Wheelchair services and use outcomes: A cross-sectional survey in Kenya and the Philippines.

BACKGROUND: The World Health Organisation recommends that services accompany wheelchair distribution. This study examined the relationship of wheelchair service provision in Kenya and the Philippines and wheelchair-use-related outcomes. METHOD: We surveyed 852 adult basic manual wheelchair users. Participants who had received services and those who had not were sought in equal numbers from wheelchair-distribution entities. Outcomes assessed were daily wheelchair use, falls, unassisted outdoor use and performance of activities of daily living (ADL). Descriptive, bivariate and multivariable regression model results are presented. RESULTS: Conditions that led to the need for a basic wheelchair were mainly spinal cord injury, polio/post-polio, and congenital conditions. Most Kenyans reported high daily wheelchair use (60%) and ADL performance (80%), while these practices were less frequent in the Philippine sample (42% and 74%, respectively). Having the wheelchair fit assessed while the user propelled the wheelchair was associated with greater odds of high ADL performance in Kenya (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.6, 5.1) and the Philippines (OR 2.8, 95% CI 1.8, 4.5). Wheelchair-related training was associated with high ADL performance in Kenya (OR 3.2, 95% CI 1.3, 8.4). In the Philippines, training was associated with greater odds of high versus no daily wheelchair use but also odds of serious versus no falls (OR 2.5, 95% CI 1.4, 4.5). CONCLUSION: Select services that were associated with some better wheelchair use outcomes and should be emphasised in service delivery. Service providers should be aware that increased mobility may lead to serious falls.

Erratum: Wheelchair services and use outcomes: A cross-sectional survey in Kenya and the Philippines.

[This corrects the article DOI: 10.4102/ajod.v6i0.318.].

Sociocultural factors perpetuating the practices of early marriage and childbirth in Sylhet District, Bangladesh.

BACKGROUND: The practice of adolescent marriage continues in communities throughout Bangladesh, with adolescent childbearing a common result. This early childbearing is associated with increased medical risks for both mothers and their newborns. METHODS: Because of the need to understand the persistence of these behaviors in spite of the risks, various qualitative research methods were used to identify and better understand the various socio cultural factors perpetuating the practices of early marriage and childbirth. RESULTS: Delaying the first birth after marriage can cause rumors of infertility, bring shame on the family, and in some cases lead the husband's family to seek another wife for their son. In addition, social stigma for childless women, emigration of husbands, and the belief that using modern contraceptives prior to the birth of the first child results in infertility also inhibits couples from delaying their first pregnancy. DISCUSSION AND CONCLUSIONS: Future efforts to promote delay in marriage and subsequent early childbearing should focus on allaying the fears of infertility related to delay in childbearing or secondary to contraceptive use, both for newly married couples and household decision-makers such as mothers-in-law.

Apolipoproteins do not add prognostic information beyond lipoprotein cholesterol measures among individuals with obesity and insulin resistance syndromes: the ARIC study.

AIMS: There are conflicting guidelines regarding the measurement of apolipoproteins (apoB, apoA-1), in addition to standard lipoprotein cholesterol measures, for cardiovascular risk assessment among individuals with obesity or insulin resistance syndromes. This study aims to assess whether apolipoprotein assessments add prognostic information regarding coronary heart disease (CHD) risk beyond standard lipoprotein cholesterol measurements among individuals with obesity, diabetes, and the metabolic syndrome. METHODS AND RESULTS: We followed 9026 participants in the Atherosclerosis Risk in Communities (ARIC) study without cardiovascular disease at baseline (visit 4, 1996-99). We compared the associations of apoB, apoA-1, and their respective lipoprotein cholesterol measures with incident CHD events among individuals with and without obesity, the metabolic syndrome, or diabetes. Over a median follow up of 10.1 years, there were 903 CHD events. Among participants with obesity, the top quintiles of apoB (HR 2.00, 95% CI 1.40-2.85 compared with the bottom quintile) and the apoB/apoA-1 ratio (HR 2.47, 95% CI 1.53-4.01) did not demonstrate stronger associations with CHD than the top quintiles of non-high-density-lipoprotein cholesterol (non-HDL-C) (HR 2.54, 95% CI 1.65-3.89) and the ratio of non-HDL-C/HDL-C (HR 4.28, 95% CI 2.29-8.03). Analogous findings were seen among patients with diabetes and the metabolic syndrome. In models adjusted for non-HDL-C and HDL-C, apoB (p = 0.94) and apoA-1 (p = 0.55) were not significantly associated with CHD events among those with obesity, in contrast to non-HDL-C and HDL-C (p = 0.02 for both). CONCLUSIONS: Among individuals with obesity and insulin resistance syndromes, apolipoproteins did not provide prognostic information regarding CHD risk beyond that provided by non-HDL-C and HDL-C.

