Screening and diagnosis of COPD and asthma based on government guidelines empowering peripheral health workers in Pune district Maharashtra, India: A study protocol.

COPD is the second leading cause of death in India. The guidelines for early detection of COPD were released by the Government of India in 2019. However, due to the COVID-19 pandemic, its implementation could not be optimal. Diagnosis of COPD is based on the presence of respiratory symptoms, the presence of exposure to risk factors, and the presence of poorly reversible airflow obstruction as assessed using a spirometer. Spirometers are currently available only at a few district hospitals. The existing guidelines expect the patient to visit the Rural hospital/ Community Health Centre, which does not have a spirometer or a pulmonary medicine specialist. Also, it is not feasible or accessible for patients to visit the district hospital to get diagnosed. The current study will be implemented to determine the prevalence, annual incidence of COPD and asthma, quality of life, and nutritional status of COPD and asthma patients. The novelty of this implementation research, which will be conducted in collaboration with Zilla Parishad (i.e., Government), Pune district, is the empowerment of an Accredited Social Health Activist (ASHA), a peripheral health worker to screen all individuals using a peak flow meter and confirmation of the diagnosis at health and wellness center (HWC). An accredited Social Health Activist (ASHA) will take relevant history to suspect COPD and asthma in 30+-year-old adults, and she will refer the suspected cases to the Community Health Officer (CHO) at the Health and Wellness Center. The CHO/ Medical officer of PHC will initiate the appropriate treatment after confirming the diagnosis using a portable spirometer. The difficult-to-diagnose patients with comorbidity and acute exacerbations will be referred to the nearest higher center, i.e., Primary Health Centre (PHC) or Community Health Centre (CHC), where a primary care physician is available. The ASHA workers will provide two follow-ups to these patients in a year, depending on the severity, to ensure compliance with the treatment. Thus, early diagnosis and appropriate treatment of COPD and asthma at the community level may help to reduce the episodes of acute exacerbations.

Nuances of Cohort Studies and Risk Ratio.

Post-graduate students and faculty usually conduct case-control studies. However, sometimes they conduct cohort studies that are short-duration. Most investigators enroll the participants in two groups according to the exposure. Then, follow the participants for some duration. At the end of the study, relative risk is calculated, and the work is published in some journal. The exposure may be one time, which may or may not be quantified. The follow-up duration may not be participant-specific, and differential follow-up does not exist. The author has given three examples: the first example of consanguineous marriages and congenital disabilities, the second example of the ABO blood group system and childhood asthma, and the third example of insecticide spraying and stillbirth. In the given examples, cumulative or density incidence cannot be calculated in a true sense and, therefore, risk ratio. Even estimating the incidence of outcome variables in some studies is not appropriate. Risk ratio calculation in such scenarios is questionable because exposure quantification, follow-up period, and combination are the limiting factors. In case-control studies, the prevalence ratio is calculated, which is analogous to relative risk. The author suggests that, in such circumstances, prevalence ratio calculation will be more appropriate.

Implementation of preconception care for preventing adverse pregnancy outcomes in rural and tribal areas of Nashik District, India.

Introduction: The World Health Organization has suggested preconception care to improve pregnancy outcomes. Hence, the study aimed to compare the effect of preconception care on pregnancy outcomes, particularly prematurity and low birth weight. Methods: We carried out interventions in one tribal and one non-tribal block. For comparison, one adjacent tribal block and one non-tribal block were included in Nashik district, India. The total study period was from April 2018 to July 2021. All reproductive age group women desiring pregnancy within one year in selected four blocks participated in the study. The services included clinical examination, laboratory investigations, treatment, six-monthly deworming, anemia management, folic acid supplementation, family planning services, and behavioral change communication using different media. The existing healthcare workers provided services to the women until they became pregnant or until the end of the follow-up period (27 months). We monitored pregnancy outcomes, including abortion, stillbirth, and live birth; among live births, low birth weight, preterm birth, congenital physical anomaly, and neonatal death. Results: The study enrolled 7,875 women, and 3,601 had outcomes. The proportion of preterm births in the intervention and comparison block was 11.18 % and 14.99 %, respectively (p = 0.001), and the proportion of low-birth-weight babies was 9.23 % and 11.25 %, respectively (p = 0.01). The adjusted prevalence ratio showed that the risk of preterm births in the absence of intervention was 1.3 (CI: 1.1-1.6). Preterm birth was a mediator between preconception care and low birth weight. Conclusion: Reduction in proportion of low birth weight and preterm babies can be achieved through preconception care using minimal additional resources.

