Sutapa Bandyopadhyay Neogi

Birth Prevalence of Neural Tube Defects and Orofacial Clefts in India: A Systematic Review and Meta-Analysis

Background In the last two decades, India has witnessed a substantial decrease in infant mortality attributed to infectious disease and malnutrition. However, the mortality attributed to birth defects remains constant. Studies on the prevalence of birth defects such as neural tube defects and orofacial clefts in India have reported inconsistent results. Therefore, we conducted a systematic review of observational studies to document the birth prevalence of neural tube defects and orofacial clefts. Methods A comprehensive literature search for observational studies was conducted in MEDLINE and EMBASE databases using key MeSH terms (neural tube defects OR cleft lip OR cleft palate AND Prevalence AND India). Two reviewers independently reviewed the retrieved studies, and studies satisfying the eligibility were included. The quality of included studies was assessed using selected criteria from STROBE statement. Results The overall pooled birth prevalence (random effect) of neural tube defects in India is 4.5 per 1000 total births (95% CI 4.2 to 4.9). The overall pooled birth prevalence (random effect) of orofacial clefts is 1.3 per 1000 total births (95% CI 1.1 to 1.5). Subgroup analyses were performed by region, time period, consanguinity, and gender of newborn. Conclusion The overall prevalence of neural tube defects from India is high compared to other regions of the world, while that of orofacial clefts is similar to other countries. The majority of studies included in the review were hospital based. The quality of these studies ranged from low to moderate. Further well-designed, high quality community-based observational studies are needed to accurately estimate the burden of neural tube defects and orofacial clefts in India.

Does facility based newborn care improve neonatal outcomes? A review of evidence.

ContextFacility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality.ObjectiveTo assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes.Evidence acquisitionElectronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966–Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered.ResultsA total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories-regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths.ConclusionsCountries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.

Is intravenous iron sucrose the treatment of choice for pregnant anemic women

Anemia during pregnancy remains an important public health problem in developing countries like India. Anemia is the direct cause of 12–15% of maternal deaths. Iron deficiency is the commonest cause for anemia in the Indian subcontinent. Several preventive and therapeutic approaches are in practice. The available routes of iron supplementation are oral and intravenous. In spite of oral iron being least invasive, cheap and safe, the ineffectiveness of oral iron due to dietary inhibitors and poor compliance are well known. Intravenous iron sucrose can be a promising therapy for moderate to severely anemic pregnant women and has been in practice for quite some time in private and public health practices. In this article, we report the current evidence on the safety and efficacy of intravenous iron sucrose in anemic pregnant women on hematological and clinical outcomes. Though the evidence on its efficacy in improving hemoglobin and serum ferritin is convincing, its effect on maternal and fetal outcomes are unclear. This is primarily due to lack of well‐designed and larger studies powered to detect difference in clinical outcomes. Hence, there is a need to gather evidence from a well‐designed large randomized clinical trial conducted in a developing country. The results of such a study would feed into the national policy and would form the basis to frame guidelines for management of anemia in developing countries.

Scope for Rotavirus Vaccination in India: Revisiting the Scientific Evidence

Rotavirus vaccines have been developed to prevent deaths resulting from severe diarrhea of rotavirus origin. The use of vaccines as an intervention at scale to prevent and control the burden of rotavirus diarrhea is supported by the argument that prevailing public health measures such as hygiene and sanitation, breast feeding and use of ORS have failed to prevent severe dehydration resulting from diarrhea. The article reviews the existing evidence on the rationale of using rotavirus vaccine as against the feasibility of scaling it up in developing countries like India. The vaccines currently available may not cover the strains circulating in Indian population. The diversity of Rotavirus infection in the country is tremendous and since the safety, immunogenicity and efficacy data has not been collected for India, there is first a need to conduct studies to measure the extent of protection and cross-protection provided by the available vaccines for local strains, before venturing into Rotavirus vaccination program. The potential benefits of immunization have to be first vetted against the risks involved by the policymakers and other stakeholders.