Local understandings and current barriers to optimal birth intervals among recently delivered women in Sylhet District, Bangladesh.

BACKGROUND: Sylhet Division in Bangladesh has the highest proportion of births spaced less than 36 months (46.5%) in Bangladesh. METHODS: Formative research was conducted on current fertility-related practices in order to explore how to integrate the promotion of healthy fertility practices into a package of maternal and neonatal care interventions. In-depth interviews, focus group discussions and other qualitative methods were utilized with recently delivered women, their families, community health workers and community leaders in Sylhet Division. RESULTS: Mothers of young children generally understood the benefits of both healthy timing and spacing of pregnancies. However, a variety of factors prevent these desired behaviours from becoming actualized, including the roles of women in the provision of children/grandchildren, local understandings of modern contraceptive methods, perceived side effects, lack of communication regarding healthy fertility practices between partners and extended family members, and limited female autonomy. CONCLUSIONS: In order to increase families' ability to achieve optimal birth intervals, we propose the promotion and integration of healthy fertility practices into antenatal and newborn care interventions, focusing on providing biomedically correct and culturally appropriate information on modern contraceptive methods to the entire family, while simultaneously encouraging open spousal and family communication patterns regarding timing and spacing of pregnancy.

Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet, Bangladesh.

OBJECTIVE: To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh. METHODS: In a cluster-randomized controlled trial, two strategies for neonatal care--known as home care and community care--were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy--compared with that of the pre-existing levels of maternal and neonatal care--was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis. FINDINGS: The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833-7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72-265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844-7628) and US$ 104.62 (95% CI: 65.15-266.60), respectively. The home-care package was cost-effective--with 95% certainty--if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective. CONCLUSION: The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.

Safety and efficacy of simplified antibiotic regimens for outpatient treatment of serious infection in neonates and young infants 0-59 days of age in Bangladesh: design of a randomized controlled trial.

BACKGROUND: Because access to care is limited in settings with high mortality, exclusive reliance on the current recommendation of 7-10 days of parenteral antibiotic treatment is a barrier to provision of adequate treatment of newborn infections. METHODS: We are conducting a trial to determine if simplified antibiotic regimens with fewer injections are as efficacious as the standard course of parenteral antibiotics for empiric treatment of young infants with clinical signs suggestive of severe infection in 4 urban hospitals and in a rural surveillance site in Bangladesh. The reference regimen of intramuscular procaine-benzyl penicillin and gentamicin given once daily for 7 days is being compared with (1) intramuscular gentamicin once daily and oral amoxicillin twice daily for 7 days and (2) intramuscular penicillin and gentamicin once daily for 2 days followed by oral amoxicillin twice daily for additional 5 days. All regimens are provided in the infant's home. The primary outcome is treatment failure (death or lack of clinical improvement) within 7 days of enrolment. The sample size is 750 evaluable infants enrolled per treatment group, and results will be reported at the end of 2013. DISCUSSION: The trial builds upon previous studies of community case management of clinical severe infections in young infants conducted by our research team in Bangladesh. The approach although effective was not widely accepted in part because of feasibility concerns about the large number of injections. The proposed research that includes fewer doses of parenteral antibiotics if shown efficacious will address this concern.

The association of plasma lactate with incident cardiovascular outcomes: the ARIC Study.

