South Asia faces a critical deficit in surgical, obstetric, trauma, and anaesthesia (SOTA) care, with over 1.6 billion people lacking access to safe and affordable surgical services. Addressing this inequity requires urgent workforce capacity building beyond traditional specialization. This study, conducted by the G4 Alliance Asia Working Group, employs a Multiple-Case Study design utilizing Cross-Case Synthesis to present six initiatives from Nepal, Bhutan, Pakistan, and India, mapped against a SOTA care workforce capacity building framework. We describe initiatives by training type (programmatic vs. non-programmatic), intent (upskilling vs. reskilling), and workforce outcomes such as task-shifting (delegating tasks to less specialized cadres), task-sharing (multi-cadre collaborative care), and task-creation (developing new cadre roles). Cross-case synthesis revealed distinct pathways for addressing workforce shortage and maldistribution. First, programmatic reskilling initiatives in Nepal, Bhutan, and Pakistan demonstrate how formalizing task shifting to mid-level providers and generalist doctors creates sustainable rural cadres recognized by national health systems. Second, non-programmatic models in India highlight the utility of upskilling existing surgeons to facilitate task sharing, thereby rapidly increasing the functional density of the workforce in resource-limited settings. Crucially, the analysis introduces task creation as a distinct workforce outcome to fill a specific “task-cadre gap” by establishing novel community engagement roles for SOTA care that do not exist in standard hierarchies. The synthesis indicates that while programmatic models support long-term retention through state absorption, non-programmatic interventions offer vital flexibility for immediate service delivery. Indigenously initiated, state-integrated models, providing secure career paths, achieved better sustainability, whereas foreign donor-dependent and non-programmatic models faced challenges. These initiatives underscore that locally driven, context-specific solutions can effectively bridge healthcare disparities. Facilitating cross-learning on the successes and limitations of these diverse models is essential to scale effective interventions and integrate them into national and regional policy plans, thereby ensuring equitable access to SOTA care across South Asia.

Hysterectomy, removal of the uterus, is a commonly performed surgery for gynaecological morbidities. Emerging evidence indicates that hysterectomy performed before age 45 (early hysterectomy), is associated with considerable risks to women’s health. While most evidence on hysterectomy is from high-income settings, national surveys from India report high prevalence of early hysterectomy in specific regions, as well as higher prevalence amongst women in rural areas and with less education. The median age at hysterectomy in India is close to ten years before the onset of natural menopause. India has recently introduced national guidelines to address early hysterectomy, but large evidence gaps on the causes and consequences remain – which in turn limits the potential effectiveness of interventions at the clinical, health system and community level. Methods SAHELI is a Team Science study that will examine: (i) individual, social and health system determinants of early hysterectomy; (ii) women’s treatment pathways to hysterectomy and for gynaecological morbidity in general; and (iii) the consequences of undergoing hysterectomy on women’s physical, mental, economic and social well-being across the life course. This mixed-methods study includes population surveys amongst women in ages 25–49 in three high-prevalence states; qualitative health systems research to trace treatment journeys with women, health care providers and other stakeholders; evidence syntheses; and knowledge translation activities to ensure findings inform co-produced strategies and interventions. The study is grounded in a feminist epidemiology approach, aiming to examine individual and structural causes of vulnerability and prioritising the views of women, particularly in knowledge translation. Conclusions SAHELI, implemented by an all-women, multi-disciplinary team, is the first study in India to examine the causes and consequences of hysterectomy in a life course approach. We aim to influence interventions, policy and future research on women’s health, particularly access to quality gynaecological care and comprehensive health services through the life course.

Background The Surgical Accredited & Trained Healthcare Initiative (SATHI) project demonstrates how community healthcare workers (CHWs) with merely 8 y of formal schooling and training for a short period can reduce unmet surgical needs.Methods A pilot study was carried out in the slums of a metropolitan city in India to know the effectiveness of a SATHI in reducing the burden of unmet surgical needs. In total, 12 730 people from 3000 households were included in the study for a duration of 6 months.Results We found 10% surgical needs (n=293) out of which 57% had unmet surgical needs. Out of total surgical needs, about half of the needs were cataract and abdominal, followed by extremities and chest conditions. SATHIs were able to convert 99 patients (60%) from unmet to met needs, who underwent surgery/treatment. The conversion from unmet to met among all surgery needs was highest for abdominal conditions (29%) followed by cataracts (17%).Conclusions SATHIs with short training can reduce the burden of unmet surgical needs. SATHIs were able to convert a significant proportion of unmet to met needs by trust building, facilitating access to healthcare and ensuring post-operative adherence. Scaling up could help in the achievement of equitable healthcare across India.

