The crossroads of work and home: linkages between smoke-free policies at work and household environments.

BACKGROUND: Tobacco use causes over eight million global deaths annually, with seven million directly attributed to tobacco use and 1.2 million to second hand smoke (SHS). Smoke-free environments are crucial to counter SHS. Although India banned smoking in public places in 2008, SHS exposure remains high. Studies have noted that limiting smoking in workplaces, restaurants, etc., helps to reduce overall smoking and reduce SHS exposure. Under this background, the study explores the linkages between smoke-free workplaces and living in smoke-free homes in India. METHODS: The two rounds of the GATS India (2009-10 and 2016-17) have been used for the study. The study focuses on male tobacco smokers working indoors or outdoors or both indoors and outdoors. The sample for the study was 2,969 for GATS 1 and 2,801 for GATS 2. Dependent variables include living in a smoke-free home, while the independent variables were adherence to a smoke-free office policy and socio-demographic variables. The two rounds of the GATS data were pooled for analysis. Statistical analysis involves bivariate and multivariate analysis. RESULTS: Findings reveal that 41% of respondents worked in smoke-free workplaces in GATS 2. Nationally, smoke-free homes increased from 35% in 2009-2010 to 44% in 2016-17. Individuals with smoke-free workplaces were more likely to have smoke-free homes. The Southern region consistently exhibited the highest proportion of smoke-free homes. Urban areas and higher education correlated with increased smoke-free homes. Logistic regression analysis confirmed that workplace smoke-free status is a significant predictor of smoke-free homes. In GATS 2, respondents aged 30 years and above were less likely to have smoke-free homes, while education and Southern region residence positively influenced smoke-free homes. CONCLUSIONS: The correlation between smoke-free workplaces and smoke-free homes is linked to stringent workplace no-smoking policies, potentially deterring individuals from smoking at home. Opportunities exist for the expansion and stringent implementation of the smoke-free policies among Indian working adults, leveraging the workplace as a key setting for evidence-based tobacco control. The study highlights positive trends in India's smoke-free homes, crediting workplace policies. Effective policies, education, and regional strategies can advance smoke-free homes, stressing the pivotal role of workplace policies and advocating broader implementation.

Effect of chronic lung diseases on angina pectoris among Indian adults: longitudinal ageing study in India.

The study aimed to evaluate the effect of chronic lung diseases, namely chronic obstructive pulmonary diseases (COPD) and asthma, on angina pectoris in individuals aged 45 years and above. Identifying vulnerable subpopulations suffering from COPD and asthma at higher risk of future cardiovascular events using the rose angina questionnaire is imperative for tailored primary and secondary prevention approaches. The present study utilizes the data from the Longitudinal Ageing Study in India, wave 1, conducted during 2017-2018. The sample size included 58,830 individuals aged 45 years and above. Angina was measured based on seven questions from Rose's questionnaires. Descriptive statistics and bivariate analysis were employed to examine the prevalence of angina among individuals with COPD and asthma. Further, multivariable logistic regression and propensity score matching (PSM) methods were used to assess the independent effect of COPD and asthma on angina after controlling the selected background characteristics. We employed PSM in two different models and included various additional factors in model 2, such as smoking, chewing tobacco, alcohol use, ADL, IADL, body mass index, physical activity, high cholesterol, hypertension, diabetes, and chronic heart disease. The current study shows that the prevalence of angina pectoris, COPD and asthma was 6.0%, 2.3% and 4.7%, respectively, among individuals aged 45 years and above in India. The prevalence of angina pectoris was higher among individuals with COPD (9.6% vs. 5.8%) and asthma (9.9% vs. 5.7%) than those without COPD and asthma, respectively. Additionally, angina pectoris was more prevalent among females and rural respondents with COPD (10.8% and 11.0%) and asthma (10.3% and 10.3%) compared to males and urban respondents with COPD (8.0% and 5.7%) and asthma (8.9% and 7.9%). Moreover, in the adjusted model, individuals with COPD (AOR 1.43, 95% CI 1.03 1.98) and asthma (AOR 1.44, 95% CI 1.17 1.77) had nearly 1.5-fold higher odds of having angina pectoris than those without COPD and asthma. The PSM estimates showed that individuals with COPD had 8.4% and 5.0% increased risk of angina pectoris compared to those without COPD in model 1 and model 2, respectively. We observed that, after adjusting to lifestyle, health-related and morbidity factors in model 2, both average treatment effect on untreated (ATU) and average treatment effect (ATE) values decreased by nearly 3.5%. Additionally, the PSM estimates demonstrated that individuals with asthma had a 3.4% and 2.9% increased risk of angina pectoris compared to those without asthma in model 1 and model 2, respectively. The study suggests that COPD and asthma are significantly associated with angina pectoris, and individuals with COPD and asthma have a higher risk of developing angina pectoris. Additionally, angina pectoris was more prevalent among females, rural respondents and adults aged 45-54 with COPD compared to males, urban respondents and those aged 65 and above, respectively, with COPD. Moreover, the findings of our study underscore the targeted primary and secondary interventions and team-based care approach among individuals with COPD and asthma to reduce the risk of CVD events in future.

