Person:

Regan, Mathilda

Objectives: To assess input and process capacity for basic delivery and newborn (intrapartum care hereafter) care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across states. Design: Cross-sectional study. Setting: Data from the nationally representative 2012–2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 states and union territories in India. Participants: 8536 PHCs and 4810 CHCs. Outcome measures We developed a summative index of 33 structural and process capacity items matching the Indian Public Health Standards for PHCs as a metric of minimum facility capacity for intrapartum care. We assessed differences in performance on this index across facility type and location. Results: About 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low: median monthly delivery volume was 8 (IQR=13) in PHCs and 41 (IQR=73) in CHCs. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77vs0.74). Gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37% of districts from these states receiving scores in the lowest third of the facility capacity index (<0.70), compared with 21% of districts otherwise. Conclusions: Basic intrapartum care capacity in Indian public primary care facilities is weak in both rural and urban areas, especially lacking in the poorest states with worst health outcomes. Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required.

Context: The association between linear growth faltering and child development outcomes is generally well-recognized; however, the relationship between metrics of acute undernutrition and development has received less attention. Objectives: We aimed to quantify the association between acute undernutrition in childhood with development outcomes in low- and middle-income countries (LMIC). Methods: We conducted a systematic literature review of observational studies that assessed the association between metrics of acute undernutrition, including body mass index-for-age z-score (BMIZ), mid-upper arm circumference (MUAC), weight-for-height/length z-score (WHZ/WLZ), wasting (WHZ/ WLZ <-2), and severe acute malnutrition (SAM) among children under 5 years of age with cognitive, motor, language, and socio-emotional development assessed to 19 years of age. We estimated the pooled correlation and standardized mean difference (SMD) for cross-sectional and longitudinal studies. Results: A total of 113 studies from 40 LMICs were identified. Metrics of acute undernutrition were associated with lower cognitive and motor development outcomes. In longitudinal studies that reported multivariable-adjusted estimates for the cognitive domain, SAM was associated with -1.06 SD lower scores (95% CI: -1.41, -0.72) as compared to non-SAM children. SAM was also associated with lower motor scores in longitudinal studies with unadjusted estimates (SMD: -0.42; 95% CI: -0.68, -0.15). In longitudinal studies with multivariable estimates, wasting was associated with lower motor scores (SMD: -0.30; 95% CI: -0.54, -0.06), but there was no association with language (SMD: -0.08; 95% CI: -0.24, 0.07) and prosocial development scores (SMD: -0.18; 95% CI: -0.38, 0.02). Conclusion: Metrics of acute undernutrition in childhood were consistently associated with lower development scores, and the magnitude appeared stronger for children with SAM or wasting.