Introduction: We carried out a household study of surgical unmet needs and trust in the physician and perception of quality in the health system in a rural Tribal area and an urban slum in India. Methods: A community-based, cross-sectional study was carried out in a Tribal and in an urban slum in Gujarat, India. We surveyed 7914 people in 2066 households in urban slum and 5180 people of 1036 households in rural Tribal area. The Surgeons Overseas Assessment of Surgical need was used to identify surgical met and unmet needs. Two instruments for trust deficit 'the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting' and 'Patient perceptions of quality' were also administered to understand perception about healthcare. Frequencies and proportions (categorical variable) summarized utilization of surgical services and surgical needs. P < 0.05 was statistically significant. Results: Slums and Tribal areas were significantly different in sociodemographic indicators. Unmet surgical needs in Tribal area were less than 5% versus 39% in the urban slum. Major need of surgery in Tribal area was for eye conditions in older population, while surgical conditions in extremities and abdomen were predominant in the urban area. Trust level was high for physicians in both areas.Conclusions: Surgical unmet needs were significantly lower in Tribal versus urban area, possibly due to high priority given by the Indian government to alleviate poverty, social deprivation and participation of NGOs. Our study will give impetus to study unmet surgical needs and formulation of health policies in India and low-and -middle-income countries.

Pre-eclampsia (PE) is a pro-inflammatory disease associated with pregnancy. The only known remedy is to deliver the fetus and placenta. Hypertension and proteinuria after the 20th week of pregnancy are clinical indicators of PE. Early onset pre-eclampsia (EOPE), a severe variant of PE, is defined as clinical signs appearing before 34 weeks of pregnancy. Human dendritic cell (DC) subtypes (CD1c+, CD141+ myeloid DCs, and plasmacytoid DCs) are intricately implicated in the inflammatory process and are considerably changed in a variety of proinflammatory illnesses. These alterations provide value for monitoring DC subsets as potential biomarker(s) and as targets for immunotherapeutic treatment. The main objective of the study is to delineate how the three DC subsets are altered quantitatively and functionally in blood and decidua of EOPE patients, compared to normal pregnant women. DC subsets play an important role in normal pregnancy by facilitating effective trophoblast migration and invasion and establishing an anti-inflammatory milieu of immunotolerance. In contrast, a detailed examination of the makeup and function of DC subsets in the proinflammatory milieu of EOPE pregnancy is required. In this regard, the developed methodology examines how DC subsets differ (quantitatively and functionally) in EOPE patients versus normal pregnant women. The multiparametric flow cytometry method is used to determine alterations in the profile of DC subsets in the blood and decidua of EOPE patients. Normal pregnant women are included as controls. Identifying possible biomarkers will be based on an understanding of alterations in the profile of DC subsets in blood samples from EOPE patients. The basis for creating innovative immunotherapeutic techniques targeting various DC subsets or their products for the treatment of EOPE will similarly be variations in the profile of DC subsets in the decidua of EOPE patients. Overall, the methodology will support the development of future large-scale, prospective clinical trials with a focus on developing approaches for the early detection and treatment of EOPE in pregnant women.