Is the quality of public health facilities always worse compared to private health facilities: Association between birthplace on neonatal deaths in the Indian states.

BACKGROUND: The role of place of delivery on the neonatal health outcomes are very crucial. Although the quality of care is being improved, there is no consensus about who is the better healthcare provider in low and middle-income countries (LMICs), public or private facilities. The aim of this study is to assess the differentials in neonatal mortality by the type of healthcare providers in India and its states. METHODS: We used the data from the fourth wave of the National Family Health Survey 2015-16 (NFHS-4). Information on 259,627 live births to women within the five years preceding the survey was examined. Neonatal mortality rates for state and national levels were calculated using DHS methodology. Multi-variate logistics regression was performed to find the effect of birthplace on neonatal deaths. Propensity score matching (PSM) was used to evaluate the relationship between place of delivery and neonatal deaths to account for the bias attributable to observable covariates. RESULTS: The rise in parity of the women and purchasing power influences the choice of healthcare providers. Increased neonatal mortality was found in private hospital delivery compared to public hospitals in Punjab, Rajasthan, Chhattisgarh, Madhya Pradesh, Bihar, Jharkhand, Odisha, Goa, Maharashtra, Andhra Pradesh and Karnataka states using propensity score matching analysis. However, analysis on the standard of pre-natal and post-natal care indicates that private hospitals generally outperformed public hospitals. CONCLUSIONS: The study observed a significant variation in neonatal mortality among public and private health care systems in India. Findings of the study urges that more attention be paid to the improve care at the place of delivery to improve neonatal health. There is a need of strengthened national health policy and public-private partnerships in order to improve maternal and child health care in both private and public health facilities.

A longitudinal study of incident hypertension and its determinants in Indian adults aged 45 years and older: evidence from nationally representative WHO-SAGE study (2007-2015).

Objectives: Hypertension (HT) is a leading cause of mortality and morbidity in developing countries. This study aimed to estimate the incidence of HT among adults aged 45 years and older in India and its associated risk factors. Methods: This study used longitudinal data from the Indian sample of the first and second waves of the World Health Organization Study on Global Ageing and Adult Health (WHO-SAGE). A bivariate analysis using Pearson's chi-square test was done to examine the associations of individual, lifestyle, and household characteristics with HT status reported in Wave 2. Incident HT changes were analyzed by adjusting for various covariates in the generalized estimating equation (logit link function) with an exchangeable correlation matrix and robust standard errors. Results: The study found that during the 8-year period from 2007 to 2015, the incidence of HT in individuals aged 45 years and over was 20.8%. Pre-hypertensive individuals had an overall incidence rate of 31.1 per 1,000 [95% confidence interval (CI): 26.20-35.9] and a 2.24 times higher odds ratio: 2.24 (95% CI: 1.65-3.03) of developing incident HT compared to those who were normotensive. Adults aged 45 years and older, overweight/obese individuals, and women were more at risk of incident HT. Conclusion: One in five individuals had developed HT over 8 years, with a greater risk of incident HT among women than men. Pre-hypertensive individuals were at a greater risk of developing incident HT compared to normotensive individuals. The study recommends comprehensive and effective management of pre-HT to tackle the burden of HT.

Decomposition analysis of the decline in binary and triad undernutrition among preschool children in India.