We examined the association of plasma lactate at rest, a marker of oxidative capacity, with incident cardiovascular outcomes in 10,006 participants in the Atherosclerosis Risk in Communities (ARIC) Study visit 4 (1996-1998). We used Cox proportional-hazards models to estimate hazard ratios of incident coronary heart disease, stroke, heart failure, and all-cause mortality by quartiles of plasma lactate (Q1, ≤5.3 mg/dL; Q2, 5.4-6.6; Q3, 6.7-8.6; and Q4 ≥8.7). During a median follow-up time of 10.7 years, there were 1,105 coronary heart disease cases, 379 stroke cases, 820 heart failure cases, and 1,408 deaths. A significant graded relation between lactate level and cardiovascular events was observed in the demographically adjusted model (all P for trend < 0.001). After further adjustment for traditional and other potential confounders, the association remained significant for heart failure (Q4 vs. Q1: hazard ratio (HR) = 1.35, 95% confidence interval (CI): 1.07, 1.71) and all-cause mortality (HR = 1.27, 95% CI: 1.07, 1.51) (P for trend < 0.02 for these outcomes) but not for coronary heart disease (HR = 1.02, 95% CI: 0.84, 1.24) and stroke (HR = 1.26, 95% CI: 0.91, 1.75). The results for heart failure were robust across multiple subgroups, after further adjustment for N-terminal pro-B-type natriuretic peptide and after exclusion of participants with incident heart failure within 3 years. The independent associations of plasma lactate with heart failure and all-cause mortality suggest an important role for low resting oxidative capacity.

Clustering of neonatal deaths in Bangladesh: results from the Projahnmo studies.

BACKGROUND: Neonatal mortality (NM) tends to be clustered within a small subset of mothers, households and/or geographical areas. Knowledge of the maternal and newborn factors associated with NM can help identify high-risk mothers and guide the targeting of intervention programmes. METHOD: Data from pregnancy history surveys conducted as part of the Project for Advancing the Health of Newborns and Mothers (Projahnmo) in Sylhet and Mirzapur districts of Bangladesh were used to investigate risk factors for NM. We analysed data from babies born between 2001 and 2005 in the control clusters of the Projahnmo trials. Generalised linear mixed models were applied to quantify the heterogeneity among mothers and to investigate factors that contribute to this heterogeneity. RESULTS: There was an indication of correlation among siblings' outcomes. Neonates whose preceding sibling had died as a neonate in the mothers' lifetime pregnancy history were more likely (up to 1.9 times) to die than those with a living sibling. Factors that varied at the child and mother levels as well as the preceding siblings' outcome explained a large proportion (60% in Sylhet and 70% in Mirzapur) of the between-mother variation in NM. CONCLUSION: The preceding sibling's outcome may be a surrogate for genetic and other maternal health factors such as nutrition, infection or environmental factors that were not measured within Projahnmo. Further research into these factors is required in order to explain the variation in the risk for NM.

Diabetes and risk of fracture-related hospitalization: the Atherosclerosis Risk in Communities Study.

OBJECTIVE: To examine the association between diabetes, glycemic control, and risk of fracture-related hospitalization in the Atherosclerosis Risk in Communities (ARIC) Study. RESEARCH DESIGN AND METHODS: Fracture-related hospitalization was defined using International Classification of Diseases, 9th revision, codes (733.1-733.19, 733.93-733.98, or 800-829). We calculated the incidence rate of fracture-related hospitalization by age and used Cox proportional hazards models to investigate the association of diabetes with risk of fracture after adjustment for demographic, lifestyle, and behavioral risk factors. RESULTS: There were 1,078 incident fracture-related hospitalizations among 15,140 participants during a median of 20 years of follow-up. The overall incidence rate was 4.0 per 1,000 person-years (95% confidence interval [CI], 3.8-4.3). Diagnosed diabetes was significantly and independently associated with an increased risk of fracture (adjusted hazard ratio [HR], 1.74; 95% CI, 1.42-2.14). There also was a significantly increased risk of fracture among persons with diagnosed diabetes who were treated with insulin (HR, 1.87; 95% CI, 1.15-3.05) and among persons with diagnosed diabetes with hemoglobin A1c (HbA1c) ≥8% (1.63; 1.09-2.44) compared with those with HbA1c <8%. Undiagnosed diabetes was not significantly associated with risk of fracture (HR, 1.12; 95% CI, 0.82-1.53). CONCLUSIONS: This study supports recommendations from the American Diabetes Association for assessment of fracture risk and implementation of prevention strategies in persons with type 2 diabetes, particularly those persons with poor glucose control.

Rarity of anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibodies in statin users, including those with self-limited musculoskeletal side effects.

