedic physicians and nurses.

Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India.

BACKGROUND: Although legal, access to safe abortion remains limited in India. Given positive experiences of task-shifting from other developing countries, there is a need to explore the feasibility of expanding the manual vacuum aspiration (MVA) provider base to include nurses in India. STUDY DESIGN: A prospective, two-sided equivalence study was undertaken in five facilities of a non-government organisation in Bihar and Jharkhand to explore whether efficacy and safety rates associated with MVA provided by newly trained nurses were equivalent to those provided by physicians. Eight hundred and ninety-seven consenting women with gestation ages of ≤ 10 weeks were recruited. RESULTS: Nurses were as skilled as physicians in assessing gestation age and completed abortion status, performing MVA and obtaining patient compliance. Overall failure and complication rates were low and equivalent between the two provider types, and both provider types were equally acceptable to women who underwent the procedure (98%). CONCLUSION: Findings of the study make a compelling case for amending existing laws to expand the MVA provider base in order to increase access to safe abortion in India.

The need for investigations to elucidate causes and effects of abnormal uterine bleeding.

This article describes a modern perspective on the basic investigations for abnormal uterine bleeding (AUB) in low-resource settings compared with a much more detailed approach for high-resource settings, bearing in mind issues of effectiveness and cost effectiveness. AUB includes any one or more of several symptoms, and it should be evaluated for the characteristics of the woman's specific bleeding pattern, her "complaint" and the presence of other symptoms (especially pain), the impact on several aspects of body functioning and lifestyle, and the underlying cause(s), especially cancer. Ideally, the evaluation is comprehensive, considering each of the potential etiological domains defined by the International Federation of Gynecology and Obstetrics PALM-COEIN system for the classification of causes. However, the detail of the questions and the extent of investigations will be significantly influenced by the technologies available and the time allotted for a consultation. In general, investigations should be performed only if they will make a material difference to the management approaches that can be offered. This should be an important consideration when a range of costly high-technology tests is accessible or when certain tests only have limited availability.

Management of abnormal uterine bleeding in low- and high-resource settings: consideration of cultural issues.

In non industrialized countries the incidence of heavy menstrual bleeding (HMB) appears to be similar to that of industrialized countries, although data is scanty. In low-resource settings, women with abnormal uterine bleeding (AUB) often delay seeking medical care because of cultural beliefs that a heavy red menstrual bleed is healthy. Efforts to modify cultural issues are being considered. A detailed history and a meticulous examination are the important foundations of a definitive diagnosis and management in low-resource settings but are subject to time constraints and skill levels of the small numbers of health professionals. Women's subjective assessment of blood loss should be combined, if possible, with a colorimetric hemoglobin assessment, if full blood count is not possible. Outpatient endometrial sampling, transvaginal sonography, and hysteroscopy are available in some non industrialized countries but not in the lowest resource settings. After exclusion of serious underlying pathology, hematinics should be commenced and antifibrinolytic or nonsteroidal anti-inflammatory drugs considered during menses to control the bleeding. Intrauterine or oral progestogens or the combined oral contraceptive are often the most cost-effective long-term medical treatments. When medical treatment is inappropriate or has failed, the surgical options available most often are myomectomy or hysterectomy. Hysteroscopic endometrial resection or newer endometrial ablation procedures are available in some centers. If hysterectomy is indicated the vaginal route is the most appropriate in most low-resource settings. In low-resource settings, lack of resources of all types can lead to empirical treatments or reliance on the unproven therapies of traditional healers. The shortage of human resources is often compounded by a limited availability of operative time. Governments and specialist medical organizations have rarely included attention to AUB and HMB in their health programs. Local guidelines and attention to training of doctors, midwives, and traditional health workers are critical for prevention and improvement in management of HMB and its consequences for iron deficiency anemia and postpartum hemorrhage, the major killer of young women in developing countries.

Evaluation of a network of medical abortion providers in two districts of Maharashtra, India.

The objective of this study was to examine experiences and service delivery of private medical doctors participating in a professional network designed to improve knowledge and service quality of medical abortion (MA) procedures. A cross-sectional assessment of 87 Medical Abortion Provider Network (MAPnet) participants was conducted between December 2006 and January 2007 to describe participants' service delivery and network experiences. After participating in MAPnet, providers reported a statistically significant amount of more MA services (92%), national protocol adherence for timing of drug administration (93%) and drug dosage protocols (82%) when compared to their reports before MAPnet affiliation. In addition, MAPnet providers offered contraceptive counselling (100%) and pain management (54%). Nearly three-quarters of providers were interested in continuing their association with the network initiatives. However, the network failed to adequately facilitate inter-network sharing of knowledge and experiences. These findings suggest that establishing and nurturing a network of private medical doctors can improve availability and quality of safe and early abortion services through MA.