Effect of Diet Counseling on Nutritional Status of Chronic Respiratory Diseases Patients Enrolled in the Pulmonary Rehabilitation Program in a Teaching Hospital: A Pre-Post Intervention Study.

We conducted the study to assess the effect of patient-tailored diet counseling on the nutritional status of chronic respiratory disease (CRD) patients under the pulmonary rehabilitation program from June 2021-May 2022. These patients completed 2 months of patient-tailored diet counseling sessions under the pulmonary rehabilitation program, which consisted of 4-5 interactive diet counseling sessions fortnightly. The pre- and postassessment was done using standardized outcomes: Malnutrition Universal Screening Tool (MUST), body mass index (BMI), and ideal body weight. The study enrolled 110 CRD patients. There was a statistically significant improvement in pre- and postassessment in MUST score, appetite, and unintentional weight loss (P < 0.001). Most of the patient's BMI normalized. In prenutritional assessment, most of the patients were malnourished and in postassessment, the number of malnourished and anemic patients was reduced. This study concludes that nutritional counseling effectively improves nutritional status and anemia.

Chronic respiratory diseases: A rapidly emerging public health menace.

Chronic respiratory diseases, especially the common chronic obstructive pulmonary disease (COPD) and asthma, are increasing at a swift pace. Although smoking is the most typical risk factor globally, indoor and outdoor air pollution is more important in India. Deaths due to COPD have been next to coronary heart disease since 2014. It causes about 64 deaths per lakh population. It is a chronic and progressive disease having many exacerbations. Mostly senior males are affected. Often, the exacerbation needs intensive care, which may be taxing to the limited intensive care units and may deprive other more warranting patients. The diagnosis requires spirometry, which is available only in private or government tertiary care hospitals. The mainstay of treating both diseases is the inhalation of bronchodilators with or without steroids. The diagnosis and treatment are costly, and treatment is required lifelong. Reduction in risk factors is a challenging and long journey. It requires behavioral change communication. The government in the health sector has critical options. On the one hand, the disease is increasing for various reasons; on the other hand, resources are enormously required for prevention and management. The ASHA system and health and wellness centers, which have not been given due importance, can screen, diagnose, and manage majorly patients. Public health specialists should forcefully advocate for resources required for training and equipment.

Effect of bacterial vaginosis on preterm birth: a meta-analysis.

PURPOSE: Bacterial vaginosis is a common genital tract disorder. It can lead to preterm birth, but its contribution is equivocal. Bacterial vaginosis is curable and, if diagnosed and appropriately treated, may reduce preterm births. The study desired to confirm the association between bacterial vaginosis and preterm birth. METHODS: It was a meta-analysis. We included articles published from 2008 to 2022. The authors included studies that measured the association between bacterial vaginosis and preterm birth by relative risk/risk ratio (RR) or odds ratio (OR). We excluded studies with qualitative data. The study utilized five search engines, PubMed, Scopus, Google Scholar, Cochrane, and LILAC. We used the statistical package for social sciences (SPSS) to draw forest and funnel plots separately for RR and OR. RESULTS: After an extensive search, the study included 20 articles yielding 26 relevant results with a total of 290,397 observations. This meta-analysis proves that bacterial vaginosis is undoubtedly associated with preterm birth. The overall relative risk of preterm delivery is about two-fold as overall OR1.79 (95% Confidence Interval 1.32-2.43). The overall RR of preterm birth is 1.44 (95% Confidence Interval 1.19-1.73). CONCLUSION: Our study shows a significant association between bacterial vaginosis and preterm birth. The study concludes that investigation for bacterial vaginosis and management should be a part of the routine examination of a pregnant woman. The health system must initiate this strategy soon to reduce the prevalence of preterm births and consequent neonatal mortality.

Symptomatic survey of COVID-19 in the rural health and demographic surveillance site of Maharashtra, India.