Risk Factors for Stillbirth: Findings from a Population-Based Case–Control Study, Haryana, India

BACKGROUND Stillbirth is a prevalent adverse outcome of pregnancy in India despite efforts to improve care of women during pregnancy. Risk factors for stillbirths include sociodemographic factors, medical complications during pregnancy, intake of harmful drugs, and complications during delivery. The objective of the study was to examine the risk factors for stillbirth with a focus on sex selection drugs (SSDs). METHODS A population-based case-control study was undertaken in Haryana. Cases of stillbirths were identified from the Maternal Infant Death Review System portal of Haryana state for the months of August-September 2014. A consecutive birth from the same geographical area as the case was selected as the control. The sample size was 325 per group. Mothers were interviewed using a validated tool. Bivariate analyses and logistic regression were conducted to examine the association between risk factors and stillbirth. Attributable risk proportions (ARP) and population attributable risk proportions (PARP) were estimated. RESULTS The sociodemographic profiles of the cases and controls were similar. History of intake of SSDs [adjusted odds ratio (OR) 2.6, 95% confidence interval (CI) 1.5, 4.5] emerged as a risk factor. Other significant factors were preterm <37 weeks (OR 3.5, 95% CI 2.1, 6.0), history of previous stillbirths (OR 4.0, 95% CI 2.1, 7.8), and complications during labour (OR 3.3, 95% CI 2.1, 5.3). Estimates of the ARP and PARP for intake of SSDs were 0.60 (95% CI 0.32, 0.77) and 0.1 (95% CI -0.13, 0.28), respectively. CONCLUSIONS SSDs could be attributed as a risk factor in a fifth of the cases of stillbirths. The number needed to harm for the use of SSDs in causing adverse effect of stillbirths was 5, suggesting thereby that for every five mothers exposed to SSDs, one would have stillbirth. Greater efforts are required to inform people about the harmful effects of SSD consumption during pregnancy.

Assessment of Newborn Care Corners in Selected Public Health Facilities in Bihar.

Background: A functional newborn care corner (NBCC) is critical to provide immediate care to newborns including resuscitation, warmth, and initial care to sick newborns. NBCC provides an acceptable environment for all infants at birth, and it is mandatory for all delivery points at all levels in the health system including operation theaters. Objective: The objective of this study was to find the status of availability of NBCCs and service provision in selected public health facilities of Bihar. Methods: A total of 57 NBCCs, having high delivery load (>100 deliveries/month), across 25 high-priority districts in Bihar, were selected purposively in consultation with the State Health Society, Bihar, for the assessment. These facilities were assessed for the availability and/or functioning of infrastructure, equipment maintenance, human resource, supply of drugs and consumables, adherence to protocols, and record keeping. Results: Only 22.8% of the NBCCs were found to be fully functional, majority (68.4%) were partially functional, and 9% were nonfunctional. Thirty-seven (64.9%) NBCCs were located inside the labor room premises. Approximately, one-third of the neonates delivered were kept in NBCCs. Equipment though available lacked the provision of annual maintenance contract. Essential drugs such as adrenaline (24.6%) and Vitamin K injection (42.1%) were not available in many facilities. Only 6.2% of the newborns had low birth weight, indicating underreporting. Majority of the health-care staff available were trained but possessed poor skills. Data recording and reporting was also suboptimal. Conclusion: The network of NBCCs needs to be strengthened across the state and linked with higher facilities to achieve the desired reduction in neonatal morbidity and mortality.

Diagnostic accuracy of haemoglobin colour strip (HCS-HLL), a digital haemoglobinometer (TrueHb) and a non-invasive device (TouchHb) for screening patients with anaemia.