BACKGROUND: To examine the socio-demographic factors associated with the decline in undernutrition among preschool children in India from National Family Health Survey (NFHS)-3, 2005-06 to NFHS- 5, 2019-21. METHODS: For this study data were obtained from India's nationally representative datasets such as NFHS-3 and NFHS-5. The outcome variables for this study were Binary undernutrition which were defined as the coexistence of anemia and either stunting or wasting and Undernutrition triad which were defined as the presence of Iron deficiency anemia, stunting and wasting, respectively. Decomposition analysis was used to study the factors responsible for a decline in undernutrition. This method was employed to understand how these factors contributed to the decline in undernutrition whether due to change in the composition (change in the composition of the population) or propensity (change in the health-related behaviour of the population) of the population over a period of 16 years. RESULTS: Results showed that rate, which contributes 85.26% and 65.64%, respectively, to total change, was primarily responsible for a decline in both binary undernutrition and undernutrition triad. Reduction in Binary undernutrition was mainly explained by the change in the rate of education level of the mothers and media exposer during the inter-survey period. On the other hand, the decline in the Undernutrition triad can be explained by household wealth index, mother's education, birth order and a change in people's knowledge or practice about the preceding birth interval. CONCLUSION: Identifying important factors and understanding their relationship with the decline of undernutrition can be beneficial for reorienting nutrition-specific policies to achieve the targets of the Sustainable Development Goals by 2030.

Sex-specific prevalence, awareness, treatment and control of hypertension in adults in India: a study for developing sex-specific public policy from the longitudinal ageing study in India (LASI) data 2017-2018.

BACKGROUND AND OBJECTIVE: Hypertension is a key risk factor for cardiovascular disease and the leading cause of mortality among Indian adults. The difference in health status between men and women is becoming a great burden in itself worldwide. This study aimed to examine the differences between men and women in the prevalence, awareness, treatment, and control of hypertension and related risk factors among people aged 45 and older in India using data from the Longitudinal Ageing Study in India in 2017-2018. METHODS: Descriptive statistics were presented separately for males and females. Multivariable logistic regression was used to analyze the socio-demographic, lifestyle behaviours, and biological factors associated with the prevalence of hypertension. All statistical analyses were conducted using Stata Version 16.0 statistical software. The study of the data was conducted using survey weights available in the LASI datasets. KEY FINDINGS: Overall, the study found that 45.1% of the study population had hypertension, with 26.9% self-reporting their condition and 30% having hypertension at the time of measurement. Approximately 41% of males and 59% of females had hypertension. The self-reported hypertension of men was found to differ significantly from measured hypertension by 8.7%, while in women the difference was only 1.2%. Diabetes was found to increase the odds of having hypertension in both males (OR = 3.65, 95% CI (3.37-3.97)) and females (OR = 3.46, 95% CI (3.21-3.74)). CONCLUSION: The difference between self-reported and measured hypertension in men and women is contributing to sex-gender and health inequalities that must be addressed. For adult females with hypertension, it is important to prioritize obesity, education level, physical activity, and regular clinic visits to manage chronic conditions. Based on our findings, policy recommendations can be made to focus on increasing women's literacy, promoting men's screening for hypertension, banning tobacco and alcohol sales, and organizing hypertension awareness campaigns specifically for men and in rural areas.

Understanding the healthcare provider role on post abortion contraception adoption in India using National Family Household Survey-5.

BACKGROUND: Post abortion contraceptive use is an important area in provisioning of services associated with child birth planning. This study examines the factors related to the type and timing of initiation of contraception adoption among women who had undergone induced abortion. Study also tries to identify the role of personnel who provided the abortion service on decision of family planning adoption using complementary log-log model in India. METHODOLOGY: The study uses the secondary data from the fifth round of the National Family Household Survey conducted during 2019-21. For, the analysis, we have used five-year women's reproductive calendar to extract information on contraceptive use, post last induced abortion among women. We used complementary log-log regression models, to estimate relative risk ratios and its 95% Confidence intervals (CI). RESULTS: According to NFHS-5, out of all the last pregnancies (2,55,549), about three percent resulted in abortion. Most of the abortion occurred in private facilities (55%), with the help of health professionals (71%). From the women's reproductive calendar, it was found that around 40% of the women adopted modern methods of contraception, with maximum adopting spacing method (33%), and only handful adopted permanent method (7%). It was also found that the likelihood of early adoption of permanent method increased to two times when the abortion is done by health professional compared to others [95% CI (1.25-3.30)]. CONCLUSION: This emphasises a need for quality counselling related to timing and types of family planning as an essential part of the family planning program ensuring client centric approach suited to their needs and contexts that helps in alleviating any apprehensions associated with adverse effects of modern contraceptive methods.

