Prevalence of anaemia in the postpartum period: a study of a North Indian village.

Anaemia is a common public health problem but there is a paucity of studies regarding anaemia in the postpartum period. The objective of this study was to investigate the prevalence of anaemia in the postpartum period and factors associated with it. This prospective community-based study was carried out in a village of Haryana, India. Blood samples were collected for haemoglobin estimation at the end of six weeks postpartum. A total of 211 women were recruited and 168 women were included in the final analysis. It was found that 70% of the study participants were anaemic (Hb < 11 g/dL). Only 37% of the population had consumed >/=90 iron folic acid (IFA) tablets. The mean haemoglobin level of women who had consumed >/=90 IFA tablets in the antepartum period was higher (10.43 g/dL) than those who consumed <90 IFA (9.9 g/dL). Multicentric studies are recommended to get the true picture for the whole country.

Maternal morbidity during postpartum period in a village of north India: a prospective study.

This prospective community-based study was conducted in the village of Chhainsa, Haryana, India, in order to discover the incidence and types of postpartum morbidity and the factors associated with the morbidities. The subjects were followed up to 42 days of postpartum with a minimum of three visits; the first visit was within 14 days of delivery and subsequent visits were every 14 days. A first visit was made to 211 women and 174 (82.46%) completed the study. Seventy-four percent reported at least one morbidity and there were 1.75 reported morbidities per woman per postpartum period. Common problems reported were: weakness, lower abdominal pain, perineal pain, abnormal vaginal discharge, high fever, breast problems, excessive vaginal bleeding, etc. There was greater morbidity among women of lower socioeconomic status, parity >4, birth interval >36 months, having a breech or caesarean delivery or a delivery assisted by relatives/neighbours. A significant positive association was found between age and non-maintenance of the 'five cleans' during delivery. Seventy-five percent of those who had reported morbidity had taken some action, but only 20% sought help from a qualified doctor and 14% from other health workers.

Tobacco and alcohol use in rural elderly Indian population.

BACKGROUND: Tobacco and alcohol use are serious health problems. Studies focusing on problems associated with tobacco and alcohol use in the elderly are limited. AIM: To find out the prevalence of tobacco and alcohol use among rural elderly population. METHODS: This cross-sectional study was conducted in the intensive field practice area of the Comprehensive Rural Health Services Project in Ballabgarh in Faridabad, Haryana, a rural field practice area of the Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi. The sample was selected using stratified random cluster sampling. The participants were >/=60 years of age at the time of interview. Data on tobacco and alcohol use pattern of 1117 elderly were collected during the interview. RESULTS: The prevalence of smoking was 71.8% in men (n=490) and 41.4% in women (n=497). Among men smokers, 41.5% were light smokers (20 beedis/day). Among women smokers, 71.8% were light smokers, 23.8% were moderate smokers and 4.4% were heavy smokers. Regular alcohol intake was seen in 16.3% of the men compared with 0.8% of the women. CONCLUSION: The finding of a high prevalence of smoking and alcohol consumption among men in this rural population of India is of serious concern and therefore needs remedial measures.

Typhoid fever in children aged less than 5 years.

