Determinants of stunting among children under 2 years in urban informal settlements in Mumbai, India: evidence from a household census.

BACKGROUND: There is limited evidence on the determinants of childhood stunting across urban India or specifically in slum settlements. This study aims to assess the extent of stunting among children under 2 years of age and examine its determinants in informal settlements of Mumbai. METHODS: Data were collected in 2014-2015 in a post intervention census of a cluster randomized controlled trial to improve the health of women and children. Census covered 40 slum settlements of around 600 households each. A total of 3578 children were included in the study. Mixed effects logistic regression models were used to identify factors associated with stunting. RESULTS: The prevalence of stunting among children aged 0-23 months was 38%. In the adjusted model, higher maternal education (AOR 0.59; 95% CI 0.42, 0.82), birth interval of at least 2 years (AOR 0.71; 95% CI 0.58, 0.87) and intended conception of the child (AOR 0.80; 95% CI 0.64, 0.99) were associated with lower odds of stunting. Maternal exposure to physical violence (AOR 1.83; 95% CI 1.21, 2.77) was associated with higher odds of being stunted. A child aged 18-23 months had 5.04 times greater odds (95% CI 3.91, 6.5) of being stunted than a child less than 6 months of age. Male child had higher odds of being stunted (AOR 1.33; 95% CI 1.14, 1.54). CONCLUSIONS: Our findings support a multidimensional aetiology for stunting. The results of the study emphasize the importance of women's status and decision-making power in urban India, along with access to and uptake of family planning and services to provide support for survivors of domestic violence. Ultimately, a multilateral effort is needed to ensure the success of nutrition-specific interventions by focusing on the underlying health and social status of women living in urban slums. TRIAL REGISTRATION: ISRCTN Register: ISRCTN56183183 , and Clinical Trials Registry of India: CTRI/2012/09/003004.

Effectiveness of NGO-government partnership to prevent and treat child wasting in urban India.

This study reviews the performance of a community-based nutrition programme in preventing and treating wasting without complications among children under age three in urban informal settlements of India. Implemented by a non-profit organization, with national (Integrated Child Development Services [ICDS]) and city-level (Municipal Corporation of Greater Mumbai [MCGM]) government partners, the programme screened 7,759 children between May 2014 and April 2015. During this period, the programme admitted 705 moderately wasted and 189 severely wasted children into the treatment group and 6,820 not wasted children into the prevention group. Both prevention and treatment groups received growth monitoring, referrals to public health facilities, and home-based counselling (if <6 months) by community health workers. Treatment groups received additional home-based counselling and access to medical screenings. Severely wasted children also received access to ready-to-use therapeutic food. The study assessed default rates, wasting status, and average weight gain 3 months after admission. Factors associated with growth faltering in the prevention group were explored using logistic regression. Default rates for the severely wasted, moderately wasted, and prevention group were 12.7%, 20.4%, and 22.1%, respectively. Recovery rate was 42.4% for the severely wasted and 61.3% for the moderately wasted. For the moderately wasted, mean weight gain was 2.1 g/kg/day, 95% confidence interval (CI) [1.6, 2.6], and 4.5 g/kg/day for the severely wasted, 95% CI [3.1, 5.9]. Among prevention group children, 3.6% faltered into wasting-3.2% into moderate and 0.4% into severe. The paper gives insights into ways in which ICDS and MCGM can successfully integrate large-scale community-based acute malnutrition programming.

Participation of pregnant women in a community-based nutrition program in Mumbai's informal settlements: Effect on exclusive breastfeeding practices.

