Factors associated with stillbirths in Haryana, India: a qualitative study.

Background: Each year, 2.6 million babies are stillborn worldwide, almost all in low- and middle-income countries. Several global initiatives, including the Sustainable Development Goals and the Every Newborn Action Plan, have contributed to a renewed focus on prevention of stillbirths. Despite being relatively wealthy, the state of Haryana in India has a significant stillbirth rate. This qualitative study explored the factors that might contribute to these stillbirths. Methods: This was a sub-study of a case-control study of factors associated with stillbirth in 15 of the 21 districts of Haryana in 2014-2015. A total of 43 in-depth interviews were conducted with mothers who had recently experienced a stillbirth, or with a family member. By use of reflexive and inductive qualitative methodology, the data set was coded to allow categories to emerge. Results: Two categories and several subcategories were identified. First, factors occurring before the woman reached a health-care facility were: lack of awareness of the mothers and family members; intake of sex-selection drugs during pregnancy, in order to have a male child; non-adherence to treatment for high blood pressure; lack of prior identification of an appropriate health-care facility for delivery; and transportation to a health-care facility for delivery. Second, factors occurring once the health-care facility was reached were: lack of timely and adequate management; and use of medication during labour. Conclusion: Intrapartum stillbirths are closely linked to the availability and accessibility of appropriate medical care. Timely and appropriate treatment and care, provided by a trained and skilled health worker during pregnancy and labour, as well as soon after delivery, is an absolute requirement for averting these stillbirths. This study underscores the importance of imparting and increasing awareness regarding factors that have a significant bearing on stillbirth and can be mitigated through prompt and adequate obstetric health-care services.

Improving reporting of infant deaths, maternal deaths and stillbirths in Haryana, India.

Underreporting hampers the accurate estimation of the numbers of infant and maternal deaths and stillbirths in India. In Haryana state, a surveillance-based model - the Maternal Infant Death Review System - was launched in 2013 to try to resolve this issue. The system is a mixture of routine passive data collection and active surveillance by specially recruited and trained field volunteers. The volunteers gather the relevant data from child day-care centres, community health centres, cremation grounds, hospitals, the municipal corporation's offices and primary health centres and regularly visit health subcentres. The collected data are triangulated against the standard death registers and discussions with relevant community members. The details of any unregistered death are rapidly uploaded on the system's web-based platform. In April 2014, we made field observations, reviewed records and conducted in-depth interviews with the key stakeholders to see if the system's performance matched the state government's planned objectives. The data collected indicate that implementation of the system has led to quantitative and qualitative improvements in reporting of infant and maternal deaths and stillbirths. Completeness and consistency in the reporting of deaths are essential for focused policy and programmatic interventions and there remains scope for improvement in Haryana via further reform and changes in policy. The model in its current form is potentially sustainable and scalable in similar settings elsewhere.

En Inde, le sous-signalement empêche d'estimer correctement le nombre de décès infantiles et maternels et de mortinaissances. Dans l'État d'Haryana, un modèle basé sur la surveillance ­ le Maternal Infant Death Review System ­ a été lancé en 2013 afin de tenter de résoudre ce problème. Ce système mélange recueil passif de données de routine et surveillance active par des bénévoles de terrain spécialement recrutés et formés à cet effet. Ces derniers recueillent des données auprès de garderies, de centres de santé communautaires, de crématoriums, d'hôpitaux, de centres de soins primaires et des bureaux des municipalités et se rendent régulièrement dans des centres de soins secondaires. Les données ainsi recueillies sont triangulées par rapport aux registres standards des décès et aux discussions avec des membres de la communauté. Les détails de tout décès non enregistré sont rapidement chargés sur la plate-forme Internet du système. En avril 2014, nous avons effectué des observations de terrain, examiné des registres et mené des entretiens approfondis avec les principales parties prenantes afin de voir si les performances du système répondaient aux objectifs du gouvernement de l'État. Les données recueillies indiquent que la mise en œuvre de ce système a entraîné une amélioration quantitative et qualitative du signalement des décès infantiles et maternels ainsi que des mortinaissances. L'exhaustivité et la cohérence du signalement des décès sont essentielles pour avoir des politiques ciblées et des interventions programmatiques, et l'État d'Haryana présente d'autres possibilités d'amélioration, via d'autres réformes et des changements stratégiques. Le modèle, dans sa forme actuelle, est potentiellement utilisable à long terme et transposable dans des lieux similaires.