BACKGROUND: Calculation of the incidence of typhoid fever during preschool years is important to define the optimum age of immunisation and the choice of vaccines for public-health programmes in developing countries. Hospital-based studies have suggested that children younger than 5 years do not need vaccination against typhoid fever, but this view needs to be re-examined in community-based longitudinal studies. We undertook a prospective follow-up study of residents of a low-income urban area of Delhi, India, with active surveillance for case detection. METHODS: A baseline census was undertaken in 1995. Between Nov 1, 1995, and Oct 31, 1996, we visited 8172 residents of 1820 households in Kalkaji, Delhi, twice weekly to detect febrile cases. Blood samples were obtained from febrile patients, and those who tested positive for Salmonella typhi were treated with ciprofloxacin. FINDINGS: 63 culture-positive typhoid fever cases were detected. Of these, 28 (44%) were in children aged under 5 years. The incidence rate of typhoid per 1000 person-years was 27.3 at age under 5 years, 11.7 at 5-19 years, and 1.1 between 19 and 40 years. The difference in the incidence of typhoid fever between those under 5 years and those aged 5-19 years (15.6 per 1000 person-years [95% CI 4.7-26.5]), and those aged 19-40 years (26.2 [16.0-36.3]) was significant (p<0.001 for both). The difference between the incidence of typhoid at 5-19 years and the incidence at 19-40 years was also significant (10.6 [6.3-14.8], p<0.001). Morbidity in those under 5 and in older people was similar in terms of duration of fever, signs and symptoms, and need for hospital admission. INTERPRETATION: Our findings challenge the common view that typhoid fever is a disorder of school-age children and of adults. Typhoid is a common and significant cause of morbidity between 1 and 5 years of age. The optimum age of typhoid immunisation and the choice of vaccines needs to be reassessed.

PIP: This study was conducted to measure the incidence of typhoid fever among preschoolers. It was suggested that children aged 5 years do not need vaccination against typhoid fever. However, it is important to re-examine this view, particularly in infants and young children in the low-income urban area of Delhi, India, through active surveillance. Blood samples were obtained from febrile patients, and those who tested positive for Salmonella typhi were treated with ciprofloxacin. Findings revealed 63 culture-positive typhoid fever cases, about 44% of which were in children under 5 years of age. Morbidity in children under age 5 and in older people was similar in terms of duration of fever, signs and symptoms, and the need for hospital admission. The incidence of typhoid fever and the age distribution of the case varied between developing countries. Thus, the age patterns of typhoid fever observed in the urban study area may differ in rural areas within India or in other developing countries. A reevaluation of the optimum age and vaccine of choice is needed.

The composite international diagnostic interview (cidi): its reliability and applicability in a rural community of northern India.

TO STUDY THE RELIABILITY AND APPLICABILITY OF THE COMPOSITE INTERNATIONAL DIAGNOSTIC INTERVIEW (CIDI) IN A RURAL COMMUNITY OF INDIA, A TWO STEPS SAMPLING PROCEDURE WAS ADOPTED, STEP I: A clinical diagnosis based on the Diagnostic and Statistical Manual of Mental Disorder-Ill-Revised (DSM-IIIR) criteria was administered to 218 persons aged 18-60 years who consulted the Primary Health Centre (PHC); Step II: Of these persons, 71 were selected for detailed examination with the CIDI Hindi version in their home environment. The current diagnoses produced by the CIDI (scored two ways DSM-III-R and ICD-10) were evaluated against the DSM-III-R clinical diagnoses. The kappa values were 0.43 and 0.64. The likelihood ratios of positive CIDI-DSM-III-R and CIDI-ICD-10 were found to be 13.11 and 17.23; the specificity rates were 95.4% in each; the positive predictive values were 96.6% and 97.4% and the sensitivity rates were 59.2% and 77.5%. A significant longer time was faken for coding one CIDI. Only 8% of the 71 CIDI interviewed required more than one sitting. 96% of those interviewed were receptive for future interviews with CIDI. The study findings emphasize the good reliability and acceptability of the CIDI in a rural community of India.

Risk factors for cerebral palsy.

