Saseendran Pallikadavath

HIV/AIDS in rural India: context and health care needs.

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their childrens care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations.

Socio-Economic Inequalities in the Use of Postnatal Care in India

Objectives First, our objective was to estimate socio-economic inequalities in the use of postnatal care (PNC) compared with those in the use of care at birth and antenatal care. Second, we wanted to compare inequalities in the use of PNC between facility births and home births and to determine inequalities in the use of PNC among mothers with high-risk births. Methods and Findings Rich–poor ratios and concentration indices for maternity care were estimated using the third round of the District Level Household Survey conducted in India in 2007–08. Binary logistic regression models were used to examine the socio-economic inequalities associated with use of PNC after adjusting for relevant socio-economic and demographic characteristics. PNC for both mothers and newborns was substantially lower than the care received during pregnancy and child birth. Only 44% of mothers in India at the time of survey received any care within 48 hours after birth. Likewise, only 45% of newborns received check-up within 24 hours of birth. Mothers who had home births were significantly less likely to have received PNC than those who had facility births, with significant differences across the socio-economic strata. Moreover, the rich-poor gap in PNC use was significantly wider for mothers with birth complications. Conclusions PNC use has been unacceptably low in India given the risks of mortality for mothers and babies shortly after birth. However, there is evidence to suggest that effective use of pregnancy and childbirth care in health facilities led to better PNC. There are also significant socio-economic inequalities in access to PNC even for those accessing facility-based care. The coverage of essential PNC is inadequate, especially for mothers from economically disadvantaged households. The findings suggest the need for strengthening PNC services to keep pace with advances in coverage for care at birth and prenatal services in India through targeted policy interventions.

Inequalities in advice provided by public health workers to women during antenatal sessions in rural India

Objectives Studies have widely documented the socioeconomic inequalities in maternal and child health related outcomes in developing countries including India. However, there is limited research on the inequalities in advice provided by public health workers on maternal and child health during antenatal visits. This paper investigates the inequalities in advice provided by public health workers to women during antenatal visits in rural India. Methods and Findings The District Level Household Survey (2007–08) was used to compute rich-poor ratios and concentration indices. Binary logistic regressions were used to investigate inequalities in advice provided by public health workers. The dependent variables comprised the advice provided on seven essential components of maternal and child health care. A significant proportion of pregnant women who attended at least four ANC sessions were not advised on these components during their antenatal sessions. Only 51%–72% of the pregnant women were advised on at least one of the components. Moreover, socioeconomic inequalities in providing advice were significant and the provision of advice concentrated disproportionately among the rich. Inequalities were highest in the case of advice on family planning methods. Advice on breastfeeding was least unequal. Public health workers working in lower level health facilities were significantly less likely than their counterparts in the higher level health facilities to provide specific advice. Conclusion A significant proportion of women were not advised on recommended components of maternal and child health in rural India. Moreover, there were enormous socioeconomic inequalities. The findings of this study raise questions about the capacity of the public health care system in providing equitable services in India. The Government of India must focus on training and capacity building of the public health workers in communication skills so that they can deliver appropriate and recommended advice to all clients, irrespective of their socioeconomic status.

Maternal Tetanus Toxoid Vaccination and Neonatal Mortality in Rural North India

Objectives Preventable neonatal mortality due to tetanus infection remains common. We aimed to examine antenatal vaccination impact in a context of continuing high neonatal mortality in rural northern India. Methods and Findings Using the third round of the Indian National Family Health Survey (NFHS) 2005–06, mortality of most recent singleton births was analysed in discrete-time logistic model with maternal tetanus vaccination, together with antenatal care utilisation and supplementation with iron and folic acid. 59% of mothers reported receiving antenatal care, 48% reported receiving iron and folic acid supplementation and 68% reported receiving two or more doses of tetanus toxoid (TT) vaccination. The odds of all-cause neonatal death were reduced following one or more antenatal dose of TT with odds ratios (OR) of 0.46 (95% CI 0.26 to 0.78) after one dose and 0.45 (95% CI 0.31 to 0.66) after two or more doses. Reported utilisation of antenatal care and iron-folic acid supplementation did not influence neonatal mortality. In the statistical model, 16% (95% CI 5% to 27%) of neonatal deaths could be attributed to a lack of at least two doses of TT vaccination during pregnancy, representing an estimated 78,632 neonatal deaths in absolute terms. Conclusions Substantial gains in newborn survival could be achieved in rural North India through increased coverage of antenatal TT vaccination. The apparent substantial protective effect of a single antenatal dose of TT requires further study. It may reflect greater population vaccination coverage and indicates that health programming should prioritise universal antenatal coverage with at least one dose.

Sterilization regret among married women in India: implications for the Indian National Family Planning Program

CONTEXT In India, female sterilization accounts for 66% of contraceptive use, and age at sterilization is declining. It is likely that some women regret having been sterilized, but data on the prevalence of, and the social and economic correlates of, regret at the national level are insufficient. METHODS Data for analysis came from 30,999 sterilized women aged 15-49 interviewed in the 2005-2006 Indian National Family Health Survey. Logistic regression analyses and Wald tests were used to identify the social and demographic characteristics associated with sterilization regret. RESULTS Nationally, 5% of sterilized women aged 15-49 reported sterilization regret. Women sterilized at age 30 or older were less likely than women sterilized before age 25 to express regret (odds ratio, 0.8). Compared with women having only sons, those who had only daughters were more likely to express regret (1.3), while those having both sons and daughters were less likely to express regret (0.8). Women who had experienced child loss had higher odds of reporting regret than women who had not (for one child lost, 1.6; for two or more children lost, 2.0). CONCLUSIONS Given the large proportion of women undergoing sterilization, the potential numbers experiencing regret are considerable. If age at sterilization continues to decline, sterilization regret is likely to increase. Encouraging couples to delay sterilization and increasing the availability of highly effective reversible contraceptives are options that India may consider to avert sterilization regret.