La escasez de informes obstaculiza una estimación exacta de las cifras de muertes maternas e infantiles y mortinatos en India. En 2013, en el estado de Haryana, se lanzó un modelo basado en el seguimiento (el Sistema de Análisis de la Mortalidad Infantil y Materna) para tratar de resolver este problema. El sistema combina una recopilación de datos rutinarios pasivos y un seguimiento activo realizados por voluntarios contratados capacitados en este campo. Los voluntarios reúnen información relevante de guarderías, centros de salud, terrenos destinados a incineraciones, hospitales, oficinas de la corporación municipal y centros de atención primaria, y visitan con asiduidad subcentros de salud. Los datos recopilados se triangulan según los registros normalizados de fallecimientos y análisis con miembros relevantes de la comunidad. Los detalles sobre todas las muertes no registradas se introducen con rapidez en la plataforma en línea del sistema. En abril de 2014, se realizaron observaciones de campo, se analizaron los registros y se llevaron a cabo entrevistas en profundidad con las partes interesadas fundamentales para comprobar que el rendimiento del sistema se equiparaba con los objetivos planificados por el gobierno estatal. Los datos recopilados indican que la implementación del sistema logró mejoras cuantitativas y cualitativas a la hora de redactar informes sobre la mortalidad infantil y materna y los mortinatos. Es fundamental que los informes sobre los fallecimientos sean minuciosos y coherentes para poder realizar intervenciones políticas y programáticas, y sigue existiendo margen para implementar mejoras en Haryana mediante más reformas y cambios de las políticas. El modelo actual puede mantenerse y ampliarse en otras ubicaciones similares.

Consumption of indigenous medicines by pregnant women in North India for selecting sex of the foetus: what can it lead to?

BACKGROUND: Sex ratio is an important indicator of development. Despite all the measures undertaken for improvement, it remains an issue of concern in India, with Haryana having a very low sex ratio in the country. Studies have been conducted indicating that consumption of indigenous drugs used for sex selection (SSD) could be strongly associated with adverse effects on the foetal development, including congenital malformations. Some samples of SSDs were collected from parts of North India and analysed in a standard laboratory for its components. METHODS: Thirty SSDs used by the local community were procured from various sources in north India through a rigorous process of collection. These were subjected to laboratory tests to investigate the presence of phytoestrogen and testosterone. Following sample extraction, thin layer chromatography and high performance liquid chromatography were carried out for analysing phytoestrogen content. RESULTS: SSDs were available in various forms such as powder, tablets, mostly from faith healers. Around 87% of the samples collected from sources like doctors, quacks and faith healers were to be taken by the pregnant women after conception; 63% drugs were strongly positive for phytoestrogens (genistein, daidzein, formononetin) and 20% drugs were positive for testosterone. The average dose of the components as calculated after analyses was as follows: daidzein--14.1 mg/g sample, genistein--8.6 mg/g sample, formononetin--5 mg/g sample. CONCLUSION: These SSDs could be potentially detrimental to the growth and development of the foetus. This is likely to have implications on the health of the community. In view of the results obtained in our study, we strongly attest the importance in curbing this harmful practice by banning the supply of the drugs as well as by advocating behavioural changes in the community.

Indigenous Medicine Use for Sex Selection During Pregnancy and Risk of Congenital Malformations: A Population-Based Case-Control Study in Haryana, India.