Introduction: The COVID-19 epidemic is fast-evolving and restrictions to contain it changes quickly. The secondary attack rate (SAR) indicates the infectiousness at the household level, and it provides a clue of load of infections in the community. Rapid implementation of a large scale, but brief survey provides a nationally representative view of the pandemic's progression and impact as well as the effect of the measures taken to control the spread. Materials and Methods: This cross-sectional study was done for a period of 2 months July-August 2020, in one of the rural health and demographic surveillance system (HDSS) site in India among 11,507 households having 46,571 individuals with the objective to determine the prevalence of the COVID-19 infection and to estimate the family SAR. The data were collected using the mobile phone by calling the head of the households registered under the HDSS. The research tool was created using questions based on the guidelines provided by the Ministry of Health and Family Welfare, India. The interviewers were first trained in data collection. Results: The households of 33,780 individuals were contacted and 33 patients were diagnosed as COVID positive, prevalence rate of 0.1% was thus documented through telephonic survey. The mean age of COVID patients was found to be 37 ± 16 years, and 63% of the diagnosed patients were males, majority of them belonged to above poverty line households. During the survey, 46 individuals reported to have the symptoms suggestive of COVID, fever and cough were the most commonly reported symptoms. The family SAR of 17.2% was documented. Conclusion: Thus to conclude a low COVID-19 prevalence rate of 0.1%, a higher family SAR of 17.2% was reported in the current study. Timely diagnosis and quarantine of close contacts should be continued to be implemented rigorously to prevent the spread of the COVID-19 virus. These efforts will be useful to contain the epidemic before it reaches an alarming level in the rural areas.

Résumé Introduction: L'épidémie de COVID-19 évolue rapidement et les restrictions pour la contenir changent rapidement. Le taux d'attaque secondaire (SAR) indique l'infectiosité au niveau du ménage et fournit un indice de la charge d'infections dans la communauté. La mise en œuvre rapide d'une enquête à grande échelle mais brève fournit une vue représentative à l'échelle nationale de la progression et de l'impact de la pandémie ainsi que de l'effet des mesures prises pour contrôler la propagation. Matériels et Méthodes: cette étude transversale a été réalisée sur une période de 2 mois de juillet à août 2020, dans l'un des sites du système de surveillance sanitaire et démographique en milieu rural (HDSS) en Inde auprès de 11 507 ménages comptant 46 571 individus dans le but de déterminer prévalence de l'infection au COVID-19 et d'estimer le DAS familial. Les données ont été collectées à l'aide du téléphone mobile en appelant le chef de ménage inscrit au HDSS. L'outil de recherche a été créé à l'aide de questions basées sur les directives fournies par le ministère indien de la Santé et du Bien-être familial. Les enquêteurs ont d'abord été formés à la collecte de données. Résultats: les ménages de 33 780 individus ont été contactés et 33 patients ont été diagnostiqués positifs au COVID, un taux de prévalence de 0,1 % a ainsi été documenté par une enquête téléphonique. L'âge moyen des patients COVID était de 37 ± 16 ans, et 63 % des patients diagnostiqués étaient des hommes, la majorité d'entre eux appartenant à des ménages au-dessus du seuil de pauvreté. Au cours de l'enquête, 46 personnes ont déclaré avoir des symptômes évocateurs de COVID, la fièvre et la toux étaient les symptômes les plus fréquemment signalés. Le SAR familial de 17,2 % a été documenté. Conclusion: Ainsi, pour conclure à un faible taux de prévalence de la COVID-19 de 0,1 %, un DAS familial supérieur de 17,2 % a été rapporté dans la présente étude. Le diagnostic rapide et la mise en quarantaine des contacts étroits doivent être poursuivis et mis en œuvre de manière rigoureuse pour empêcher la propagation du virus COVID-19. Ces efforts seront utiles pour contenir l'épidémie avant qu'elle n'atteigne un niveau alarmant dans les zones rurales. Mots-clés: COVID 19, système de surveillance sanitaire et démographique, téléphone portable, prévalence, milieu rural, taux d'attaque secondaire.

Perceptions of and challenges faced by primary healthcare workers about preconception services in rural India: A qualitative study using focus group discussion.

