Comparing the performance of indicators of hand-washing practices in rural Indian households.

OBJECTIVE: To compare the results obtained from 26 proxy indicators of domestic hand-washing practices with those obtained from direct, 'structured' observation of hand-washing in a sample of 387 households and to assess the potential of these indicators for use in the evaluation of hygiene promotion campaigns. METHODS: Fieldwork in rural India between February 2005 and April 2006. Household-level data on hand-washing practices and the availability of soap and water were collected by structured observation, questionnaire survey, pocket voting, hand-wash demonstration and environmental check. Between them these techniques produced 27 binary indicators of hand-washing practices, each of which was used to classify households as 'hand-washing' or 'non-hand-washing. To assess the extent to which household classification based on each of 26 proxy indicators concurred with classification based on observation, we used the kappa statistic. The prevalence of households defined as 'hand-washing' according to each indicator was compared statistically with the prevalence according to structured observations by testing for a significant difference between two proportions. RESULTS: Agreement between all the proxy indicators and the observation data was poor and all but two of the indicators produced estimates of hand-washing prevalence that were significantly different from that resulting from observation. CONCLUSION: Although some interventions may be able to use proxy indicators as a guide to the magnitude and direction of their impact, these indicators do not provide an accurate guide to the actual practice or prevalence of hand-washing. Structured observation remains the best indicator of those tested.

Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study.

OBJECTIVE: To examine body size and fat measurements of babies born in rural India and compare them with white Caucasian babies born in an industrialised country. DESIGN: Community-based observational study in rural India, and comparison with data from an earlier study in the UK, measured using similar methods. SUBJECTS: A total of 631 term babies born in six rural villages, near the city of Pune, Maharashtra, India, and 338 term babies born in the Princess Anne Hospital, Southampton, UK. MEASUREMENTS: Maternal weight and height, and neonatal weight, length, head, mid-upper-arm and abdominal circumferences, subscapular and triceps skinfold thicknesses, and placental weight. RESULTS: The Indian mothers were younger, lighter, shorter and had a lower mean body mass index (BMI) (mean age, weight, height and BMI: 21.4 y, 44.6 kg, 1.52 m, and 18.2 kg/m(2)) than Southampton mothers (26.8 y, 63.6 kg, 1.63 m and 23.4 kg/m(2)). They gave birth to lighter babies (mean birthweight: 2.7 kg compared with 3.5 kg). Compared to Southampton babies, the Indian babies were small in all body measurements, the smallest being abdominal circumference (s.d. score: -2.38; 95% CI: -2.48 to -2.29) and mid-arm circumference (s.d. score: -1.82; 95% CI: -1.89 to -1.75), while the most preserved measurement was the subscapular skinfold thickness (s.d. score: -0.53; 95% CI: -0.61 to -0.46). Skinfolds were relatively preserved in the lightest babies (below the 10th percentile of birthweight) in both populations. CONCLUSIONS: Small Indian babies have small abdominal viscera and low muscle mass, but preserve body fat during their intrauterine development. This body composition may persist postnatally and predispose to an insulin-resistant state.

A prospective cohort study on the survival experience of under five children in rural western India.

OBJECTIVE: To study the role of birth weight, nutrition, immunization and other medical as well as social factors in determining child survival. DESIGN: A prospective cohort study. SETTING: 45 villages in Shirur Development Block in Pune District in Maharashtra. METHODS: A cohort of 4129 children were followed from birth till 5 years of age. Weight and length/height of the child was measured at birth and at 3 monthly home visits. Information was also obtained on common childhood morbidities, immunization status and other bio-medical factors. Cause of death was ascertained by verbal autopsy. RESULTS: The neonatal, infant and underfive mortality was rates were estimated to be 37, 60 and 79 per 1000 live births, respectively. Diarrhea and ARI contributed to the major mortality burden. The Kaplan Meier Survival curve showed a sharp fall in the neonatal period, a less rapid decline in the post-neonatal period followed by a marginal fall in the post-infancy period till 5 years age. Girls had a better survival in the early neonatal period but the trend reversed in the late neonatal period. Normal birth weight children had better survival curves compared to low birth weight children. Survival improved with increasing birth order. Multivariate analysis revealed that birth weight, immunization status, and mother's and child's nutritional status influenced infant and under five mortality. CONCLUSION: Birth weight continues to exert its influence not only on survival/mortality in early life but even as late as 5 years of age. Strategies to improve child survival should include immunization and breastfeeding.