Comparing socio-economic inequalities in self-reported and undiagnosed hypertension among adults 45 years and over in India: what explains these inequalities?

BACKGROUND: Hypertension (HTN) is a leading cause of mortality and morbidity in developing countries. For India, the hidden burden of undiagnosed hypertension is a major concern. This study aims to assess and explain socio-economic inequalities among self-reported and undiagnosed hypertensives in India. METHODS: The study utilized data from the Longitudinal Aging Study in India (LASI), a nationally-representative survey of more than 72,000 older adults. The study used funnel plots, multivariable logistic regression, concentration indices, and decomposition analysis to explain the socio-economic gap in the prevalence of self-reported and undiagnosed hypertension between the richest and the poorest groups. RESULTS: The prevalence of self-reported and undiagnosed hypertension was 27.4 and 17.8% respectively. Monthly per capita consumption expenditure (MPCE) quintile was positively associated with self-reported hypertension but negatively associated with undiagnosed hypertension. The concentration index for self-reported hypertension was 0.133 (p < 0.001), whereas it was - 0.047 (p < 0.001) for undiagnosed hypertension. Over 50% of the inequalities in self-reported hypertension were explained by the differences in the distribution of the characteristics whereas inequalities remained unexplained for undiagnosed hypertension. Obesity and diabetes were key contributors to pro-rich inequality. CONCLUSIONS: Results imply that self-reported measures underestimate the true prevalence of hypertension and disproportionately affect the poorer MPCE groups. The prevalence of self-reported HTN was higher in the richest group, whereas socio-economic inequality in undiagnosed hypertension was significantly concentrated in the poorest group. As majority of the inequalities remain unexplained in case of undiagnosed hypertension, broader health systems issues including barriers to access to health care may be contributing to inequalities.

Missed opportunities for initiation of treatment and control of hypertension among older adults in India.

Hypertension (HT) is a major public health problem globally. The unacceptably low treatment and control rates are a major concern for policy makers as they contribute to avoidable mortality and morbidity. This study quantifies the prevalence and the determinants of missed opportunities for the treatment and control of HT in older adults in India. The study utilized data from the Longitudinal Aging Study in India (LASI), a population-based national representative survey of 62,416 individuals aged over 45 years. Our findings suggest that the prevalence of missed opportunities for the treatment and control of HT was 29.9 % and 16.4 % respectively. Overall, more than 60 % of all missed opportunities were in the private sector, and 75 % were in outpatient consultations. Education, working status, diabetes, stroke, physical activities, smoking, monthly per capita consumption expenditure (MPCE) quintiles were positively associated with missed opportunities for both treatment and control of HT. Rural residents, individuals with no comorbidities, and those belonging to lower MPCE quintiles were positively associated with missed opportunities for treatment. This association was inverse in the case of missed opportunities for the control of HT. Significant missed opportunities exist with respect to the treatment and control of HT. We discuss the reasons behind low treatment and control rates, including failure to initiate treatment, suboptimal compliance, and lack of follow-up, in the context of significant financial barriers to access to health services and availability of free anti-hypertensive drugs in India.

Gastrointestinal problem among Indian adults: Evidence from longitudinal aging study in India 2017-18.