Background: Providing preconception care through healthcare workers at the primary health care level is a crucial intervention to reduce adverse pregnancy outcomes, consequently reducing neonatal mortality. Despite the availability of evidence, this window of opportunity remains unaddressed in many countries, including India. The public health care system is primarily accessed by rural and tribal Indian population. It is essential to know the frontline healthcare workers perception about preconception care. The study aimed to identify barriers and suggestions for framing appropriate strategies for implementing preconception care through primary health centers. Methods: The authors conducted a qualitative study using focus group discussions (FGDs) with 45 healthcare workers in four FGDs (8-14 participants in each), in four blocks of Nashik district. The transcribed discussions were analyzed in MAXQDA software using the Socio-Ecological Model as an initial coding guide, including four levels of factors (individual, interpersonal, community, and institutional) that influenced an individual's behavior to use preconception care services. Results: Healthcare workers had some knowledge about preconception care, limited to adolescent health and family planning services. The interpersonal factors included heavy workload, stress, lack of support and co-operation, and paucity of appreciation, and motivation. The perceived community factors included poverty, migration, poor knowledge of preconception care, lack of felt need for preconception services, the influence of older women in the household decision, low male involvement, myths and misconceptions regarding preconception services. The identified institutional factors were lack of human resources, specialized services, logistics, and challenges in delivering adolescent health and family planning programs. Healthcare workers suggested the need for program-specific guidelines, training and capacity building of human resources, an un-interrupted supply of logistics, and a unique community awareness drive supporting preconception care services. Conclusion: Multi-level factors of the Socio-Ecological Model influencing the preconception care services should be considered for framing strategies in the implementation of comprehensive preconception care as a part of a continuum of care for life cycle phases of women.

Prevalence of preconception risk factors for adverse pregnancy outcome among women from tribal and non-tribal blocks in Nashik district, India: a cross-sectional study.

BACKGROUND: Although critical, the preconception phase in women's lives is comparatively ignored. The presence of some risk factors during this phase adversely affects the wellbeing of the woman and the pregnancy outcome. The study objectives were to measure the prevalence of various known risk factors for adverse pregnancy outcome in the preconception period of women and their comparison between blocks. METHODS: This was a community-based cross-sectional study in two tribal and two non-tribal blocks each in Nasik district, Maharashtra, India. The study included married women desiring to conceive within 1 year. Trained Accredited Social Health Activists (field level health worker) collected information from women using a validated interview schedule through house-to-house visits and obtained women's anthropometric measurements in a standard manner. The study assessed the presence of 12 documented risk factors. RESULTS: The study enlisted 7875 women desiring pregnancy soon. The mean age of women was 23.19 (± 3.71) years, and 16% of them were adolescents. Women's illiteracy was higher in tribal areas than non-tribal (p < 0.001). About two-thirds of women have at least one risk factor, and 40.0% have a single risk factor. The most common risk factor observed was no formal education (44.35%). The prevalence of selected risk factors was significantly higher among women from tribal areas. The mean BMI of women was 19.73 (± 3.51), and a higher proportion (40.5%) of women from tribal areas had BMI < 18.5. Despite being of high parity status (≥ 4), about 7.7% of women from the tribal area and 3% from non-tribal desired pregnancy. Tobacco and alcohol consumption was higher among tribal women. The majority of women consumed meals with family members or husbands. Protein and calorie intake of about 1.4% of women was less than 50% of the recommended daily allowance; however, most of them perceived to have abundant food. CONCLUSIONS: Health risks, namely younger age, illiteracy, high parity, consumption of tobacco, low protein, and calorie intake, were quite prevalent, and the risks were significantly more among women from tribal areas. "Continuum of care" must comprise preconception care inclusive of Behavioral Change Communication, particularly for easily modifiable risk factors and specially for tribal women.

Women's health during the preconception phase although important, is an ignored period in her life cycle. Literature has shown that the presence of risk factors in women during the preconception phase is hazardous to the health of women and newborns. The present study is a cross-sectional study conducted in four blocks of Nasik district, Maharashtra, India, to measure risk factors for adverse pregnancy outcome among women and its comparison between blocks.We included married women desiring conception within 1 year. Accredited Social Health Activists asked questions using a validated interview schedule and recorded women's anthropometric measures.Of the 7875 women, 16% were adolescents, and the mean age of women was 23.19 ± 3.71 years. About two-fifth of women had one risk factor, the commonest being no formal education. Overall mean BMI of women was 19.73 (± 3.51). The prevalence of risk factors was significantly higher among women from tribal areas. Despite having ≥ 4 parity a higher proportion of women from tribal areas desired to conceive. About 1.4% of women had protein and calorie intake below 50% recommended consumption.In conclusion, the prevalence of selected risk factors was significantly higher among tribal women. The study identifies the need for preconception care services.