Background The increased global discourse on nutrition challenges has underscored the imperative to comprehend and monitor diverse manifestations of malnutrition. The comprehensive monitoring of various forms of malnutrition, including undernutrition, overnutrition, and micronutrient deficiencies, plays a pivotal role in assessing the progress towards the Global Nutrition Targets (GNTs) established by the World Health Assembly (WHA), as well as nutrition-related SDGs (SDGs). To this end, a Composite Index (CI) of six nutrition indicators centred on GNTs has been formulated to gauge and appraise progress across India’s various States and Union Territories (UTs). Methods To calculate the CI, the authors apply a methodology developed by Webb et al. (2015). Disparities in performance between Indian States and UTs are highlighted. The analysis uses data from two surveys: the National Family Health Survey (NFHS) of 2015-16 and the NFHS of 2019-21. The main analytical tool is a rank-order analysis of the CI scores among states and union territories, with higher scores representing greater progress in achieving the targets for the six indicators. Results Based on data from both NFHS-4 and NFHS-5, India’s overall estimated CI-WHA score stood at 2.80 and 2.86, respectively. Notably, the CI-WHA exhibited considerable inter-State/UT variation, ranging from 2.16 in Dadra and Nagar Haveli and Daman and Diu to 5.07 in Manipur, as per NFHS-4, and from 2.14 in Gujarat to 5.25 in Manipur, as per NFHS-5. Among the 34 States/UTs for which complete data sets for all six WHA targets were available from NFHS-4, the top five performers according to the developed CI-WHA targets were Manipur (5.07), Mizoram (4.87), Nagaland (4.12), Kerala (4.00), and Telangana (3.80). In contrast, the bottom five States/UTs based on NFHS-4 data were Dadra and Nagar Haveli and Daman and Diu (2.16), Uttar Pradesh (2.31), Meghalaya (2.40), Haryana (2.40) and Madhya Pradesh (2.43). However, based on NFHS-5 data, the top five States/UTs were Manipur (5.25), Mizoram (4.29), Puducherry (UT) (4.15), Goa (3.89), and Kerala (3.87), while the bottom five were Gujarat (2.14), Tripura (2.16), West Bengal (2.20), Bihar (2.31), and Assam (2.46). Conclusions Applying the CI to monitor States/UTs’ progress in reaching WHA targets. Furthermore, it offers a means to track the progress made on nutrition-related SDGs at the sub-national level. This can help identify States/UTs whose nutrition policies and programs require targeted enhancements to comprehensively improve India’s performance concerning GNTs. It aims to empower policymakers with the information required to make informed decisions and implement effective measures to enhance overall nutrition outcomes, especially in under-performing States/UTs.

Objectives: We carried out a mixed method study to understand why patients did not avail of surgical care in an urban slum in India. Methods: In our earlier study, we found that out of 10,330 people, 3.46% needed surgery; 42% did not avail of surgery (unmet needs). We conducted a follow-up study to understand reasons for not availing surgery, 141 in met needs, 91 in unmet needs. We administered 2 instruments, 16 in-depth interviews and 1 focused group discussion. Results: Responses from the 2 groups for "the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting" scale did not have significant difference except for, prescription of medicines, patients with unmet needs were less likely to agree (p = 0.076). Results between 2 groups regarding "Patient perceptions of quality" did not show significant difference except for doctors answering questions where a higher proportion of unmet need group agreed (p = 0.064). Similar observations were made in the in depth interviews and focus group. Conclusion: There is a need for understanding trust issues with health service delivery related to surgical care for marginalized populations.

Objective: Compared to the adults there is paucity of literature regarding manifestation of COVID-19 in children. We decided to study the clinical manifestation of COVID-19 in children during the second wave of COVID-19 pandemic in Gujarat, India. Method: A cross-sectional survey study was designed for children with COVID-19 infection. An online survey form was designed with demographic details, details of clinical manifestations, investigations, treatment and recovery time. The survey was lled by 573 parents of which 539 were included in the study. Results: Of the 539 patients, 72.5 % of the patients presented in April(p<0.000). The child was the index case in only 7.4% of cases. There was a higher incidence of cases in boys (53.2%) (p<0.000) and in 0-5 years age group (39.5%) (p<0.00). The common presenting symptoms were fever (91.9%), cough/cold (52.4%), headache (19.5%), body-ache (23.6%), and gastrointestinal symptoms (21.1%). There was an age-wise variability in symptoms. Majority of the patients (98.2%) recovered with home treatment; only 1.8% required hospitalization. Complete resolution of symptoms occurred within a week in 78% of the patients(p<0.000). There was no mortality in our study. Conclusion: Children affected with COVID-19 during the second wave in Gujarat had mild disease. The child was index case in only a few cases and contracted COVID-19 from adult household contact. Most children recovered with home treatment and the course of the disease was short.