Introduction: Diseases and illnesses of the gastrointestinal system (GIS) have grown in the last decade due to considerable lifestyle changes. People with gastrointestinal (GI) diseases have a high prevalence of depression, stress, anxiety, and impaired central nervous system functioning. Therefore, this study aims to explore the factors associated with the self-reported gastrointestinal problems among the Indian elderly and to explore the relationship between non-communicable diseases (NCDs), such as hypertension, heart diseases, diabetes, and neurological or psychiatric and gastrointestinal disorder. Methods: This study uses data from the Longitudinal Aging Study in India (LASI), a population-based national survey, conducted during 2017-2018 with a representative sample of 72,250 individuals. Descriptive statistics were used to provide the frequency distribution of sociodemographic and economic profiles of adults. Bivariate analysis was used to understand the percentage distribution of adults suffering from gastrointestinal problems by their background characteristics. Binary logistic regression was used to determine the factors associated with gastrointestinal problems. In the binary logistic regression analysis, a systematic model building procedure was adopted. Results: The overall prevalence of self-reported gastrointestinal problems was 18%, with significant variations among regions, and it substantially increased with the increasing age of men. Hypertension and neurological problems have significant individual effects on gastrointestinal problems. Prevalence was higher in those who suffered from neurological or psychiatric problems (27%) than in those who suffered from hypertension (22%) and heart disease (23%). Adults from the age group 45-54 (1.11, p < 0.01) and 55-64 (1.09, p < 0.01) years were significantly more likely to have gastrointestinal problems compared with the <44 years age group. Former and current smokers and adults with the habits of chewing tobacco were significantly more likely to report gastrointestinal problems than their counterparts. Moreover, the increasing economic status significantly and positively increased the likelihood of having self-reported gastrointestinal problems among adults. Conclusion: Aging-related gastrointestinal problems are physiological or pathological and more prevalent in the elderly population aged 64 years and above. Hence, policies and interventions have to be made age-specific. Gastrointestinal problems among older adults are acquiring greater importance in clinical practices to plan effective treatment, administration of gastrointestinal drugs, the early screening of gastrointestinal diseases. Given the policy focus through Health and Wellness centers for accessible NCD care, it is important that gastro-intestinal illnesses receive more focus and systemic support.

Validity of self-reported hypertension in India: Evidence from nationally representative survey of adult population over 45 years.

Self-reported measures of health, in the context of developed countries, are well-researched and commonly regarded as reliable predictors of the underlying health of the population. However, the validity of these measures is under-researched and questionable in the context of low- and middle-income countries. The authors used Longitudinal Ageing Study in India (LASI) survey data from India to compare self-reported hypertension with biometrically-measured hypertension. The results are reported in terms of sensitivity, specificity, and kappa as a measure of agreement. Logistic regression was undertaken to examine the characteristics of those who were unaware of their hypertensive status. Our analysis showed a low sensitivity of 56% and a high specificity of 90.5%. Agreement between self-reported data and biometric measurement of hypertension was observed to be moderate (κ = 0.48). Large variations were observed among states and sub-groups. The odds of false negative reporting of hypertension were lower in the individuals with higher age, high education, and greater wealth status. The authors conclude that self-reported hypertension has important limitations and may be a source of systematic bias. It is recommended that planning and policy-making in India be based more on an objective assessment of hypertension.

Diagnosis and Treatment of Hypertension Among People Aged 45 Years and Over in India: A Sub-national Analysis of the Variation in Performance of Indian States.

Introduction: Cardiovascular disease (CVD) is the single largest contributor to non-communicable disease (NCD) deaths, with hypertension contributing to a significant proportion of these deaths. This study aims to provide estimates of the prevalence, awareness, treatment and control of hypertension at sub-national levels in India and identifies well and under-performing states with respect to the diagnosis and treatment of hypertension. Methods: The study utilises data from the Longitudinal Study of Ageing in India (LASI), a nationally representative survey of more than 72,000 individuals. Age-sex adjusted prevalence rates of self-reported hypertension was calculated using the direct standardisation method. Multivariable logistic regression was performed to assess the association of self-reported hypertension with the various individual co-morbidity, lifestyle, and household factors. Self-reported prevalence was compared with an objective measure of hypertension for each state, and funnel plots were constructed to assess the performance of states. Results: Our findings suggest that the overall prevalence of age-sex adjusted self-reported hypertension was 25.8% in India with significant variation among states. Results based on logistic regression confirm that those individuals who are elderly, obese, belong to a higher socio-economic group and have associated co-morbidities are at increased odds of reporting hypertension. Overall, 4 out of 10 adults over 45 years of age in India are not aware of their hypertensive condition, and of those who are aware, 73% are currently taking medication, and only 10% of these have their hypertension under control. Based on the performance, states were classified into high and low performing categories. States with an increased proportion of population below the poverty line had significantly lower performance with respect to the diagnosis of hypertension, whereas states with higher literacy rates and greater availability of specialist doctors at community health centres (CHCs) had significantly better performance with respect to treatment-seeking behaviour. Conclusion: The findings of this study and its policy implications are discussed. Based on state performance, strategies are proposed in terms selective targeting vs. population-based strategies. High impact states and sub-groups are identified where intense efforts are needed to tackle the growing menace of hypertension in India.

Declining trend of smoking and smokeless tobacco in India: A decomposition analysis.