PIP: Findings are presented from a prospective study conducted in 45 villages in Shirur Development Block in Pune District, Maharashtra, to gain insight into the role of birth weight, nutrition, immunization, and other medical and social factors in determining child survival. 4129 children were followed from birth until age 5 years, with child weight and length/height measured at birth and at 3 monthly home visits. Information was also obtained on common childhood morbidities, immunization status, and other biomedical factors, and the cause of death was ascertained through verbal autopsy. The neonatal, infant, and under-five mortality rates were estimated to be 37, 60, and 79 per 1000 live births, respectively. Diarrhea and acute respiratory infections (ARI) contributed to the major mortality burden. The Kaplan Meier Survival curve showed a sharp fall in the neonatal period, a less rapid decline during the post-neonatal period, followed by a marginal fall in the post-infancy period until age 5 years. Girls had a better survival during the early neonatal period, but the trend reversed during the late neonatal period. Normal birth weight children had better survival curves compared to low birth weight children. Survival improved with increasing birth order. Multivariate analysis found that birth weight, immunization status, and mother's and child's nutritional status influenced infant and under-five mortality. Since birth weight continues to influence survival and mortality even up to age 5 years, strategies to improve child survival should include immunization and breast-feeding.

Unsafe motherhood: the determinants of maternal mortality.

PIP: Maternal mortality is a three-step process (pregnancy, pregnancy-related complications, and death). Close birth spacing, early pregnancy, unwanted pregnancy, and access to family planning are determinants of maternal mortality. World Fertility Survey figures show that 35% of maternal deaths in Asia could be prevented if all women who did not want children had access to contraceptives. The status of women affects health during pregnancy. Many years of physical neglect and inequitable distribution of food, health care, and other resources effect stunting, an inadequately formed pelvis, low pre-pregnancy weight, anemia, and chronic illnesses such as malaria. Conditions such as aseptic abortion can be prevented. Clean delivery practices, proper management of the third stage of labor, and tetanus immunization are other preventive measures. Many complications are difficult to prevent and to predict; some studies have estimated that up to 50% of maternal deaths were to "low risk" women. The timing of detection of complication and the effectiveness and speed of treatment impact on survival. Intervention means preventing delays in seeking care, delays in reaching an appropriate facility (substantial numbers of deaths occur en route), and delays in receiving treatment, even after reaching the appropriate facility. The timing between the occurrence of the emergency and death involves sociocultural, logistic, and health services factors. When safe motherhood efforts become part of child survival efforts, maternal health will improve.^ieng

Determinants of low birth weight: a community based prospective cohort study.

The study aimed at identifying and quantifying determinants of low birth weight (LBW) by following a community based prospective cohort of pregnant women in 45 villages in Pune district. In the 1922 live births born to mothers without a chronic illness, in whom birth weight was available within 24 hours, the cumulative incidence of LBW (< 2500 g) was 29%. The unadjusted relative risks for LBW were significantly higher for lower socio-economic status (RR = 1.71), maternal age less than 20 years (RR = 1.27), primiparity (RR = 1.32), last pregnancy interval less than 6 months (RR = 1.48), non-pregnant weight less than 40 kg (RR = 1.3), height below 145 cm (RR = 1.51), hemoglobin less than 9 g/dl (RR = 1.53) and third trimester bleeding (RR = 1.87). Multivariate logistic regression analysis showed that the adjusted odds ratio for LBW decreased with increasing gestational duration, non-pregnant weight, parity and rising education level of the mother. Socio-economic status, non-pregnant weight, maternal height, and severe anemia in pregnancy had substantial attributable risk per cent for LBW (41.4%, 22.9%, 29.5% and 34.5%, respectively). The findings suggest that selectively targetted interventions such as improving maternal education and nutrition, specifically anemia, wider availability of contraception to delay the first pregnancy and to increase pregnancy intervals may help in identifying and ensuring adequate care for those women at greatest risk of LBW.