Cerebral palsy is a major cause of crippling in children, but it's etiology is poorly understood. This case control study was done to assess some of the identified risk factors for cerebral palsy, 125 cerebral palsy cases selected from hospital clinic and 125 age and sex matched neighbourhood controls, all aged less than 5 years and residing in Delhi (India) were studied. Information regarding antenatal, natal and postnatal period was collected by mother's interview, and wherever available, from hospital records with the study subjects. Most common type of cerebral palsy was spastic (88%). Quadriplegia was the commonest topographical subtype (86.4%). Birth asphyxia was found to be present in only 25.6% of cases. The commonest risk factor amongst cases was low birth weight (28.8%). The multivariate odds ratios (confidence limits) for the risk factors found to be significantly associated with cerebral palsy were 36.1 (7.76-160) for birth asphyxia, 13.8 (4.95-38.3) for low birth weight, 37.4 (4.47-313) for neonatal convulsion, 23 (4.7-112) for neonatal jaundice, 14.4 (3.69-56.4) for neonatal infection, 24.9 (2.78-223) for instrument assisted delivery and 15.4 (1.57-152) for antepartum hemorrhage. Precipitate labour, caesarean section, twins, toxemia, breech delivery and head injury were not found to be significantly associated with cerebral palsy. Thus birth asphyxia, low birth weight, neonatal convulsions, neonatal jaundice, neonatal infection, instrument assisted delivery and antepartum hemorrhage are significant risk factors for cerebral palsy.

Characteristics of mental morbidity in a rural primary heath centre of haryana.

The prevalence of mental morbidity including comorbidity with physical illnesses in a rural primary health centre is very high. Most common entitites in the diagnostic group according to DSM-IU-R were mood disorders (28%), somatoform disorders (27%), and anxiety disorders (17.6%). Majority of them presented with somatic symptoms. There were significant differences in rates for mental disorders when age (particularly 35-44 years), marital status, types of family, and females operated for tubectomy were analysed. The study emphasises the need for effective mental health care to the rural community through primary health centres.

Epidemiological characteristics of new borns in a rural community.

All births (1211) were recorded in a rural area for 1985 by monthly domiciliary visits and the sociological characteristics were collected from mothers within a month. The analysis of 1201 births is presented: 52.7% were male births, 95.7% were delivered in village itself, 80.4% were delivered by trained dais, 99.5% were live born, 12.9% were born before 37 weeks of gestation, 61.5% were put to breast feed within 6 hours, 35% were of gravida 4 and above, 68.9% did not receive any antenatal care, 67.1% had not received any tetanus toxoid, 70.8% did not receive any folifer tablet, 0.8% had abortion and another 0.8% had still birth in preceding outcome, 1.58% had lost a live born dead in preceding out come, 89.6% stopped breast feeding at conception, 31.7% had birth interval less than 2 years, but 2.2% had less than one year, 2/3rd were born in second half of the year, 17.8% had taken extra food during pregnancy, 21.2% reduced the work after becoming pregnant, 9.5% were born to mothers of less than 20 years age, 98.5% of mothers were housewives and 95.9% mothers were illiterate, 33.5% were born in nuclear family, 22.3% were living in 'Kacha' house, 34.8% had no electricity connection, 37.0% were born to land less, 42.2% had no radio in the house, 7.1% had no conveyance, 52.0% families had piped water supply. These findings have been discussed here.

Management of ARI for control of mortality in underfives.

WHO advocated a standard case management for control of ARI related mortality. India has started an ARI control programme in 15 districts. Conflicting reports appeared regarding the effectiveness of case management strategy. Authors reported earlier that it was not effective. The coverage was only about 57% in pneumonias, and 23% in severe pneumonias. Health agencies & health workers have a low utilization (13.7%), and RMPs were used in large numbers (36.9%). Most of the deaths were in those treated by RMPs (75%). The efficacy of standard case management (88%) is highlighted. The problem of coverage and assumptions behind the strategy were discussed and recommendations for improvement were suggested.

Socio-biological factors in underfive deaths in a rural area.