OBJECTIVE: Statins, among the most commonly prescribed medications, are associated with a wide range of musculoskeletal side effects. These include a progressive autoimmune myopathy with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibodies that requires immunosuppression. However, it remains unknown whether these antibodies are found in statin users with and without self-limited musculoskeletal side effects; this limits their diagnostic utility. The current work assessed the prevalence of anti-HMGCR antibodies in these groups of statin users. METHODS: We determined the prevalence of anti-HMGCR antibodies in 1,966 participants (including 763 current statin users) in a substudy of the community-based Atherosclerosis Risk in Communities (ARIC) Study and 98 French Canadian subjects with familial hypercholesterolemia, including 51 with documented statin intolerance. RESULTS: No participant in the ARIC substudy, including those with past or current statin exposure at the time of sample collection, had anti-HMGCR antibodies. Similarly, none of 51 patients with self-limited statin intolerance or 47 statin-tolerant patients receiving maximal statin therapy were anti-HMGCR positive. CONCLUSION: The majority of patients with and without statin exposure, including those with self-limited statin intolerance, do not develop anti-HMGCR antibodies. Therefore, anti-HMGCR antibodies are highly specific for those with an autoimmune myopathy.

Effect of knowledge of community health workers on essential newborn health care: a study from rural India.

BACKGROUND: This study explored the relationship between the knowledge of community health workers (CHWs)-anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)-and their antenatal home visit coverage and effectiveness of the visits, in terms of essential newborn health care practices at the household level in rural India. METHODS: We used data from 302 AWWs and 86 ANMs and data from recently delivered women (RDW) (n=13,023) who were residents of the CHW catchment areas and gave birth to a singleton live baby during 2004-05. Using principal component analysis, knowledge scores for preventive care and danger signs were computed separately for AWWs and ANMs and merged with RDW data. A multivariate logistic regression model was used to estimate the adjusted effect of knowledge level. A generalized estimating equation (GEE) was used to account for clustering. RESULTS: Coverage of antenatal home visits and newborn care practices were positively correlated with the knowledge level of AWWs and ANMs. Initiation of breastfeeding in the first hour of life (odds ratio 1.97; 95% confidence interval (CI): 1.55-2.49 for AWW, and odds ratio 1.62; 95% CI: 1.25-2.09 for ANM), clean cord care (odds ratio 2.03; 95% CI: 1.64-2.52 for AWW, and odds ratio 1.43; 95% CI: 1.17-1.75 for ANM) and thermal care (odds ratio 2.16; 95% CI: 1.64-2.85 for AWW and odds ratio 1.88; 95% CI: 1.43-2.48 for ANM) were significantly higher among women visited by AWWs or ANMs who had better knowledge compared with those with poor knowledge. CONCLUSION: CHWs' knowledge is one of the crucial aspects of health systems to improve the coverage of community-based newborn health care programmes as well as adherence to essential newborn care practices at the household level.

Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh.

BACKGROUND: Lack of data is a critical barrier to addressing the problem of stillbirth in countries with the highest stillbirth burden. Our study objective was to estimate the levels, types, and causes of stillbirth in rural Sylhet district of Bangladesh. METHODS: A complete pregnancy history was taken from all women (n=39 998) who had pregnancy outcomes during 2003-2005 in the study area. Verbal autopsy data were obtained for all identified stillbirths during the period. We used pre-defined case definitions and computer programs to assign causes of stillbirth for selected causes containing specific signs and symptoms. Both non-hierarchical and hierarchical approaches were used to assign causes of stillbirths. RESULTS: A total of 1748 stillbirths were recorded during 2003-2005 from 48,192 births (stillbirth rate: 36.3 per 1000 total births). About 60% and 40% of stillbirths were categorized as antepartum and intrapartum, respectively. Maternal conditions, including infections, hypertensive disorders, and anemia, contributed to about 29% of total antepartum stillbirths. About 50% of intrapartum stillbirths were attributed to obstetric complications. Maternal infections and hypertensive disorders contributed to another 11% of stillbirths. A cause could not be assigned in nearly half (49%) of stillbirths. CONCLUSION: The stillbirth rate is high in rural Bangladesh. Based on algorithmic approaches using verbal autopsy data, a substantial portion of stillbirths is attributable to maternal conditions and obstetric complications. Programs need to deliver community-level interventions to prevent and manage maternal complications, and to develop strategies to improve access to emergency obstetric care. Improvements in care to avert stillbirth can be accomplished in the context of existing maternal and child health programs. Methodological improvements in the measurement of stillbirths, especially causes of stillbirths, are also needed to better define the burden of stillbirths in low-resource settings.