Aim Estimation of haemoglobin (Hb) remains a challenge, particularly in outreach settings. There is a need to have a simple and cost-effective device to detect anaemia. Three devices (haemoglobin colour scale (HCS)-HLL (Hindustan Lifecare Limited), TrueHb V.1.1, TouchHb Alpha 1.1- non-invasive) have been developed in India recently. This study aimed to determine the diagnostic accuracy of these tests (index) for the screening of anaemia against haematological autoanalyzer (reference). Methods The study was conducted in four medical colleges of India. All consenting adult patients (>18 years of age) undergoing routine investigations were included. Each patient underwent the reference test and at least one index test. Outcome assessors for the index tests were blinded to the results of the reference test. Diagnostic accuracy was calculated using cut-offs proposed by WHO. Results A total of 5244 patients underwent the reference test while HCS-HLL, TrueHb and TouchHb tests were conducted on 2745, 2331 and 2874 patients respectively. The positive likelihood ratio of HCS-HLL using capillary blood (1.2), venous blood (1.7) and TouchHb (1.5) was lower than TrueHb capillary (3.7; 95% CI 3.3 to 4.2) and venous blood (5.7; 95% CI 4.9 to 6.6). TrueHb had a sensitivity of 74.4% (95% CI 71.9% to 76.8%) for venous and 82.0% (95% CI 79.8% to 89.2%) for capillary samples. The specificity was high (>75.0%). The area under receiver operating characteristic was close to 80.0%. Consistent results were seen for detection of severe anaemia. Conclusions The digital method (TrueHb) emerged as a better diagnostic method for screening anaemia. Its effectiveness should be established in outreach settings before further recommendation.

A Mixed-Method Study to Determine the Benefits of Periconceptional Folic Acid Supplementation and Effects of Folic Acid Deficiency in Mothers on Birth Outcomes.

Background Evidence from high income countries shows mothers who are supplemented with folic acid in their periconceptional period and early pregnancy have significantly reduced adverse outcomes like birth defects. However, in India there is a paucity of data on association of birth defects and folic acid supplementation. We identified a few important questions to be answered using separate scientific methods and then planned to triangulate the information. Objective In this paper, we describe the protocol of our study that aims to determine the association of folic acid and pregnancy outcomes like neural tube defects (NTDs) and orofacial clefts (OFCs). We decided to fill the gaps in knowledge from India to determine public health consequences of folic acid deficiency and factors influencing dietary and periconceptional consumption of folic acid. Methods The proposed study will be carried out in five stages and will examine the questions related to folic acid deficiency across selected locations in South and North India. The study will be carried out over a period of 4 years through the hierarchical evidence-based approach. At first a systematic review was conducted to pool the current birth prevalence of NTDs and orofacial clefts OFCs in India. To investigate the population prevalence, we plan to use the key informant method to determine prevalence of NTDs and OFCs. To determine the normal serum estimates of folic acid, iron, and vitamin B12 among Indian women (15-35 years), we will conduct a population-based, cross-sectional study. We will further strengthen the evidence of association between OFCs and folic acid by conducting a hospital-based, case-control study across three locations of India. Lastly, using qualitative methods we will understand community and health workers perspective on factors that decide the intake of folic acid supplements. Results This study will provide evidence on the community prevalence of birth defects and prevalence folic acid and vitamin B12 deficiency in the community. The case-control study will help understand the association of folic acid deficiency with OFCs. Conclusions The results from this study are intended to strengthen the evidence base in childhood disability for planning and policy initiatives.

Computer tablet-based health technology for strengthening maternal and child tracking in Bihar

Background: UNICEF along with the State Government of Bihar launched a computer tablet-based Mother and Child Tracking System (MCTS) in 2014, to capture real-time data online and to minimize the challenges faced with the conventional MCTS. Objective: The article reports the process of implementation of tablet-based MCTS in Bihar. Methods: In-depth interviews with medical officers, program managers, data managers, auxiliary nurse midwives (ANMs), and a monitoring and evaluation specialist were conducted in October 2015 to understand the process of implementation, challenges and possibility for sustainability, and scale-up of the innovation. Results: MCTS innovation was introduced initially in one Primary Health Centre each in Gaya and Purnia districts. The device, supported with Android MCTS software and connected to a dummy server, was given to ANMs. ANMs were trained in its application. The innovation allows real-time data entry, instant uploading, and generation of day-to-day work plans for easy tracking of beneficiaries for providing in-time health-care services. The nonlinking of the dummy server to the national MCTS portal has not lessened the burden of data entry operators, who continue to enter data into the national portal as before. Conclusion: The innovation has been successfully implemented to meet its objective of tracking the beneficiaries. The national database should be linked to the dummy server or visible impact. The model is sustainable if the challenges can be met. Mobile technology offers a tremendous opportunity to strengthen the capacity of frontline workers and clinicians and increase the quality, completeness, and timeliness of delivery of critical health services.

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

Abstract 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.