In 1985-86, 286 underfive deaths occurred among a population of 30,000 in a rural area of Haryana. Two hundred and eighty one were analysed for socio-biological factors related to under five mortality. Females had a higher mortality. About 2/3 of the deaths were in infants, and 90% in first 3 years. Most of the deaths (94%) occurred in the village itself, 58.4% did not seek any medical care during the terminal illness, 80-90% did not receive even a single dose of BCG, DPT or O.P.V., and 36.7% died in the first attack of illness. Though 68% had at least one episode earlier, 31.0% had been admitted in hospitals for an earlier episode of illness. In 42.8% of deaths, the birth order was IV or above. Deaths in socially and economically disadvantaged cases constituted 77.6%. The triad of diarrhea, ARI and malnutrition claimed 56% deaths. In 93% of the deaths, the mothers were illiterate and 96.4% were house wives. There was a sibling death earlier in the family in 78.3%, and 60.1% deaths were of those living in poor housing conditions. About 50% had radio for communication, 85.8% had bicycle for conveyance, and in 66.9% the family had piped water supply. All these findings have been discussed in the study.

PIP: Physicians analyzed data on 286 deaths among less than 5-year-old children who lived in 20 villages in a rural area of Haryana, India, to determine the sociobiological factors of child mortality. Field workers collected the data during home visits in 1985 and 1985. The infant mortality rate was 71.9/1000 live births. The mortality rate for 1-to-4-year-old children was 14.1. 89.3% of all deaths occurred in children less than 3 years old demonstrating the need for health services to target this age group. Even though 85.8% had access to a bicycle to contact a health worker, they chose not to do so as indicated by the fact that 58.4% did not seek any medical care during the fatal illness. 94% of all children died in the village. More than 80% had never received a DPT, oral polio virus, or BCG vaccine. Thus, rural health services need to strengthen quality and quantity of care at the village level as well as improve referral services. There was excess mortality of females (55.5% of deaths), confirming neglect of girls in rural Haryana. 63.3% of all children had been sick before the fatal episode. Just 31% of these children had been admitted to a hospital for the last illness, suggesting that the earlier contact with the medical community did not instill enough confidence in them to seek hospital care again. 77.6% were members of lower castes. 66.9% had a piped water supply. 55.9% died from diarrhea, acute respiratory infections, and malnutrition, suggesting a need to strengthen health education. 93.6% of the mothers were illiterate and 78.3% of them had experienced the death of an earlier child. Thus, health services should target mothers who had an earlier child loss. 50.2% of the households had a radio.

Supplementary feeding pattern in children living in a resettlement colony.

PIP: A nutrition survey was conducted among 543 mothers of 547 3-year old children living in Sector 1 of Dr. Ambedkar Nagar, a resettlement community, in South Delhi, India to examine weaning practices and the supplementation pattern among these poor urban women. 33.3% of the 3-month old infants had already received animal milk. In fact, 22.9% of these infants 1st received animal milk within the 1st month. 44.6% of 3-6 month infants received animal milk and other supplements. This figure was 74.2% for 6-9 month olds and 88.7% for 9-12 month olds. When mothers 1st began giving animal milk, most (80%) added plain water to the animal milk at a ratio of 3:1. Those giving their infants infant formula also diluted it. Of the children using bottles, 92.2% and 88.6% had only 1 bottle and 1 nipple, respectively. Only 1.2% of the mothers sterilized the bottle properly. 84.5% gave their infants supplementary feeds because they believed they no longer had enough breast milk. They also tended to start supplementary feeds themselves (80.5%). Mothers had a tendency to delay supplementation as evidenced by the average age for introduction of semisolid foods which was 10.3 months. Weaning foods were dal, khichri, rice, chapati, and biscuits. 34.2% of the children were not weaned until after they reached their 1st birthday. These results indicated a high risk of infection due to the early introduction of fluids other than breast milk to young infants. The children were also at risk of malnutrition because of the tendency to introduced semisolid foods later than the recommended age of 4-6 months. Health workers must educate mothers about proper child feeding practices whenever possible since most made the decision to supplement breast milk on their own.^ieng

Effectiveness of measles immunization on diarrhea and malnutrition related mortality in 1-4 year olds.