Effect of timing of first postnatal care home visit on neonatal mortality in Bangladesh: a observational cohort study.

OBJECTIVE: To assess the effect of the timing of first postnatal home visit by community health workers on neonatal mortality. DESIGN: Analysis of prospectively collected data using time varying discrete hazard models to estimate hazard ratios for neonatal mortality according to day of first postnatal home visit. DATA SOURCE: Data from a community based trial of neonatal care interventions conducted in Bangladesh during 2004-5. MAIN OUTCOME MEASURE: Neonatal mortality. RESULTS: 9211 live births were included. Among infants who survived the first day of life, neonatal mortality was 67% lower in those who received a visit on day one than in those who received no visit (adjusted hazard ratio 0.33, 95% confidence interval 0.23 to 0.46; P<0.001). For those infants who survived the first two days of life, receiving the first visit on the second day was associated with a 64% lower neonatal mortality than in those who did not receive a visit (adjusted hazard ratio 0.36, 0.23 to 0.55; P<0.001). First visits on any day after the second day of life were not associated with reduced mortality. CONCLUSIONS: In developing countries, especially where home delivery with unskilled attendants is common, postnatal home visits within the first two days of life by trained community health workers can significantly reduce neonatal mortality.

Effectiveness of home-based management of newborn infections by community health workers in rural Bangladesh.

BACKGROUND: : Infections account for about half of neonatal deaths in low-resource settings. Limited evidence supports home-based treatment of newborn infections by community health workers (CHW). METHODS: : In one study arm of a cluster randomized controlled trial, CHWs assessed neonates at home, using a 20-sign clinical algorithm and classified sick neonates as having very severe disease or possible very severe disease. Over a 2-year period, 10,585 live births were recorded in the study area. CHWs assessed 8474 (80%) of the neonates within the first week of life and referred neonates with signs of severe disease. If referral failed but parents consented to home treatment, CHWs treated neonates with very severe disease or possible very severe disease with multiple signs, using injectable antibiotics. RESULTS: : For very severe disease, referral compliance was 34% (162/478 cases), and home treatment acceptance was 43% (204/478 cases). The case fatality rate was 4.4% (9/204) for CHW treatment, 14.2% (23/162) for treatment by qualified medical providers, and 28.5% (32/112) for those who received no treatment or who were treated by other unqualified providers. After controlling for differences in background characteristics and illness signs among treatment groups, newborns treated by CHWs had a hazard ratio of 0.22 (95% confidence interval [CI] = 0.07-0.71) for death during the neonatal period and those treated by qualified providers had a hazard ratio of 0.61 (95% CI = 0.37-0.99), compared with newborns who received no treatment or were treated by untrained providers. Significantly increased hazards ratios of death were observed for neonates with convulsions (hazard ratio [HR] = 6.54; 95% CI = 3.98-10.76), chest in-drawing (HR = 2.38, 95% CI = 1.29-4.39), temperature <35.3 degrees C (HR = 3.47, 95% CI = 1.30-9.24), and unconsciousness (HR = 7.92, 95% CI = 3.13-20.04). CONCLUSIONS: : Home treatment of very severe disease in neonates by CHWs was effective and acceptable in a low-resource setting in Bangladesh.

Impact of an integrated nutrition and health programme on neonatal mortality in rural northern India.