There has been a relative reduction of tobacco consumption between Global Adult Tobacco Survey-India (GATS-India) 2009-10 and GATS-India 2016-17. However, in terms of absolute numbers, India still has the highest number of tobacco consumers. Therefore, this paper aims to examine the socioeconomic correlates and delineate the factors contributing to a change in smoking and smokeless tobacco use from GATS (2009-10) to GATS (2016-17) in India. We used multivariable binary logistic regressions to examine the demographic and socioeconomic correlates of smoking and smokeless tobacco use for both the rounds of the survey. Further decomposition analysis has been applied to examine the specific contribution of factors in the decline of tobacco consumption over a period from 2009 to 2016. Results indicated that the propensity component was primarily responsible for major tobacco consumption decline (smoking- 41%, smokeless tobacco use- 81%). Most of the decrease in propensity to smoke has been explained by residential type and occupation of the respondent. Age of the respondent contribute significantly in reducing the prevalence of smokeless tobacco consumption during the seven-year period, regardless of change in the composition of population. To achieve the National Health Policy, 2017 aim of reducing tobacco use up to 15% by 2020 and up to 30% by 2025, targeted policies and interventions addressing the inequalities identified in this study, must be developed and implemented.

Sex differences in child health and healthcare: A reappraisal for India.

India has an unenviable reputation as one of the world's most gender disparate countries. Previous studies of sex bias in childhood have shown large differences between Indian boys and girls in immunization and curative healthcare, but little difference in health status as indicated by anaemia and stunting. India has changed rapidly in past decades, hence we reappraise the situation with the National Family Health Survey-4 (2015-16). We found no evidence of sex differentials in immunization coverage but a small degree of discrimination in favour of boys in medical treatment for common symptoms of infection. This discrimination was no greater in the North and Central regions of India, where severe excess mortality among female children persists. Sex differences in anaemia and stunting were small, with no regional pattern. We found no evidence that healthcare or health status of girls was influenced by the presence of other daughters in the family.

Assessment of Variation in Cesarean Delivery Rates Between Public and Private Health Facilities in India From 2005 to 2016.

Importance: The rates of cesarean deliveries have more than doubled in India, from 8% of deliveries in 2005 to 17% of deliveries in 2016. The World Health Organization recommends that cesarean deliveries should not exceed 10% to 15% of all deliveries in any country. An understanding of the association of private and public facilities with the increase in cesarean delivery rates in India is needed. Objective: To assess the association of public vs private sector health care facilities with cesarean delivery rates in India and to estimate the potential cost savings if private sector facilities followed World Health Organization recommendation for cesarean deliveries. Design, Setting, and Participants: This cross-sectional study used institutional delivery data from the representative National Family Health Survey (NFHS) in India, including data from the NFHS-1 (1992-1993), the NFHS-3 (2005-2006), and the NFHS-4 (2015-2016). The NFHS-3 and NFHS-4 provided data on 22 647 deliveries and 195 366 deliveries, respectively. The NHFS-4 was the first survey to provide data on out-of-pocket expenditures for delivery by facility type, allowing for a comparison of cesarean deliveries and costs between public and private facilities. The primary sample comprised all pregnant women who delivered infants in public and private institutional facilities in India and who were included the NFHS-3 and the NFHS-4; data on pregnant women who were included in the NFHS-1 were used for comparison. The study's findings were analyzed through geographic mapping, data tabulation, funnel plots, multivariate logistic regression analyses, and potential cost-savings scenario analyses. Data were analyzed from June to December 2019. Main Outcomes and Measures: The main outcome was the rate of cesarean deliveries by facility type (public vs private) and by participant socioeconomic, demographic, and health characteristics. Secondary outcomes were the potential number of avoidable cesarean deliveries and the potential cost savings if private sector facilities followed the World Health Organization recommendations for cesarean deliveries. Results: In the NFHS-3, 22 610 total births occurred at institutional facilities. Of those, 2178 births (15.2%) were cesarean deliveries in public facilities, and 3200 births (27.9%) were cesarean deliveries in private facilities. Of 195 366 total institutional births in the NFHS-4, 15 165 births (11.9%) were cesarean deliveries in public facilities, and 20 506 births (40.9%) were cesarean deliveries in private facilities. The cesarean delivery rate in public health facilities increased from 7.2% in the NFHS-1 to 11.9% in the NFHS-4, whereas in private health facilities, the rate increased from 12.3% to 40.9% during the same period. A substantial increase was found in cesarean delivery rates between the NFHS-3 (2005-2006) and the NFHS-4 (2015-2016), with 22 states exceeding the World Health Organization's upper threshold of 15% in the NFHS-4. The odds ratio for cesarean deliveries in private facilities compared with public facilities increased from 1.62 (95% CI, 1.49-1.76) in the NFHS-3 to 4.17 (95% CI, 4.04-4.30) in the NFHS-4. The number of avoidable cesarean deliveries would have been 1.83 million, with a potential cost savings of $320.60 million, if private sector facilities in India had followed the 15% threshold for cesarean delivery rates recommended by the World Health Organization. Conclusions and Relevance: In this study, private sector health facilities were associated with a substantial increase in cesarean deliveries in India. Further research is needed to assess the factors underlying the increase in cesarean deliveries in private sector facilities.