All the children between 1-4 year old were followed from January 1985 to December 1987 and all eligible children 9-24 months were given measles vaccine using annual pulse method in November-December 1985 and 86 in the study area. The children in C.R.H.S. Project area were used as controls for comparison. At the end of 2 years and 2 rounds of immunization with measles, significant reductions were observed in 1-4 year old mortality due to diarrhea and malnutrition in the study area in contrast to control area. Using epidemiological data and method of pulse immunization with measles vaccine can bring considerable benefit to this age group.

Control of tetanus neonatorum in a rural area.

Experience in the control of tetanus neonatorum (TN) in a rural area is presented. TN was reduced by training of dais, increasing the coverage of tetanus toxoid to pregnant women and distribution of presterilized delivery kits to pregnant ladies for use by birth attendants. The problems of untrained birth attendants, effectiveness of tetanus toxoid coverage and place of delivery are discussed.

PIP: Researchers analyzed 1972, 1977, 1982, 1987 data on neonatal tetanus death and birth attendants from the Comprehensive Rural Health Services Project in rural Ballabgarh, India which comprised 28 villages. Health workers visited each house in an area monthly. Even though they began vaccinating pregnant women with the tetanus toxoid (TT) in 1970, the TT coverage percentage did not fall substantially until between 1977-1982 (31.6%-70%), by 1983, TT coverage stood at 93%. It was not until TT coverage reached 85% did neonatal tetanus deaths fall significantly. In 1982, they gave every women near the end of pregnancy a sterilized delivery kit complete with gauze, half a razor blade, and thread. The health workers instructed the women to request anyone who delivers the child to use the contents of the kit. Regardless of the year, around 90% of deliveries occurred at home. Except for 1982, untrained individuals attended about 70% of deliveries. 1982 was the year with the highest percentage of trained dais involved in home delivery (27.6%). The percentage of deliveries my primary health care staff did rise from 4.2-12.1% between 1972-1987, however. In this time period, neonatal mortality fell gradually from 42.3-17.9. Moreover neonatal deaths from tetanus fell consistently but dramatically from 14.6-0. The drop in tetanus related deaths between 1972-1977, was not significant, however, because tetanus and septicemia were not differentiated and health staff seldom saw tetanus cases in hospitals. In conclusion, the Comprehensive Rural Health Services Project of India should expand prenatal care including TT to all pregnant women, distribute sterilized delivery kits to these women between 36-40 weeks gestation, and include instructions on how to use the contents of the kit.

Epidemiology of diarrhea and its implications for providing services.

This study was conducted in children under the age of four years for a period of one year. By domiciliary visits the diarrheal episodes were recorded, analysed and presented. The findings are based on the diarrheal experience of 4860 children. The attack rate was 2.6/child/year. Family with more than one child had more attacks. Mean duration was 5.76 days and 11.2% had lasted more than 7 days. All the age groups are similarly affected. 75.6% were just plain loose motions and only 4.9% had blood, mucus or fever associated with loose motions. Case fatality was 0.6%. Attack rate was more in June-August and December-February than the other quarters. 42.2% were shown to R.M.P.s. and 33.6% consulted friends or relatives. More than 2/3 gave mainly home made ORS. 69.9% restricted food during attack.

Effectiveness of ARI control strategy on underfive mortality.

A prospective intervention study was conducted in Ballabgarh block of Haryana. The study area has a population of about 30,000 under a state run P.H.C. area. The control area has a population of about 60,000 under Comprehensive Rural Health Services Project of All India Institute of Medical Sciences. ARI control strategies as advocated by WHO was instituted in the study area. Measles and DPT immunization was strengthened. The ARI cases detected or reported to Health Workers were managed as per the standard case management procedure. The underfives mortality, infant and 1-4 years mortality rates were initially higher in study area and differences were statistically significant. After 2 years, the reductions in study area were substantial and differences were not statistically significant. The ARI mortality in underfives, and 1-4 years were higher in study area at the beginning compared to control area. Though they were less than in control area after 2 years of intervention the observed differences were not statistically significant in both periods. The reduction of 37% in underfives mortality and 26% due ARI mortality is substantial. More benefit was attained with measles immunization than with standard case management. ARI control programme is advocated for application on national level vigourously covering with measles immunization and to include the village based private practitioners in the strategy for effective case management.

