Person: Shankar, Anuraj
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Shankar
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Anuraj
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Shankar, Anuraj
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Publication Reproductive healthcare utilization in urban poor settlements of Delhi: Baseline survey of ANCHUL (Ante Natal and Child Health care in Urban Slums) project(BioMed Central, 2015) Devasenapathy, Niveditha; Jerath, Suparna Ghosh; Allen, Elizebeth; Sharma, Saket; Shankar, Anuraj; Zodpey, SanjayBackground: Disparity in utilization of reproductive healthcare services between the urban poor and the urban non-poor households in the developing nations is well known. However, disparity may also exist within urban poor households. Our objective was to document the extent of disparity in reproductive healthcare utilization among the urban poor and to identify the socio-demographic determinants of underutilization with a view to characterizing this vulnerable subpopulation. Methods: A survey of 16,221 households was conducted in 39 clusters from two large urban poor settlements in Delhi. From 13,451 consenting households, socio-demographic data and information on births, maternal and child deaths within the previous year was collected. Details of antenatal care (ANC) was collected from 597 pregnant women. Information on ANC and postnatal care was also obtained from 596 recently delivered (within six months) mothers. All data were captured electronically using a customized and validated smart phone application. Households were categorized into quintiles of socio-economic position (SEP) based on dwelling characteristics and possession of durable assets using principal component analysis. Potential socio-demographic determinants of reproductive healthcare utilization were examined using random effects logistic regression. Results: The prevalence of facility based birthing was 77 % (n = 596 mothers). Of the 596 recently delivered mothers only 70 % had an ANC registration card, 46.3 % had ANC in their first trimester, 46 % had visited a facility within 4 weeks post-delivery and 27 % were using modern contraceptive methods. Low socio-economic position was the most important predictor of underutilization with a clear gradient across SEP quintiles. Compared to the poorest, the least poor women were more likely to be registered for ANC (OR 1.96, 95 %CI 0.95-4.15) and more likely to have made ≥ 4 ANC visits (OR 5.86, 95 %CI 2.82-12.19). They were more likely to have given birth in a facility (OR 4.87, 95 %CI 2.12-11.16), to have visited a hospital within one month of childbirth (OR 3.18, 95 %CI 1.62-6.26). In general, government funded health insurance and conditional cash transfers schemes were underutilized in this community. Conclusion: The poorest segment of the urban poor population utilizes reproductive healthcare facilities the least. Strategies to improve access and utilization of healthcare services among the poorest of the poor may be necessary to achieve universal health coverage. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0635-8) contains supplementary material, which is available to authorized users.Publication Ante natal care (ANC) utilization, dietary practices and nutritional outcomes in pregnant and recently delivered women in urban slums of Delhi, India: an exploratory cross-sectional study(BioMed Central, 2015) Ghosh-Jerath, Suparna; Devasenapathy, Niveditha; Singh, Archna; Shankar, Anuraj; Zodpey, SanjayBackground: Antenatal Care (ANC) is one of the crucial factors in ensuring healthy outcomes in women and newborns. Nutrition education and counselling is an integral part of ANC that influences maternal and child health outcomes. A cross sectional study was conducted in Pregnant Women (PW) and mothers who had delivered in the past three months; Recently Delivered Women (RDW) in urban slums of North-east district of Delhi, India, to explore ANC utilization, dietary practices and nutritional outcomes. Methods: A household survey was conducted in three urban slums to identify PW and RDW. Socio-economic and demographic profile, various components of ANC received including nutrition counselling, dietary intake and nutritional outcomes based on anthropometric indices and anaemia status were assessed. Socio-demographic characteristics, nutrient intake and nutritional status were compared between those who availed ANC versus those who did not using