Child health and unhealthy sanitary practices in India: Evidence from Recent Round of National Family Health Survey-IV.

OBJECTIVES: Despite threefold increase in investment (from Rs. 28,500 million to Rs. 90,000 million during 2014-17) in the allocation of funds for the Clean India movement, creating awareness and various social movements, more than half of the rural population (52.1%) of the country still defecates in the open. This study aims to examine the prevalence of improved sanitation facilities and safe stool disposal in India and its states. It also aims to further establish inter-linkages between safe stool disposal and child health. STUDY DESIGN: The present study uses data from the fourth round of the recently conducted cross-sectional National Family Health Survey (NFHS-4, 2015-16). METHODS: Two proxy indicators used to assess the effect on child health are: stunting and mortality of children under the age of five years. Multivariate logistic regression analysis was employed to examine the impact of improved sanitation facilities and safe stool disposal on child health measured by height-for-age as a dichotomous variable. Multivariate discrete-time logistic model was used to examine the impact of improved sanitation facilities and safe stool disposal on under-five child deaths. RESULTS: The results reveal that unsafe disposal of stools are one of the main contributing factors responsible for stunting and under-five mortality among children. The prevalence was clearly seen to be higher in households where open defecation and unsafe stool disposal were practised. CONCLUSIONS: The central behavioural change to be brought about among the people is to improve the cleanliness levels of the neighbourhood and help children spend their childhood free from the misery of malnourishment or in the worst case, death. It is not an impossible task for a country that houses the cleanest village in Asia, Mawlynnong in the Northeast state of Meghalaya, India. If one state could do it, it could be replicated in other states too.

Trends, patterns and predictive factors of infant and child mortality in well-performing and underperforming states of India: a secondary analysis using National Family Health Surveys.

OBJECTIVES: This paper analyses the patterns and trends in the mortality rates of infants and children under the age of 5 in India (1992-2016) and quantifies the variation in performance between different geographical states through three rounds of nationally representative household surveys. DESIGN: Three rounds of cross-sectional survey data. SETTING: The study is conducted at the national level: India and its selected good-performing states, namely Haryana, Kerala, Maharashtra, Punjab and Tamil Nadu, and selected poor-performing states, namely Bihar, Chhattisgarh, Madhya Pradesh and Uttar Pradesh. PARTICIPANTS: Adopting a multistage, stratified random sampling, 601 509 households with 699 686 women aged 15-49 years in 2015-2016, 109 041 households with 124 385 women aged 15-49 years in 2005-2006, and 88 562 households with 89 777 ever married women in the age group 13-49 years in 1992-1993 were selected. RESULTS: Through the use of maps, this paper clearly shows that the overall trend in infant and child mortality is on a decline in India. Computation of relative change shows that majority of the states have witnessed over 50% reduction in both infant and under-5 mortality rates from National Family Health Survey (NFHS)-I to NFHS-4. However, the improvements are not evenly distributed, and there is huge variation in performance between states over time. Funnel plots show that the most populous states like Uttar Pradesh Bihar and Madhya Pradesh have underperformed consistently across the survey period from 1992 to 2016. Regression analysis comparing high-performing and low-performing states revealed that female infants and women with shorter birth intervals had greater risk of infant deaths in poor-performing states. CONCLUSION: Attempts to reduce infant and child mortality rates in India are heading in the right direction. Even so, there is huge variation in performance between states. This paper recommends a mix of strategies that reduce child and infant mortality among the high-impact states where the biggest improvements can be expected, including the need to address neonatal mortality.