BACKGROUND: In urban Maharashtra, India, approximately half of mothers exclusively breastfeed. For children residing in informal settlements of Mumbai, this study examines factors associated with exclusive breastfeeding, and whether exclusive breastfeeding, in a community-based nutrition program to prevent and treat wasting among children under age three, is associated with enrolment during the mother's pregnancy. METHODS: The nutrition program conducted a cross-sectional endline survey (October-December 2015) of caregivers in intervention areas. Factors associated with exclusive breastfeeding for infants under six months of age were explored using multi-level logistic regressions. Additionally, program surveillance data collected during home-based counselling visits documented breastfeeding practices for children under six months of age. Using the surveillance data (January 2014-March 2016), exclusive breastfeeding status was regressed adjusting for child, maternal and socioeconomic characteristics, and whether the child was enrolled in the program in utero or after birth. RESULTS: The community-based endline survey included 888 mothers of infants. Mothers who received the nutrition program home visits or attended group counselling sessions were more likely to exclusively breastfeed (adjusted odds ratio 1.67, 95% CI 1.16, 2.41). Having a normal weight-for-height z-score (adjusted odds ratio 1.57, 95% CI 1.00, 2.45) was associated positively with exclusive breastfeeding. As expected, being an older infant aged three to five months (adjusted odds ratio 0.34, 95% CI 0.25, 0.48) and receiving a prelacteal feed after birth (adjusted odds ratio 0.57, 95% CI 0.41, 0.80) were associated with lower odds of exclusively breastfeeding. Surveillance data (N = 3420) indicate that infants enrolled in utero have significantly higher odds of being exclusively breastfed (adjusted odds ratio 1.55, 95% CI 1.30, 1.84) than infants enrolled after birth. CONCLUSIONS: Prenatal enrolment in community-based programs working on child nutrition in urban informal settlements of India can improve exclusive breastfeeding practices.

Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation.

BACKGROUND: We evaluated an adaptation of a large-scale community-based management of acute malnutrition program run by an NGO with government partnerships, in informal settlements of Mumbai, India. The program aimed to reduce the prevalence of wasting among children under age 3 and covered a population of approximately 300,000. METHODS: This study used a mixed-methods approach including a quasi-experimental design to compare prevalence estimates of wasting in intervention areas with neighboring informal settlements. Cross-sectional data were collected from March through November 2014 for the baseline and October through December 2015 for the endline. Endline data were analyzed using mixed-effects logistic regression models, adjusting for child, maternal, and household characteristics. In addition, we conducted in-depth interviews with 37 stakeholders (13 staff and 24 mothers) who reported on salient features that contributed to successful implementation of the program. RESULTS: We interviewed 2,578 caregivers at baseline and 3,455 at endline in intervention areas. In comparison areas, we interviewed 2,082 caregivers at baseline and 2,122 at endline. At endline, the prevalence of wasting decreased by 28% (18% to 13%) in intervention areas and by 5% (16.9% to 16%) in comparison areas. Analysis of the endline data indicated that children in intervention areas were significantly less likely to be malnourished (adjusted odds ratio, 0.81; confidence interval, 0.67 to 0.99). Stakeholders identified 4 main features as contributing to the success of the program: (1) tailoring and reinforcement of information provided to caregivers in informal settings, (2) constant field presence of staff, (3) holistic case management of issues beyond immediate malnourishment, and (4) persistence of field staff in persuading reluctant families. Staff capabilities were enhanced through training, stringent monitoring mechanisms, and support from senior staff in tackling difficult cases. CONCLUSION: NGO-government partnerships can revitalize existing community-based programs in urban India. Critical to success are processes that include reinforced knowledge-building of caregivers, a high level of field support and encouragement to the community, and constant monitoring and follow-up of cases by all staff levels.

Effects of women's groups practising participatory learning and action on preventive and care-seeking behaviours to reduce neonatal mortality: A meta-analysis of cluster-randomised trials.

BACKGROUND: The World Health Organization recommends participatory learning and action (PLA) in women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women's groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction. METHODS AND FINDINGS: We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women's group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women's groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02-4.22; I2 = 63.7%, 95% CI 4.4%-86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25-2.82; 67.6%, 16.1%-87.5%), birth attendant washing hands prior to delivery (1.87, 1.19-2.95; 79%, 53.8%-90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09-1.99; 68.0%, 29.2%-85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02-1.60; 0.0%, 0%-79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77-1.38; I2 = 86.3%, 95% CI 73.8%-92.8%), facility delivery (1.02, 0.93-1.12; 21.4%, 0%-65.8%), initiating breastfeeding within 1 hour (1.08, 0.85-1.39; 76.6%, 50.9%-88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93-1.48; 72.9%, 37.8%-88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women's groups and context-specific effects. CONCLUSIONS: This meta-analysis suggests that women's groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents.

Examining inequalities in uptake of maternal health care and choice of provider in underserved urban areas of Mumbai, India: a mixed methods study.