Time dependent decline of neutralizing antibody titers in COVID-19 patients from Pune, India and evidence of reinfection.

PURPOSE: To assess modulation of neutralizing antibody titers in COVID-19 patients and understand association of variables such as age, presence of comorbidity, BMI and gender with antibody titers. METHODS: Patients (n = 100) diagnosed from 20th March 2020 to 17th August 2020 and treated at two large hospitals from Pune, India were included and followed up (clinical and serologic) for varied periods. IgG-anti-SARS-CoV-2 (Spike protein-based ELISA) and neutralizing antibody titers (NAb, PRNT) were determined in all the samples. RESULTS: Of the 100 patients enrolled initially (median 60 days of diagnosis), follow up samples were collected from 70 patients (median 106 days of diagnosis). Overall, NAb titers reduced significantly (p < 0.001) and as early as 3-4 months. During two visits, 20% and 7.1% patients reported some symptoms. At the first visit, NAb titers were higher in patients with severe disease (p < 0.001), comorbidities (p < 0.005), age <50 years (p < 0.05) and male gender (p < 0.05). Multivariate analysis identified older age (p < 0.001), duration post-diagnosis and female gender as independent variables influencing NAb titers (negative correlation, p < 0.05). During the follow-up, reduction in NAb titers was recorded in patients with comorbidity (p < 0.05), mild disease (p < 0.05), age <50 years (p < 0.05), higher BMI (p < 0.05) and male gender (p < 0.001). Serology identified six cases of asymptomatic reinfections. CONCLUSIONS: Decline of NAb titers was associated with age <50 years, mild disease, comorbidities, higher BMI and male gender. At the time of follow up, 8/70 (11.4%) patients lacked neutralizing antibodies. Evidence of 6 probable asymptomatic reinfections suggests waning of immunity, but, probable protection from clinical disease needing hospitalization.

SARS-CoV-2 breakthrough infections during the second wave of COVID-19 at Pune, India.

Breakthrough infections following SARS-CoV-2 vaccination remain the global concern. The current study was conducted during the second wave of COVID-19 (1st March-7th July 2021) in Pune, India, at two tertiary care hospitals. Of the 6,159 patients diagnosed as COVID-19, 372/2,210 (16.8%) were breakthrough infections. Of these, 81.1 and 18.8% received one or two doses of Covishield or Covaxin, respectively. Of note, 30.7% patients were with comorbidities, hypertension being the commonest (12.44%). The majority of infections were mild (81.2%). Forty-three patients with breakthrough infections were hospitalized with severe (n = 27, 62.8%) or moderate (n = 16, 37.2%) disease. The receptor binding domain (RBD) sequences from vaccinated (n = 126) and non-vaccinated (n = 168) samples were used for variant analysis. The delta variant was predominant followed by kappa in both vaccinated and non-vaccinated groups. Viral load (qRT-PCR) was not different among these categories. Full-genome comparisons of sequences in relation to vaccination status did not identify any mutation characteristic of the vaccinated group. Irrespective of the number of doses, neutralizing antibody titers (PRNT50) during the first week of clinical disease were higher in the vaccinated patients than the unvaccinated category. In conclusion, though not completely, SARS-CoV-2 vaccines used for country-wide immunization did reduce disease severity among the individuals without any comorbidity by inducing rapid immune response against distinctly different delta and kappa variants. The utility against emerging variants with further mutations need to be carefully examined.

Relative risk of postpartum maternal morbidity among cesarean-delivered women: A multisite prospective cohort study in a large district, India.