logistic regression. Descriptive summary for services and counselling received; dietary and nutrient intake during ANC were presented. Results: Almost 80% (274 out of 344) women received some form of ANC but the package was inadequate. Determinants for non-utilization of ANC were poverty, literacy, migration, duration of stay in the locality and high parity. Counselling on nutrition was reported by a fourth of the population. Nutrient intake showed suboptimal consumption of protein and micronutrients like iron, calcium, vitamin A, vitamin C, thiamine, riboflavin niacin, zinc and vitamin B12 by more than half of women. A high prevalence of anaemia among PW (85%) and RDW (97.1%) was observed. There was no difference in micronutrient intake and anaemia prevalence among women who received ANC versus who did not. Conclusions: Pregnant women living in urban poor settlements have poor nutritional status. This may be improved by strengthening the nutrition counselling component of ANC which was inadequate in the ANC package received. Empowering community based health workers in providing effective nutrition counselling should be explored given the overburdened public health system.Publication Why women choose to give birth at home: a situational analysis from urban slums of Delhi(BMJ Publishing Group, 2014) Devasenapathy, Niveditha; George, Mathew Sunil; Ghosh Jerath, Suparna; Singh, Archna; Negandhi, Himanshu; Alagh, Gursimran; Shankar, Anuraj; Zodpey, SanjayObjectives: Increasing institutional births is an important strategy for attaining Millennium Development Goal -5. However, rapid growth of low income and migrant populations in urban settings in low-income and middle-income countries, including India, presents unique challenges for programmes to improve utilisation of institutional care. Better understanding of the factors influencing home or institutional birth among the urban poor is urgently needed to enhance programme impact. To measure the prevalence of home and institutional births in an urban slum population and identify factors influencing these events. Design: Cross-sectional survey using quantitative and qualitative methods. Setting: Urban poor settlements in Delhi, India. Participants: A house-to-house survey was conducted of all households in three slum clusters in north-east Delhi (n=32 034 individuals). Data on birthing place and sociodemographic characteristics were collected using structured questionnaires (n=6092 households). Detailed information on pregnancy and postnatal care was obtained from women who gave birth in the past 3 months (n=160). Focus group discussions and in-depth interviews were conducted with stakeholders from the community and healthcare facilities. Results: Of the 824 women who gave birth in the previous year, 53% (95% CI 49.7 to 56.6) had given birth at home. In adjusted analyses, multiparity, low literacy and migrant status were independently predictive of home births. Fear of hospitals (36%), comfort of home (20.7%) and lack of social support for child care (12.2%) emerged as the primary reasons for home births. Conclusions: Home births are frequent among the urban poor. This study highlights the urgent need for improvements in the quality and hospitality of client services and need for family support as the key modifiable factors affecting over two-thirds of this population. These findings should inform the design of strategies to promote institutional births.Publication Effect of Ghrelin on Mortality and Cardiovascular Outcomes in Experimental Rat and Mice Models of Heart Failure: A Systematic Review and Meta-Analysis(Public Library of Science, 2015) Khatib, Mahalaqua Nazli; Shankar, Anuraj; Kirubakaran, Richard; Agho, Kingsley; Simkhada, Padam; Gaidhane, Shilpa; Saxena, Deepak; B, Unnikrishnan; Gode, Dilip; Gaidhane, Abhay; Zahiruddin, Syed QuaziBackground: Heart failure (HF) continues to be a challenging condition in terms of prevention and management of the disease. Studies have demonstrated various cardio-protective effects of Ghrelin. The aim of the study is to determine the effect of Ghrelin on mortality and cardiac function in experimental rats/mice models of HF. Methods: Data sources: PUBMED, Scopus. We searched the Digital Dissertations and conference proceedings on Web of Science. Search methods: We systematically searched for all controlled trials (upto November 2014) which assessed the effects of Ghrelin (irrespective of dose, form, frequency, duration and route of