BACKGROUND: Discussions of maternity care in developing countries tend to emphasise service uptake and overlook choice of provider. Understanding how families choose among health providers is essential to addressing inequitable access to care. Our objectives were to quantify the determinants and choice of maternity care provider in Mumbai's informal urban settlements, and to explore the reasons underlying their choices. METHODS: The study was conducted in informal urban communities in eastern Mumbai. We developed regression models using data from a census of married women aged 15-49 to test for associations between maternal characteristics and uptake of care and choice of provider. We then conducted seven focus group discussions and 16 in-depth interviews with purposively selected participants, and used grounded theory methods to examine the reasons for their choices. RESULTS: Three thousand eight hundred forty-eight women who had given birth in the preceding 2 years were interviewed in the census. The odds of institutional prenatal and delivery care increased with education, economic status, and duration of residence in Mumbai, and decreased with parity. Tertiary public hospitals were the commonest site of care, but there was a preference for private hospitals with increasing socio-economic status. Women were more likely to use tertiary public hospitals for delivery if they had fewer children and were Hindu. The odds of delivery in the private sector increased with maternal education, wealth, age, recent arrival in Mumbai, and Muslim faith. Four processes were identified in choosing a health care provider: exploring the options, defining a sphere of access, negotiating autonomy, and protective reasoning. Women seeking a positive health experience and outcome adopted strategies to select the best or most suitable, accessible provider. CONCLUSIONS: In Mumbai's informal settlements, institutional maternity care is the norm, except among recent migrants. Poor perceptions of primary public health facilities often cause residents to bypass them in favour of tertiary hospitals or private sector facilities. Families follow a complex selection process, mediated by their ability to mobilise economic and social resources, and a concern for positive experiences of health care and outcomes. Health managers must ensure quality services, a functioning regulatory mechanism, and monitoring of provider behaviour.

Sweat, Skepticism, and Uncharted Territory: A Qualitative Study of Opinions on Data Sharing Among Public Health Researchers and Research Participants in Mumbai, India.

Efforts to internalize data sharing in research practice have been driven largely by developing international norms that have not incorporated opinions from researchers in low- and middle-income countries. We sought to identify the issues around ethical data sharing in the context of research involving women and children in urban India. We interviewed researchers, managers, and research participants associated with a Mumbai non-governmental organization, as well as researchers from other organizations and members of ethics committees. We conducted 22 individual semi-structured interviews and involved 44 research participants in focus group discussions. We used framework analysis to examine ideas about data and data sharing in general; its potential benefits or harms, barriers, obligations, and governance; and the requirements for consent. Both researchers and participants were generally in favor of data sharing, although limited experience amplified their reservations. We identified three themes: concerns that the work of data producers may not receive appropriate acknowledgment, skepticism about the process of sharing, and the fact that the terrain of data sharing was essentially uncharted and confusing. To increase data sharing in India, we need to provide guidelines, protocols, and examples of good practice in terms of consent, data preparation, screening of applications, and what individuals and organizations can expect in terms of validation, acknowledgment, and authorship.

Best Practices for Ethical Sharing of Individual-Level Health Research Data From Low- and Middle-Income Settings.

Sharing individual-level data from clinical and public health research is increasingly being seen as a core requirement for effective and efficient biomedical research. This article discusses the results of a systematic review and multisite qualitative study of key stakeholders' perspectives on best practices in ethical data sharing in low- and middle-income settings. Our research suggests that for data sharing to be effective and sustainable, multiple social and ethical requirements need to be met. An effective model of data sharing will be one in which considered judgments will need to be made about how best to achieve scientific progress, minimize risks of harm, promote fairness and reciprocity, and build and sustain trust.

Malnutrition and infant and young child feeding in informal settlements in Mumbai, India: findings from a census.