Introduction: Family doctors manage mild to moderate postpartum morbidities that do not receive attention. The morbidities are higher after cesareans, which are increasing in number. The aim was to calculate the relative risk of various maternal morbidities occurring during 6 months postpartum among cesarean-delivered women in Pune District, India. Material and Methods: This was a large multisite study, which included all 11 non-teaching government hospitals performing at least five cesarean sections per month, one teaching government hospital, and one private teaching hospital. All eligible cesarean delivered and an equal number of age and parity matched vaginally delivered women were the participants. The obstetricians interrogated women before discharge, after 4 weeks, 6 weeks, and 6 months. Results: In this study 3,112 women participated. At any visit and among any group lost to follow-up proportion was <10%. There was no major intra-operative complication among vaginally delivered women. The relative risks of acute and severe morbidity as intensive care unit admission and blood transfusion among cesarean-delivered women were 2.59 [95% confidence interval (CI) = 1.96 to 3.44], 4.33 (95% CI = 2.17 to 8.92), respectively. The adjusted relative risk of surgical site pain and infection at 4 weeks; surgical site pain at 6 weeks; and lower abdominal pain, breast engorgement/mastitis, urinary incontinence, and weakness at 6 months among cesarean-delivered women was higher (P < 0.05). Vaginally delivered women resumed family activities earlier. Conclusion: Health care workers, including family doctors, during follow-up of cesarean-delivered women, must assess for pain, induration/discharge at the surgical site, urinary incontinence, and breast engorgement/mastitis.

Coherence between Existing System of Defining Urban Poor with Kuppuswamy and Hashim's System; Which is More Relevant?

BACKGROUND: Identification of below poverty line (BPL) households is of paramount importance to provide benefits under poverty alleviation and other programs. OBJECTIVES: (1) To assess households in urban slums in terms of housing, assets, and amenities. (2) To compare three different systems of socioeconomic status (SES) - ration card holders, Modified Kuppuswamy Scale, and Hashim's system. MATERIALS AND METHODS: A cross-sectional, community-based study was conducted in urban slums of field practice area of a medical college, Pune. Considering 35% of urban households in India qualify as poor, sample size of 593 households was calculated. A predesigned, validated, pretested questionnaire was used, covering sociodemographic domains including indicators of three systems. Agreement between these scales was calculated by kappa statistics. RESULTS: Total 639 households were surveyed covering 3078 slum population. Percentage of BPL families according to possession of yellow ration card, Modified Kuppuswamy Scale, and Hashim's system were 35.99%, 48.67%, and 48.51%, respectively. The proportion of agreement between Kuppuswamy scale and ration card was 55.71% and for Hashim system and ration card was 51.79%. CONCLUSIONS: The present study revealed no agreement between these three systems. Hashim system gives more accurate and realistic picture of SES of the urban slums households owing to its holistic approach.

Prevalence of the Acute Respiratory Infections and Associated Factors in the Rural Areas and Urban Slum Areas of Western Maharashtra, India: A Community-Based Cross-Sectional Study.

Acute respiratory infections (ARIs) continue to be the most important cause of morbidity and mortality among under-five children. Some demographic and environmental factors are associated with ARIs among under-five children. This study was conducted with the objective to estimate the prevalence of ARIs among under-five children in the rural areas and densely populated urban slum areas in Maharashtra, India and to assess the association of the selected sociodemographic and household environmental factors with ARI. This study was conducted in 16 selected clusters from the rural areas and densely populated urban slum areas of the two districts in Maharashtra, India. Structured and validated proforma was used for collecting the data on the sociodemographic and household environmental risk factors. A total of 3,671 under-five children were surveyed. The prevalence of ARIs for the preceding month was 50.4%. It was higher among the children living in the rural areas (54.2%) compared to the children living in the urban areas (46.7%) (p = 0.01). The prevalence of ARIs was reported to be 51.4 and 49.4% in boys and girls, respectively. In the multivariate analysis, the researchers found that living in rural areas (p = 0.01) and parental smoking (p = 0.04) were significantly associated with the ARIs. An intervention such as reducing parental smoking habits at the household level may reduce ARIs.

Effect of Behavior Change Communication on the Incidence of Pneumonia in Under Five Children: A Cluster Randomized Controlled Trial.