administration) on mortality and cardiac function in rats/ mice models of HF. Ghrelin administration irrespective of dose, form, frequency, duration and route of administration. Data collection and analysis: Two authors independently assessed each abstract for eligibility and extracted data on characteristics of the experimental model used, intervention and outcome measures. We assessed the methodological quality by SYRCLE’s risk of bias tool for all studies and the quality of evidence by GRADEpro. We performed meta-analysis using RevMan 5.3. Results: A total of 325 animals (rats and mice) were analyzed across seven studies. The meta-analysis revealed that the mortality in Ghrelin group was 31.1% and in control group was 40% (RR 0.83, 95% CI 0.46 to 1.47) i.e Ghrelin group had 68 fewer deaths per 1000 (from 216 fewer to 188 more) as compared to the control group. The meta-analysis reveals that the heart rate in rats/mice on Ghrelin was higher (MD 13.11, 95% CI 1.14 to 25.08, P=0.66) while the mean arterial blood pressure (MD -1.38, 95% CI -5.16 to 2.41, P=0.48) and left ventricular end diastolic pressure (MD -2.45, 95% CI -4.46 to -0.43, P=0.02) were lower as compared to the those on placebo. There were insignificant changes in cardiac output (SMD 0.28, 95% CI -0.24 to 0.80, P=0.29) and left ventricular end systolic pressure (MD 1.48, 95% CI -3.86 to 6.82, P=0.59). Conclusions: The existing data provides evidence to suggest that Ghrelin may lower the risk of mortality and improve cardiovascular outcomes. However; the quality of evidence as assessed by GRADEpro is low to very low. Clinical judgments to administer Ghrelin to patients with HF must be made on better designed animal studies.Publication Determinants of childhood immunisation coverage in urban poor settlements of Delhi, India: a cross-sectional study(BMJ Publishing Group, 2016) Devasenapathy, Niveditha; Ghosh Jerath, Suparna; Sharma, Saket; Allen, Elizabeth; Shankar, Anuraj; Zodpey, SanjayObjectives: Aggregate data on childhood immunisation from urban settings may not reflect the coverage among the urban poor. This study provides information on complete childhood immunisation coverage among the urban poor, and explores its household and neighbourhood-level determinants. Setting: Urban poor community in the Southeast district of Delhi, India. Participants: We randomly sampled 1849 children aged 1–3.5 years from 13 451 households in 39 clusters (cluster defined as area covered by a community health worker) in 2 large urban poor settlements. Of these, 1343 completed the survey. We collected information regarding childhood immunisation (BCG, oral polio vaccine, diphtheria–pertussis–tetanus vaccine, hepatitis B and measles) from vaccination cards or mothers’ recall. We used random intercept logistic regression to explore the sociodemographic determinants of complete immunisation. Results: Complete immunisation coverage was 46.7% and 7.5% were not immunised. The odds of complete vaccination (OR, 95% CI) were lower in female children (0.70 (0.55 to 0.89)) and Muslim households (0.65 (0.45 to 0.94)). The odds of complete vaccination were higher if the mother was literate (1.6 (1.15 to 2.16)), if the child was born within the city (2.7 (1.97 to 3.65)), in a health facility ( 1.5 (1.19 to 2.02)), belonged to the highest wealth quintile (compared with the poorest; 2.46 (1.5 to 4.02)) or possessed a birth certificate (1.40 (1.03 to 1.91)). Cluster effect due to unmeasured neighbourhood factors expressed as median OR was 1.32. Conclusions: Immunisation coverage in this urban poor area was much lower than that of regional surveys reporting overall urban data. Socioeconomic status of the household, female illiteracy, health awareness and gender inequality were important determinants of coverage in this population. Hence, in addition to enhancing the infrastructure for providing mother and child services, efforts are also needed to address these issues in order to improve immunisation coverage in deprived urban communities. Trial registration number CTRI/2011/091/000095.Publication Making Stillbirths Count, Making Numbers Talk - Issues in Data collection for Stillbirths(BioMed Central, 2009) Frøen, J Frederik; Gordijn, Sanne J; Abdel-Aleem, Hany; Bergsjø, Per; Betran, Ana; Duke, Charles W; Fauveau, Vincent; Flenady, Vicki; Hinderaker, Sven Gudmund; Hofmeyr, G Justus; Jokhio, Abdul