INTRODUCTION: Congenital malformations (CMFs) are a major public health problem in India. Consanguineous marriages, infections during pregnancy, folic acid deficiency during the periconceptional period, exposure to pesticides and a history of intake of drugs during pregnancy have been hypothesized as risk factors. Drugs include oral contraceptive pills, progesterone analogues, medications for ailments and indigenous drugs to bear male offspring. It is important to analyze the risk factors in order to implement preventive measures. The prime objective of this study was to study the risk factors of visible structural CMFs, with a focus on indigenous medicines for sex selection. METHODS: A population-based, case-control study was undertaken in Haryana state. Cases included children (0-18 months) with any apparent structural deformity as reported by various Government sources. A consecutive birth from the same area as the case was labelled and included as the control. The sample size calculated was 175 in each group. Mothers of every case and control were interviewed at their respective homes using a structured tool. Descriptive analysis, bivariate analysis, followed by logistic regression was conducted to establish the association between risk factors and CMFs. RESULTS: The sociodemographic profiles of the cases and controls were similar. Among the various risk factors studied, more than two living children (unadjusted odds ratio [OR] 1.6, 95 % CI 1.04-2.4) and intake of sex-selection drugs (unadjusted OR 2.8, 95 % CI 1.6-5.1) were significant risk factors on bivariate and regression analyses. The risk of having a child with CMFs was threefold more among mothers with a history of intake of indigenous medicines for sex selection (adjusted OR 3; 95 % CI 1.7-5.6). CONCLUSIONS: The intake of indigenous drugs during pregnancy increased the risk of CMFs almost threefold. This has social as well as economic implications, and hence needs further investigation.

Risk factors for low birth weight in an Indian urban setting: a nested case control study.

This study explores the risk factors for low birth weight (LBW) in an urban Indian setting by using a nested case-control design. Information on potential risk factors was sought from 384 pregnant women attending an antenatal clinic, and they were followed until birth. Based on birth weight, the babies of these women were categorized as cases or controls. Bivariate analyses between each risk factor and birth weight showed an unadjusted significant association (P < .05) for maternal age ≤20 years, antenatal clinic registration after the first trimester, ≤5 antenatal visits, and <80% of the recommended dietary allowance (RDA) for calories and proteins. Multiple logistic regression analysis showed an adjusted significant association for calorie intake <80% RDA (P < .048), low zinc intake (P < .001), and ≤5 antenatal visits (P < .001). This study emphasizes the continuing importance of timely and regular antenatal visits and intake of appropriate amount of calories. The role of zinc as a risk factor for LBW warrants further research.

Ethnic differences in glycaemic control in people with type 2 diabetes mellitus living in Scotland.

BACKGROUND AND AIMS: Previous studies have investigated the association between ethnicity and processes of care and intermediate outcomes of diabetes, but there are limited population-based studies available. The aim of this study was to use population-based data to investigate the relationships between ethnicity and glycaemic control in men and women with diabetes mellitus living in Scotland. METHODS: We used a 2008 extract from the population-based national electronic diabetes database of Scotland. The association between ethnicity with mean glycaemic control in type 2 diabetes mellitus was examined in a retrospective cohort study, including adjustment for a number of variables including age, sex, socioeconomic status, body mass index (BMI), prescribed treatment and duration of diabetes. RESULTS: Complete data for analyses were available for 56,333 White Scottish adults, 2,535 Pakistanis, 857 Indians, 427 Chinese and 223 African-Caribbeans. All other ethnic groups had significantly (p<0.05) greater proportions of people with suboptimal glycaemic control (HbA1c >58 mmol/mol, 7.5%) compared to the White Scottish group, despite generally younger mean age and lower BMI. Fully adjusted odds ratios for suboptimal glycaemic control were significantly higher among Pakistanis and Indians (1.85, 95% CI: 1.68-2.04, and 1.62,95% CI: 1.38-1.89) respectively. CONCLUSIONS: Pakistanis and Indians with type 2 diabetes mellitus were more likely to have suboptimal glycaemic control than the white Scottish population. Further research on health services and self-management are needed to understand the association between ethnicity and glycaemic control to address ethnic disparities in glycaemic control.