BACKGROUND: Improving health education of the mother by providing community-based interventions is known to help control pneumonia. OBJECTIVES: To determine the effect of behavior change communication (BCC) activities for mothers in reducing the incidence of childhood pneumonia. DESIGN: Open-label cluster randomized controlled trial. SETTING: Urban slums and villages in two districs of Maharashtra. PARTICIPANTS/CLUSTER: Under-five children and their mothers from households in the randomly selected 16 clusters out of total 45 clusters, stratified into Pune and Sangli districts and further into rural and urban areas before randomization. INTERVENTION: Three forms of BCC activities were imparted, viz., interactive sessions of education using pictorial mothers' booklet, screening of a audio-visual film, and virtual hand wash demonstration and use of flashcard. Routine care under the National health program was provided by the Accredited Social Health Activists (ASHA) workers in both the arms. OUTCOME: The primary outcome was pneumonia as per the IMNCI criteria assessed during fortnightly visits of the ASHA/anganwadi workers to the houses of under-five children, who received at least one follow-up visit in a period of one year. RESULTS: The incidence of pneumonia in 1993 and 1987 under-five children in the intervention and control arm was 0.80 and 0.48 episodes per child per year, respectively (P=0.03). CONCLUSIONS: BCC for mothers is not sufficient to reduce the incidence of childhood pneumonia.

Meager Perception of Preconception Care Among Women Desiring Pregnancy in Rural Areas: A Qualitative Study Using Focus Group Discussions.

Background: India has the second-highest number of under-five deaths in any country in the world. WHO and the Government of India recommended the rollout of preconception care (PCC) to reduce maternal and child mortality. However, very few countries, including India, have started a comprehensive package of PCC services. It implies that women, mainly from rural and tribal areas, are not aware of PCC. PCC has been rolled out through the government health system in two blocks of Nashik district in Maharashtra state, India, among all women who desire to be pregnant within 1 year. This project is the first of its kind in India. To assess basic perceptions, knowledge, and behavior of women on PCC before the implementation of the project, focus group discussions (FGDs) were carried out. The authors think that the finding may help to develop strategies for behavioral change communication. Methods: From each of the four blocks, two villages having subcenter were selected for conducting FGD. A house-to-house survey was conducted by Accredited Social Health Activist (ASHA) to enlist women who desire a baby in 1 year and invite them to subcenter for FGDs, which were conducted in June 2018. Results: A total of 76 women having a mean age of 23.97 years participated in the FGDs. Most of them (46.05%) had completed 10 years of education. About 50% of pregnancies were planned. The decision about the timing of the first pregnancy is influenced by the mother-in-law. Women knew that they should not conceive before 20 years of age, and their suboptimal weight may have an adverse impact on the health of the newborn. There are many myths about food like "hot and cold foods" and "forbidden food" etc. Women had some knowledge about the adverse effects of tobacco and alcohol; very few consumed these. Most of them did not practice behaviors or accessed services related to PCC. Conclusions: Women neither have the knowledge nor adopt behaviors or accessed services related to PCC. Roll out of PCC among them may help in further reduction of maternal and neonatal morbidity and mortality in India.

Assessment of difference in postpartum depression among caesarean and vaginally delivered women at 6-week follow-up in hospitals in Pune District, India: an observational cohort study.

OBJECTIVES: To compare the proportion of postpartum depression at 6 weeks among women who had caesarean delivery and women who had vaginal delivery and to assess its association with some sociodemographic factors. DESIGN: This is a descriptive comparative study with prospective enrolment. We followed the enrolled women and assessed them for postpartum depression 6 weeks after delivery. SETTING: We conducted the study in Pune District, India from July 2017 to December 2018. The study sites were all non-teaching government hospitals performing five or more caesarean sections per month and two teaching hospitals: one government and one private. PARTICIPANTS: We included in the study group women who have undergone caesarean section in the participating hospitals and were residents of Pune District. Women who delivered vaginally and matched in age and parity were included in the comparison group. We followed 1556 women in each group. MAIN OUTCOME MEASURES: An Edinburgh Postnatal Depression Scale score of 10 or more for each woman was the primary outcome. χ2 test and multivariable binary logistic regression were performed to assess the effect of mode of delivery on postpartum depression. RESULTS: The proportion of postpartum depression at 6 weeks was 3.79% among women who had caesarean delivery and 2.35% among those who had vaginal delivery (χ2=4.50, p=0.03). The adjusted OR was 1.86 (95% CI 1.14 to 3.03). Women of age less than 25 years had higher risk of postpartum depression. The adjusted OR was 2.10 (95% CI 1.21 to 3.65). The study did not observe any association between postpartum depression and income, education, occupation or sex of the newborn child. CONCLUSIONS: We conclude that young women particularly those who had caesarean delivery should be screened 6 weeks after delivery.