PIP: In India, medical social workers followed a cohort of 1922 pregnant women in 45 contiguous villages in Pune District at monthly intervals so researchers could identify and quantify risk factors of low birth weight (LBW: 2500 g). 29% of the infants were LBW infants. LBW infants were significantly more likely to be born to mothers of very low socioeconomic status (unadjusted relative risk [RR] = 1.71), aged less than 20 (RR = 1.27), pregnant for the first time (RR = 1.32), whose last pregnancy interval was shorter than 6 months (RR = 1.48), whose nonpregnant weight was less than 40 kg (RR = 1.3), whose height was less than 145 cm (RR = 1.51), whose hemoglobin was less than 9 g/dl (RR = 1.53), who bled during the third trimester (RR = 1.87), and who delivered the infant prematurely (i.e., 32 weeks) (RR = 3.84). Mothers with 8-10 years of formal schooling were less likely to have an LBW infant than illiterate mothers (RR = 0.78). Boys were less likely to be LBW infants than girls (RR = 0.78). The multivariate logistic regression analysis revealed that the adjusted odds ratio for LBW fell as gestational age (0.207), nonpregnant weight (0.711), parity (0.835), and maternal educational status (0.869) increased. The attributable risk percentages for risk factors were 73.9% for premature birth, 46.6% for third trimester bleeding, 41.4% for very low socioeconomic status, 34.5% for hemoglobin less than 9 g/dl, 32.5% for last pregnancy interval shorter than 6 months, 29.5% for height less than 145 cm, 24.4% for primiparity, 22.9% for nonpregnant weight less than 40 kg, 21.3% for adolescent mother, and 21.5% (preventive fraction) for high maternal educational status. These findings suggest that health professionals should target limited resources to improving maternal education and nutrition status (i.e., reducing anemia), to providing wider availability of contraception to delay age at first pregnancy and to increase intervals between births, and to making sure that mothers at greatest risk of delivering a LBW infant receive appropriate care.

Male bias in health care utilization for under-fives in a rural community in western India.

A cross-sectional survey, in 1991, of 3100 families in 45 contiguous villages in the Pune district of Maharashtra state showed that 456 under-5-year-olds had suffered an acute respiratory infection and/or diarrhoea during the previous 7 days. Significantly more boys (88.9%) than girls (76.5%) were treated by a registered private medical practitioner (odds ratio (OR) = 2.51). Referrals for further treatment were followed by parents significantly more often in the case of their sons (69.2%) than daughters (25%) (OR = 6.75). An average of Rs 35 (US$1 1.16) was spent on the treatment of a son, compared with Rs 23 (US$ 0.76) for a daughter. In general, parents were willing to travel a greater distance (> 2 km) to seek medical treatment for their sons. These differences persisted even after adjusting for severity of illness, parent's income, occupation and education, and the birth order of the child. Intervention programmes directed at under-fives would need to correct the bias against girls if equitable access to health care is to be achieved.

Foot tape measure for identification of low birth weight newborns.

The majority of births in rural India take place at home, Logistic constraints make early and reliable identification of low birth weight babies difficult. Using neonatal foot length as a proxy measure for birth weight, we devised a tri colored foot tape intended for use at home by the neonatal caretaker or birth attendant. The tape was field tested in a rural community in the Pune district. Results showed a sensitivity of 68.2% and a predictive value of 45.5% for identifying low birth weight. For very low birth weights (< 1500 g) the sensitivity was 100%, specificity 95.2% and the positive predictive value 60%. Interobserver reliability comparing a trained medical social worker and the household member was high (kappa score of 0.82). If implemented on a larger scale this simple, low cost technology has the potential to significantly enhance the yield of identification of low birth weight babies born at home.