OBJECTIVE: To assess the impact of the newborn health component of a large-scale community-based integrated nutrition and health programme. METHODS: Using a quasi-experimental design, we evaluated a programme facilitated by a nongovernmental organization that was implemented by the Indian government within existing infrastructure in two rural districts of Uttar Pradesh, northern India. Mothers who had given birth in the 2 years preceding the surveys were interviewed during the baseline (n = 14 952) and endline (n = 13 826) surveys. The primary outcome measure was reduction of neonatal mortality. FINDINGS: In the intervention district, the frequency of home visits by community-based workers increased during both antenatal (from 16% to 56%) and postnatal (from 3% to 39%) periods, as did frequency of maternal and newborn care practices. In the comparison district, no improvement in home visits was observed and the only notable behaviour change was that women had saved money for emergency medical treatment. Neonatal mortality rates remained unchanged in both districts when only an antenatal visit was received. However, neonates who received a postnatal home visit within 28 days of birth had 34% lower neonatal mortality (35.7 deaths per 1000 live births, 95% confidence interval, CI: 29.2-42.1) than those who received no postnatal visit (53.8 deaths per 1000 live births, 95% CI: 48.9-58.8), after adjusting for sociodemographic variables. Three-quarters of the mortality reduction was seen in those who were visited within the first 3 days after birth. The effect on mortality remained statistically significant when excluding babies who died on the day of birth. CONCLUSION: The limited programme coverage did not enable an effect on neonatal mortality to be observed at the population level. A reduction in neonatal mortality rates in those receiving postnatal home visits shows potential for the programme to have an effect on neonatal deaths.

Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial.

BACKGROUND: Neonatal mortality accounts for a high proportion of deaths in children under the age of 5 years in Bangladesh. Therefore the project for advancing the health of newborns and mothers (Projahnmo) implemented a community-based intervention package through government and non-government organisation infrastructures to reduce neonatal mortality. METHODS: In Sylhet district, 24 clusters (with a population of about 20 000 each) were randomly assigned in equal numbers to one of two intervention arms or to the comparison arm. Because of the study design, masking was not feasible. All married women of reproductive age (15-49 years) were eligible to participate. In the home-care arm, female community health workers (one per 4000 population) identified pregnant women, made two antenatal home visits to promote birth and newborn-care preparedness, made postnatal home visits to assess newborns on the first, third, and seventh days of birth, and referred or treated sick neonates. In the community-care arm, birth and newborn-care preparedness and careseeking from qualified providers were promoted solely through group sessions held by female and male community mobilisers. The primary outcome was reduction in neonatal mortality. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number 00198705. FINDINGS: The number of clusters per arm was eight. The number of participants was 36059, 40159, and 37598 in the home-care, community-care, and comparison arms, respectively, with 14 769, 16 325, and 15 350 livebirths, respectively. In the last 6 months of the 30-month intervention, neonatal mortality rates were 29.2 per 1000, 45.2 per 1000, and 43.5 per 1000 in the home-care, community-care, and comparison arms, respectively. Neonatal mortality was reduced in the home-care arm by 34% (adjusted relative risk 0.66; 95% CI 0.47-0.93) during the last 6 months versus that in the comparison arm. No mortality reduction was noted in the community-care arm (0.95; 0.69-1.31). INTERPRETATION: A home-care strategy to promote an integrated package of preventive and curative newborn care is effective in reducing neonatal mortality in communities with a weak health system, low health-care use, and high neonatal mortality.

NGO facilitation of a government community-based maternal and neonatal health programme in rural India: improvements in equity.

Socio-economic disparities in health have been well documented around the world. This study examines whether NGO facilitation of the government's community-based health programme improved the equity of maternal and newborn health in rural Uttar Pradesh, India. A quasi-experimental study design included one intervention district and one comparison district of rural Uttar Pradesh. A household survey conducted between January and June 2003 established baseline rates of programme coverage, maternal and newborn care practices, and health care utilization during 2001-02. An endline household survey was conducted after 30 months of programme implementation between January and March 2006 to measure the same indicators during 2004-05. The changes in the indicators from baseline to endline in the intervention and comparison districts were calculated by socio-economic quintiles, and concentration indices were constructed to measure the equity of programme indicators. The equity of programme coverage and antenatal and newborn care practices improved from baseline to endline in the intervention district while showing little change in the comparison district. Equity in health care utilization for mothers and newborns also showed some improvements in the intervention district, but notable socio-economic differentials remained, with the poor demonstrating less ability to access health services. NGO facilitation of government programmes is a feasible strategy to improve equity of maternal and neonatal health programmes. Improvements in equity were most pronounced for household practices, and inequities were still apparent in health care utilization. Furthermore, overall programme coverage remained low, limiting the ability to address equity. Programmes need to identify and address barriers to universal coverage and care utilization, particularly in the poorest segments of the population.