The COVID-19 pandemic has spawned crises of violence, hunger and impoverishment. Maternal and Infant Health Canada (MIHCan) conducted this policy action study to explore how changes that have arisen during the COVID-19 pandemic may catalyze potential improvements in global women's health toward the creation of a more equitable post-pandemic world. In this mixed methods study, 280 experts in women's health responded to our survey and 65 subsequently participated in focus groups, including professionals from India, Egypt/Sudan, Canada and the United States/Mexico. From the results of this study, our recommendations include augmenting mental health through more open dialogue, valuing and compensating those working on the frontlines through living wages, paid sick leave and enhanced benefits and expanding digital technology that facilitates flexible work locations, thereby freeing time for improving the wellbeing of caregivers and families and offering telemedicine and telecounseling, which delivers greater access to care. We also recommend bridging the digital divide through the widespread provision of reliable and affordable internet services and digital literacy training. These policy recommendations for employers, governments and health authorities aim to improve mental and physical wellbeing and working conditions, while leveraging the potential of digital technology for healthcare provision for those who identify as women, knowing that others will benefit. MIHCan took action on the recommendation to improve mental health through open conversation by facilitating campaigns in all study regions. Despite the devastation of the pandemic on global women's health, implementing these changes could yield improvements for years to come.

We conceptualized Surgical Accredited and Trained Healthcare Initiative (SATHI) as a community-based worker through which patients who are unaware or undecided of surgical conditions would be linked to service providers. These personnel will help patients to attain the benefits of health schemes and will offer counseling through trust-building and elimination of fear of surgical procedures to reduce the surgical unmet needs. Our baseline study identified five common surgical problems among the study population: extremity injuries/wounds; kidney stones; cataracts; abdominal pain, including external hernias, and menstrual disorders. Based on these findings, we designed a modular, skills-focused curriculum and recruited six full-time staff who have undergone didactic and practical training. Upon finding any suspected health condition, SATHI staff are trained to encourage the patient and their family to seek medical advice. They are also equipped with the basic information about the surgical management of these conditions and will offer preoperative and post-operative surgical care and psychosocial support. This publication describes the process of development of training material, methods and process. Each SATHI worker has been assigned 1000 households (~5000 population). Based on our estimates, he/she will have to cater to 64 cases of unmet surgical needs if the unmet need is 40%. This means a SATHI worker would have approximately five to six cases of unmet surgical needs per month. We are planning to analyze the survey findings, document the process of implementation, and based on learnings from the pilot project, modify the training material and protocol.

Objectives: Family history is considered as an important predictor of cardiovascular diseases (CVDs) and diabetes. Available research findings suggest that family history of chronic diseases is associated with perceived risk of disease and adoption of healthy behaviours. We examined the association between family history of cardio-metabolic diseases (CMDs) and healthy behaviours among adults without self-reported CMDs. Methods: Cross-sectional data of 12,484 adults, without self-reported CMDs, from the baseline survey of Centre for cArdiometabolic Risk Reduction in South-Asia (CARRS) cohort study were analysed. Results: Family history was positively associated with non-smoking and high fruits & vegetables consumption in the age group of 45–64 years and moderate to high physical activity in the age group ≥65 years after adjusting for sex, education, wealth index, city and body mass index. Conclusions: Understanding perceived risks and cultural or psychological factors related to family history through ethnographic studies may deepen understanding of these associations.

OBJECTIVE:To discover the prevalence and distribution of high-risk human papilloma virus (HPV) subtypes in urban slums and their implications. METHODS:A cross-sectional study was performed to discover prevalence and distribution of high-risk HPV subtypes. We screened 956 women. Data were analyzed using SPSS v.25. Inclusion criterion was married women between 30 and 45 years of age. Exclusion criteria were women with known cervical cancer at the time of the survey or those who had undergone hysterectomy. RESULTS:Of the women, 32.47% were HPV positive and of these, about 84.50% were positive for high-risk HPV. HPV type 6 (HPV 6) and HPV 11 were not seen in the population. After HPV 16 and HPV 18, type 58 was the most common variant seen in our study. Currently-used vaccines in India do not cover HPV 58. CONCLUSION:Knowing and understanding the distribution of high-risk HPV are necessary for an effective strategy to eliminate cervical cancer from India. Deoxyribonucleic acid-based HPV screening is a useful method along with vaccination to prevent cervical cancer.