Hakeem; Lawn, Joy; Lumbiganon, Pisake; Merialdi, Mario; Pattinson, Robert; Shankar, AnurajBackground: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. Discussion: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. Summary: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.Publication Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries(Elsevier BV, 2017) Smith, Emily; Shankar, Anuraj; Wu, Lee S-F; Aboud, Said; Adu-Afarwuah, Seth; Ali, Hasmot; Agustina, Rina; Arifeen, Shams; Ashorn, Per; Bhutta, Zulfiqar A; Christian, Parul; Devakumar, Delanjathan; Dewey, Kathryn G; Friis, Henrik; Gomo, Exnevia; Gupta, Piyush; Kæstel, Pernille; Kolsteren, Patrick; Lanou, Hermann; Maleta, Kenneth; Mamadoultaibou, Aissa; Msamanga, Gernard; Osrin, David; Persson, Lars-Åke; Ramakrishnan, Usha; Rivera, Juan A; Rizvi, Arjumand; Sachdev, H P S; Urassa, Willy; West, Keith P; Zagre, Noel; Zeng, Lingxia; Zhu, Zhonghai; Fawzi, Wafaie; Sudfeld, ChristopherAbstract Objective To identify individual-level effect modifiers of the effect of multiple micronutrient supplementation (MMS) containing iron and folic acid (IFA) during pregnancy, compared to IFA alone, on the risk of stillbirth, infant mortality, and birth outcomes. Methods We performed an individual patient data meta-analysis. Study-specific estimates were generated, and we pooled subgroup estimates using fixed effects models. Findings We included 17 randomized controlled trials (including 112,953 pregnancies). MMS resulted in greater reductions in low birthweight (RR 0.81; 95% CI: 0.74–0.89), small-for-gestational age births (RR 0.91; 95% CI: 0.87–0.96), and six-month mortality (RR: 0.71; 95% CI: 0.60–0.86) among anemic (hemoglobin <110g/L) as compared with non-anemic pregnant women. MMS had a greater impact on preterm birth among underweight pregnant women (body mass index <18.5kg/m2) (RR: 0.84; 95% CI: 0.78–0.90) compared to those with BMI ≥18.5 (RR: 0.94; 95% CI 0.90–0.98) (p value heterogeneity 0.01). MMS provided significantly greater reductions in infant mortality for female (RR: 0.87; 95% CI: 0.77–0.99) as compared to male infants (RR: 1.05; 95% CI: 0.93–1.18) (p value heterogeneity 0.04). In general, the survival and birth outcome effects of MMS were greater with high adherence (≥95%) to supplementation. Conclusion MMS produced greater birth outcome benefits for pregnant women with indicators of nutritional deficiency and improved survival for female infants.Publication The effects of a household conditional cash transfer programme on coverage and quality of antenatal care: a secondary analysis of Indonesia’s pilot programme(BMJ, 2017) Triyana, Margaret; Shankar, AnurajObjective To analyse the effectiveness of a household conditional cash transfer programme (CCT) on antenatal care (ANC) coverage reported by women and ANC quality reported by midwives. Design The CCT was piloted as a cluster randomised control trial in 2007. Intent-to-treat parameters were estimated using linear regression and logistic regression. Setting Secondary analysis of the longitudinal CCT impact evaluation survey, conducted in 2007 and 2009. This included 6869 pregnancies and 1407 midwives in 180 control subdistricts and 180 treated subdistricts in Indonesia. Outcome measures ANC component coverage index, a composite measure of each ANC service component as self-reported by women, and ANC provider quality index, a composite measure of ANC service provided as self-reported by midwives. Each index was created by principal component analysis (PCA). Specific ANC component items were also assessed. Results The CCT was associated with improved ANC component coverage index by 0.07 SD (95% CI 0.002 to 0.141). Women were more likely to receive the following assessments: weight (OR 1.56 (95% CI 1.25 to 1.95)), height (OR 1.41 (95% CI 1.247 to 1.947)), blood pressure (OR 1.36 (95% CI 1.045 to 1.761)), fundal height measurements (OR 1.65 (95% CI 1.372 to 1.992)), fetal heart beat monitoring (OR 1.29 (95% CI 1.006 to 1.653)), external pelvic examination (OR 1.28 (95% CI 1.086 to 1.505)), iron-folic acid pills (OR 1.42 (95% CI 1.081 to 1.859)) and information on pregnancy complications (OR 2.09 (95% CI 1.724 to 2.551)). On the supply side, the CCT had no significant effect on the ANC provider quality index based on reports from midwives. Conclusions The CCT programme improved ANC coverage for women, but midwives did not improve ANC quality. The results suggest that enhanced ANC utilisation may not be sufficient to improve health outcomes, and steps to improve ANC quality are essential for programme impact.