Childhood malnutrition remains common in India. We visited families in 40 urban informal settlement areas in Mumbai to document stunting, wasting, and overweight in children under five, and to examine infant and young child feeding (IYCF) in children under 2 years. We administered questions on eight core WHO IYCF indicators and on sugary and savory snack foods, and measured weight and height of children under five. Stunting was seen in 45% of 7450 children, rising from 15% in the first year to 56% in the fifth. About 16% of children were wasted and 4% overweight. 46% of infants were breastfed within the first hour, 63% were described as exclusively breastfed under 6 months, and breastfeeding continued for 12 months in 74%. The indicator for introduction of solids was met for 41% of infants. Only 13% of children satisfied the indicator for minimum dietary diversity, 43% achieved minimum meal frequency, and 5% had a minimally acceptable diet. About 63% of infants had had sugary snacks in the preceding 24 h, rising to 78% in the second year. Fried and salted snack foods had been eaten by 34% of infants and 66% of children under two. Stunting and wasting remain unacceptably common in informal settlements in Mumbai, and IYCF appears problematic, particularly in terms of dietary diversity. The ubiquity of sugary, fried, and salted snack foods is a serious concern: substantial consumption begins in infancy and exceeds that of all other food groups except grains, roots, and tubers.

Intimate partner violence against women during and after pregnancy: a cross-sectional study in Mumbai slums.

BACKGROUND: At least one-third of women in India experience intimate partner violence (IPV) at some point in adulthood. Our objectives were to describe the prevalence of IPV during pregnancy and after delivery in an urban slum setting, to review its social determinants, and to explore its effects on maternal and newborn health. METHODS: We did a cross-sectional study nested within the data collection system for a concurrent trial. Through urban community surveillance, we identified births in 48 slum areas and interviewed mothers ~6 weeks later. After collecting information on demographic characteristics, socioeconomic indicators, and maternal and newborn care, we asked their opinions on the justifiability of IPV and on their experience of it in the last 12 months. RESULTS: Of 2139 respondents, 35% (748) said that violence was justifiable if a woman disrespected her in-laws or argued with her husband, failed to provide good food, housework and childcare, or went out without permission. 318 (15%, 95% CI 13, 16%) reported IPV in the year that included pregnancy and the postpartum period. Physical IPV was reported by 247 (12%, 95% CI 10, 13%), sexual IPV by 35 (2%, 95% CI 1, 2%), and emotional IPV by 167 (8%, 95% CI 7, 9). 219 (69%) women said that the likelihood of IPV was either unaffected by or increased during maternity. IPV was more likely to be reported by women from poorer families and when husbands used alcohol. Although 18% of women who had suffered physical IPV sought clinical care for their injuries, seeking help from organizations outside the family to address IPV itself was rare. Women who reported IPV were more likely to have reported illness during pregnancy and use of modern methods of family planning. They were more than twice as likely to say that there were situations in which violence was justifiable (odds ratio 2.6, 95% CI 1.7, 3.4). CONCLUSIONS: One in seven women suffered IPV during or shortly after pregnancy. The elements of the violent milieu are mutually reinforcing and need to be taken into account collectively in responding to both individual cases and framing public health initiatives.

Community resource centres to improve the health of women and children in Mumbai slums: study protocol for a cluster randomized controlled trial.

BACKGROUND: The trial addresses the general question of whether community resource centers run by a non-government organization improve the health of women and children in slums. The resource centers will be run by the Society for Nutrition, Education and Health Action, and the trial will evaluate their effects on a series of public health indicators. Each resource center will be located in a vulnerable Mumbai slum area and will serve as a base for salaried community workers, supervised by officers and coordinators, to organize the collection and dissemination of health information, provision of services, home visits to identify and counsel families at risk, referral of individuals and families to appropriate services and support for their access, meetings of community members and providers, and events and campaigns on health issues. METHODS/DESIGN: A cluster randomized controlled trial in which 20 urban slum areas with resource centers are compared with 20 control areas. Each cluster will contain approximately 600 households and randomized allocation will be in three blocked phases, of 12, 12 and 16 clusters. Any resident of an intervention cluster will be able to participate in the intervention, but the resource centers will target women and children, particularly women of reproductive age and children under 5.The outcomes will be assessed through a household census after 2 years of resource center operations. The primary outcomes are unmet need for family planning in women aged 15 to 49 years, proportion of children under 5 years of age not fully immunized for their ages, and proportion of children under 5 years of age with weight for height less than 2 standard deviations below the median for age and sex. Secondary outcomes describe adolescent pregnancies, home deliveries, receipt of conditional cash transfers for institutional delivery, other childhood anthropometric indices, use of public sector health and nutrition services, indices of infant and young child feeding, and consultation for violence against women and children. TRIAL REGISTRATION: ISRCTN Register: ISRCTN56183183Clinical Trials Registry of India: CTRI/2012/09/003004.