Background and purpose: Changes in the adrenal gland secreted prenatal stress hormones affect birth outcome. Therefore, during pregnancy, regular monitoring of the levels of these hormones such as cortisol and dehydroepiandrosterone-sulfate (DHEA-S) through reference range or quartile scoring approach is essential. Cortisol and DHEA-S regulate each other during pregnancy. In addition, the salivary and circulatory counterparts of these hormones do not correlate with each other during pregnancy. Therefore, in addition to the individual hormonal analysis, there is a need for combinatorial analysis of these hormones from multiple biological sources to understand their role in pregnancy and poor birth outcome. Methods: A prospective study involving 789 pregnant women, in their first or second trimester was conducted in the tribal regions of Modasa and Bhiloda blocks of Aravalli district, Gujarat, India for a period of two years. Blood (plasma) and saliva samples were collected simultaneously, and enzyme-linked immunosorbent assay (ELISA) was performed to determine concentrations of cortisol and DHEA-S. Concentrations of individual hormones in plasma or saliva in the dataset were divided into quartile scores. Microsoft Excel formulae were used to generate combinations of these hormones in plasma and saliva. The strength of association of individual and combinatorial categories with birth outcome was evaluated through binary logistic regression analyses. Results: For each pregnant woman in the study, along with the individual profile of prenatal stress hormones in plasma or saliva, unique 4-component and 2-component combinatorial profiles were generated through quartile scoring approach. These profiles in the dataset were characterized and unique combinations significantly associated with adverse birth outcome or low birth weight outcome were identified. Study has presented benefits of combinatorial over conventional individual component analysis for predicting poor birth outcome. Conclusion: Combinatorial profiling of prenatal stress hormones in plasma and saliva offers a novel and insightful approach for developing models for prediction of poor birth outcome.

The human immune system is not adequately equipped to eliminate new microbes and could result in serious damage on first exposure. This is primarily attributed to the exaggerated immune response (inflammatory disease), which may prove detrimental to the host, as evidenced by SARS-CoV-2 infection. From the experiences of Novel Coronavirus Disease-19 to date, male patients are likely to suffer from high-intensity inflammation and disease severity than the female population. Hormones are considered the significant pillars of sex differences responsible for the discrepancy in immune response exhibited by males and females. Females appear to be better equipped to counter invading respiratory viral pathogens, including the novel SARS-CoV-2, than males. It can be hypothesized that females are more shielded from disease severity, probably owing to the diverse action/influence of estrogen and other sex hormones on both cellular (thymus-derived T lymphocytes) and humoral immunity (antibodies).

CONTEXT:Cortisol and dehydroepiandrosterone-sulfate (DHEA-S) are indispensable hormones for normal pregnancy. It is unclear if these hormones, specifically DHEA-S can offer value for predicting poor birth outcome.OBJECTIVE:To compare prenatal cortisol and DHEA-S levels among pregnant women with normal or poor birth outcome.METHODS:Plasma and saliva were collected prospectively from women in second-third trimester of pregnancy. Women with normal birth outcome (NBO) (n = 501) included live birth, no pregnancy complications and ≥2.5 kg infant birth weight. Women with poor birth outcome included adverse birth outcome (ABO) (n = 50) or low birth weight outcome (LBW) (n = 147). Enzyme-linked immunosorbent assay was performed to measure hormone concentrations in plasma and saliva.RESULTS:Circulatory-DHEA-S levels in pregnant women with ABO were higher than women with NBO (p = .043). Among ABO, only stillbirth cases demonstrated significant increase in circulatory-DHEA-S levels (p = .006). Circulatory and salivary cortisol/DHEA-S ratio was lower among women with stillbirth (p = .004) and ABO outcome (p = .043) respectively compared with women with NBO. Consistently, increased odds of ABO were observed in pregnant women with highest circulatory-DHEA-S levels (odds ratio quartile score 1 vs. 4, 2.79, p = .027) and lowest salivary cortisol/DHEA-S ratio (score 4 vs. 2, 2.83, p = .025). Increased odds of stillbirth outcome were observed in pregnant women with highest circulatory-DHEA-S levels (odds ratio quartile score 1 vs. 4, 8.47, p = .046) and lowest circulatory cortisol/DHEA-S ratio (score 4 vs. 1, 4.803, p = .048). Associations remained significant after adjusting for confounders. Women with LBW did not demonstrate significant changes in cortisol or DHEA-S levels.CONCLUSION:Prenatal measurement of DHEA-S or cortisol/DHEA-S ratio may offer significant value for predicting adverse birth, specifically stillbirth outcome.