Epidemiology of pneumonia in rural underfives.

Rural underfives (5335) were followed for a period of one year from January to December 1987 for acute respiratory infections (ARI). Those affected with pneumonias were studied in detail to know the epidemiology. The children reported an attack rate of 0.29/child/year. Severe cases constitute 0.5%. Infants had higher attack rate (0.59/child/year), 47.7% of episodes occurred in infants and 87.7% occurred in children below 3 years. Males had a higher attack rate (0.32 vs 0.27). Mean duration of attack was 5.45 +/- 1.95 days. The attack rate was higher in winter. The case fatality rate was 1.26%. It was highest in neonates (10.7%) Females had higher case fatality rate than males (1.5% Vs 1.1%). Mortality was very high in severe cases. Case fatalities were high in seasons when the climatic change occurred, the highest being in autumn.

Knowledge, attitude and practices regarding acute respiratory infections.

One hundred and six mothers in a rural area were interviewed to determine as to how they recognise pneumonia in children, what therapies they practice with mild acute respiratory illnesses and pneumonias and the feeding practices they adopt. Most mothers recognised pneumonia by noticing fast respiratory rate and difficulty in breathing. More severe cases were recognised by these signs among a higher percentage of mothers. As regards management of mild ARI episodes, more than half the mothers preferred not to give any treatment or use only home remedies. In pneumonias, a majority of them preferred to consult a qualified doctor. Nearly a third of them were of the opinion that they would take the child to hospital if the disease was severe. Regarding feeding practices, most of them stated that they would continue feeding, fluids and breast feeds. Only 10% desired to stop and another 15% would decrease the amounts.

PIP: 106 mothers in a rural area were interviewed to determine how they would recognize pneumonia in children, what therapies they would practice with mild acute respiratory illnesses (ARI) and pneumonia, and the feeding practices they have adopted. Most mothers recognized pneumonia by observing the quick respiratory rate and difficulty in breathing. More severe cases were recognized by these among a higher % of mothers. With regard to management of mild ARI episodes, more that 1/2 of the mothers preferred not to give any treatment or to use only home remedies. In pneumonias, a majority preferred to consult a qualified doctor. Nearly 1/3 of them were of the opinion that they would take the child to a hospital if the disease was severe. Insofar as feeding is concerned, most of them stated that they would continue feeding, fluids, and breastfeeds. Only 10% said they would stop and 15% said they would decrease the amounts.

Factors influencing prevalence of breastfeeding in a resettlement colony of New Delhi.

Influence of some family and maternal characteristics on prevalence of breastfeeding was studied in a cross sectional study using WHO suggested methodology. 547 mothers with children less than three years of age were interviewed with the help of a schedule. Age and parity of the mother, sex of the child, length of urban stay, mother's going for work did not influence the prevalence of breastfeeding. Prevalence was higher among illiterate mothers and mothers belonging to lower socio-economic status. The mothers from higher socio-economic status initiated breastfeeding earlier. More mothers from higher socio-economic status and those with better education thought that supplementation was needed before the child was 4 months old and felt that breastfeeding was needed for less than two years.

Breast feeding practices in a resettlement colony and its implications for promotional activities.

The mothers of 547 children less than three years of age were interviewed for breastfeeding practices using WHO suggested methodology in a resettlement colony of South Delhi. Only 1.8% of children were never breastfed. Prelacteal feeds were given in 90.9% of infants. More than half received their first breastfeed on 3rd day or later. Among children under three months of age, one third were already receiving top milk. 68.4% of mothers felt that the child should be breastfed for as long as possible. Demand feeding was practised by 95% of the mothers. Most of the mothers did not seek privacy to breastfeed their children. The need to identify desirable and undesirable infant feeding practices prevalent in an area has been stressed so that appropriate promotional activities can be carried out more effectively.