Do antenatal care interventions improve neonatal survival in India

Although antenatal care (ANC) interventions have been in place for a long time, there is hardly any systematic evidence on the association between ANC interventions and neonatal mortality in India. The present study attempts to investigate the association between ANC interventions and neonatal mortality in India using data from the District Level Household Survey conducted in India during 2007-8. The ANC interventions included in the analysis are at least four antenatal visits, consumption of 90 or more iron-folic acid (IFA) tablets, and uptake of two or more tetanus toxoid (TT) injections. We have used discrete-time logistic regression models to investigate the association between ANC interventions and neonatal mortality. Risk of neonatal mortality was significantly lower for infants of mothers who availed four or more antenatal visits [odds ratio (OR): 0.69; 95% confidence interval (CI): 0.60-0.81], consumed 90 or more IFA tablets (OR: 0.85; 95% CI: 0.73-0.99), received two or more TT injections (OR: 0.73; 95% CI: 0.63-0.83). When we analysed different combinations of antenatal visits, IFA supplementation and TT injections, TT injections provided the main protective effect-the risk of neonatal mortality was significantly lower in newborns of women who received two or more TT injections but did not consume 90 or more IFA tablets (OR: 0.69; 95% CI: 0.60-0.78), or who received two or more TT injections but did not avail four or more antenatal visits (OR: 0.75; 95% CI: 0.66-0.86). In the statistical model, 6% (95% CI: 4-8%) of the neonatal deaths in India could be attributed to a lack of at least two TT injections during pregnancy. Indian public health programmes must ensure that every pregnant woman receives two or more TT injections during antenatal visits.

The cost of being a man: social and health consequences of Igbo masculinity

In the bid to explain reproductive health outcomes in most developing countries, men have often been seen as the cause of the problem. However, no systematic attempt has been made to examine mens perception of their own social and health needs, including how ideologies of masculinity impact mens social and physical health. This study examines the Igbo context and shows how men understand and interpret masculinity and the consequences of this for social and health behaviours. Data from adolescent and adult Igbo men aged 15–75 were collected using both quantitative survey interviews (n = 1372) and qualitative techniques such as focus-group discussion (n = 20), in-depth interviews (n = 10) and key informant interviews (n = 10) in selected areas of south-eastern Nigeria. We collected data on gender role ideologies and sexuality issues and practices. Our analysis shows that there are social and health costs associated with adherence to masculine ideologies and a strong association between masculine ideologies and mens health, risk-taking and health-seeking behaviours in the study population. We conclude that all sexual and reproductive health programmes should include services that address the specific needs of men and those negative aspects of masculinity that tend to expose men to adverse health outcomes.

Women's reproductive health, sociocultural context and AIDS knowledge in Northern India

This paper identifies sociocultural and reproductive health correlates of knowledge about HIV among ever-married women using 1998–99 National Family Health Survey data from two low HIV prevalence Indian states, Madhya Pradesh (MP) and Uttar Pradesh (UP). Logistic regressions were undertaken modelling women’s awareness of HIV, of whether the disease can be avoided and of effective means of protection. In MP 22.7 per cent women were aware of HIV; 56.4 per cent (of 22.7 per cent) knew that the disease can be avoided; and 47.5 per cent (of 56.4 per cent) possessed correct knowledge about effective means of protection. In UP 20.7 per cent women had awareness of HIV; 59.2 per cent (of 20.7 per cent) knew that the disease can be avoided; and 45.7 per cent (of 59.2 per cent) were informed about effective means of protection. In both states older, uneducated, rural, poor, those not exposed to television, and those who had never used a modern family planning method were less likely to possess HIV awareness. However, for women who were aware of HIV, acquisition of further knowledge about it had fewer socioeconomic barriers. These barriers were state specific so interventions to overcome them need to be highly focused.

Post-sterilization autonomy among young mothers in South India.

This study examined the post-sterilization autonomy of women in south India in the context of early sterilization and low fertility. Quantitative data were taken from the third round of the National Family Health Survey (NFHS-3) carried out in 2005-06, and qualitative data from one village each in Kerala and Tamil Nadu during 2010-11. The incident rate ratios and thematic analysis showed that among currently married women under the age of 30 years, those who had been sterilized had significantly higher autonomy in household decision-making and freedom of mobility compared with women who had never used any modern family planning method. Early age at sterilization and low fertility enables women to achieve the social status that is generally attained at later stages in the life-cycle. Policies to capitalize on womens autonomy and free time resulting from early sterilization and low fertility should be adopted in south India.

How much do conditional cash transfers increase the utilization of maternal and child health care services? New evidence from Janani Suraksha Yojana in India

&NA; Janani Suraksha Yojana (safe motherhood scheme, or JSY) provides cash incentives to marginal pregnant women in India conditional on having mainly institutional delivery. Using the fourth round of district level household survey (DLHS‐4), we have estimated its effects on both intended and unintended outcomes. Our estimates of average treatment effect on the treated (ATT) from propensity score matching are remarkably higher than those found in previous prominent studies using the second and third rounds of the survey (DLHS‐2 and DLHS‐3). When we apply fuzzy regression discontinuity design exploiting the second birth order, our estimates of local average treatment effect (LATE) are much higher than that of ATT. For example, due to JSY, institutional delivery increases by around 16 percentage points according to ATT estimate but about 23 percentage points according to LATE estimate.