During pregnancy, circulatory cortisol levels increase, remaining steady over the second-third trimester. In contrast, profile of salivary cortisol during pregnancy is debatable, more influenced by factors like time of sample collection in the day. Circulatory DHEA-S decrease by at least 50% over the second-third trimester of pregnancy. However, profile of salivary DHEA-S is unclear. Objective was to determine changes in salivary cortisol and DHEA-S in healthy pregnant women, compared to non-pregnant women during late morning-early afternoon sampling to avoid fluctuations associated with other times. Pregnant women in their second-third trimester prospectively (n=500) and non-pregnant women (n=133) were enrolled in study with informed consent. Live birth outcome with no pregnancy complications and >= 2.5Kg infant birth weight were included. Concentrations of salivary cortisol and DHEA-S were determined through ELISA assays. Compared to non-pregnant women, pregnant women demonstrated significant increases in salivary cortisol [median (interquartile range)=4.2 (5.1) nmol/l vs. 17.2 (13.9) nmol/l, p<0.001] and salivary DHEA-S median (interquartile range)=2.7 (2.9) nmol/l vs. 3.8 (3.2) nmol/l, p<0.001). Consistently, quartile scores representing higher levels of salivary cortisol and DHEA-S concentrations demonstrated significant association with pregnancy. Quartile scores representing higher salivary cortisol/DHEA-S ratio demonstrated significant association with pregnancy. Study suggests the indicated time range of saliva sampling might best parallel the established profile of circulatory cortisol in pregnant women. However, unlike cortisol, study indicates that the salivary DHEA-S profile is distinct from the well-known profile of circulatory DHEA-S during pregnancy. A combinatorial approach involving both salivary and circulatory compartments could provide comprehensive picture of DHEA-S and hypothalamus-pituitary-adrenal axis during pregnancy.

The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global public health problem. The SARS-CoV-2 triggers hyper-activation of inflammatory and immune responses resulting in cytokine storm and increased inflammatory responses on several organs like lungs, kidneys, intestine, and placenta. Although SARS-CoV-2 affects individuals of all age groups and physiological statuses, immune-compromised individuals such as pregnant women are considered as a highly vulnerable group. This review aims to raise the concerns of high risk of infection, morbidity and mortality of COVID-19 in pregnant women and provides critical reviews of pathophysiology and pathobiology of how SARS-CoV-2 infection potentially increases the severity and fatality during pregnancy. This article also provides a discussion of current evidence on vertical transmission of SARS-CoV-2 during pregnancy and breastfeeding. Lastly, guidelines on management, treatment, preventive, and mitigation strategies of SARS-CoV-2 infection during pregnancy and pregnancy-related conditions such as delivery and breastfeeding are discussed.

Early detection and treatment via screening can prevent up to 80% of cervical cancers in developed countries, where efficient screening programs are in place. In developing countries, however, there is limited access to effective, wide scale screening, leading to increased deaths due to cervical cancer. Despite sufficient evidence supporting the use of screening as an effective intervention, there are still few large-scale screening programs being implemented in India. This systematic review examined the current literature on knowledge and attitudes regarding cervical cancer and barriers to screening for cervical cancer among women in India. Consistent themes were found throughout the literature - the story is the same not only in India but throughout the developing world. In urban and rural areas alike, most women have heard of cervical cancer, yet there is a shockingly low uptake of screening for cervical cancer. This low uptake of cervical cancer screening can be attributed to a number of factors, as demonstrated by the literature, including low level of knowledge and awareness, low level of perceived risk, stigma associated with cancer, fear of cancer, cost, and familial obligations. India has urgent need to develop health system capacity to ensure efficient cervical cancer screening program and community level efforts to improve knowledge about cervical cancer and screening programs. This effort would help save thousands of young women and their families from a great calamity.