Background: Most published birth defects (BDs) prevalence estimates in India are estimated from hospital-based surveillance studies. We estimated the prevalence of selected major external BDs using data from active, population-based surveillance in two districts of Haryana- Ambala and Yamunanagar, India. Methods: Active surveillance of all deliveries between 2015–2019 was led by the Foundation for Survival of Women and Children (SWACH) and conducted by community healthcare workers in rural Haryana. Cases were defined as any live birth or stillbirth with a selected major external BD born to a mother residing in one of the 10 rural subdistricts of Ambala or Yamuna Nagar at the time of delivery. The prevalence of BDs was estimated overall and stratified by birth outcome, infant sex, and birth year. Results: Among 124,942 live and stillbirths, 611 infants had a major external BD. The highest prevalence (per 10,000 births) included talipes (18.6), neural tube defects (NTDs, 15.9), and orofacial clefts (9.2). The lowest prevalence included hypospadias (0.5), gastroschisis (0.5), and omphalocele (0.4). Among these cases, 533 (87.2% ) survived, and 78 (12.8%) were stillborn. Males had a higher prevalence of imperforate anus compared to females. NTDs and limb reduction defects decreased from 2015 to 2019 (p<0.004 trend). Conclusions: This study demonstrated the feasibility of implementing BD surveillance at birth through a network of community healthcare workers and provide. Findings provide first population-based estimates of major external BD prevalence among live births and stillbirths from India. In Haryana, major external BDs are common and contribute to perinatal mortality. In addition to determining burden and distribution of birth defects, the findings will help with planning prevention and clinical care activities related to BDs in Haryana.

Reducing childhood mortality by curtailing the incidence of vaccine preventable diseases is contingent upon a robust and high-performing routine immunization system. According to the available data, the full immunization coverage (FIC) in the state of Bihar (India) has reached 71

BACKGROUND:Folate and vitamin B12 deficiencies in pregnant women are associated with increased risk for adverse maternal and infant health outcomes, including neural tube defects (NTDs). METHODS:A population-based cross-sectional survey was conducted in two rural areas in Ambala District, Haryana, India in 2017 to assess baseline folate and vitamin B12 status among women of reproductive age (WRA) and predict the prevalence of NTDs. We calculated the prevalence of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 775 non-pregnant, non-lactating WRA (18-49 years). Using red blood cell (RBC) folate distributions and an established Bayesian model, we predicted NTD prevalence. All analyses were conducted using SAS-callable SUDAAN Version 11.0.4 to account for complex survey design. RESULTS:Among WRA, 10.1% (95% CI: 7.9, 12.7) and 9.3% (95% CI: 7.4, 11.6) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The prevalence of RBC folate insufficiency (<748 nmol/L) was 78.3% (95% CI: 75.0, 81.3) and the predicted NTD prevalence was 21.0 (95% uncertainly interval: 16.9, 25.9) per 10,000 live births. Prevalences of vitamin B12 deficiency (<200 pg/mL) and marginal deficiency (≥200 pg/mL and ≤300 pg/mL) were 57.7% (95% CI: 53.9, 61.4) and 23.5% (95% CI: 20.4, 26.9), respectively. CONCLUSIONS:The magnitude of folate insufficiency and vitamin B12 deficiency in this Northern Indian population is a substantial public health concern. The findings from the survey help establish the baseline against which results from future post-fortification surveys can be compared.

Introduction Reducing childhood mortality by curtailing the incidence of vaccine preventable diseases is contingent upon a robust and high-performing routine immunization system. According to the available data, the full immunization coverage (FIC) in the state of Bihar (India) has reached similar to 71%. While the government aspires to reach 90% FIC, a systematic evidence-based investigation of the reasons behind underimmunization as well as the identification of drivers and enablers to reach and sustain 90% FIC is critical. This study aimed to review the factors leading to underimmunized children in the state of Bihar and develop a forward-looking roadmap to reach and sustain 90% FIC by adopting a system strengthening approach. Method We conducted a desk review, followed by extensive stakeholder interviews and field visits to document and analyze the data and evidence relevant to routine immunization system performance in the state of Bihar. The stakeholders included the State Immunization Officer, District Immunization Officers, Block-level health officials, representatives from development agencies, healthcare workers, and caregivers. A total of eighty-six structured interviews were conducted, which included qualitative and quantitative parameters. Result While positive results were observed from the assessment of Bihar's immunization system, the implementation of targeted strategies for supply, service delivery and demand can provide a means to achieve FIC of 90%. The roadmap developed by the Government of Bihar enlists 40 + interventions across key thematic areas and has been prioritized over a 5-year time horizon as short, medium, and long-term milestones to achieve 90% FIC. These interventions include strengthening the data availability and quality, improving the governance and review mechanism, augmenting the capacity of health workers involve with immunization programme, and initiatives to increase demand for immunization services. Conclusion The Bihar's Immunization Roadmap development project work follows a methodical approach to assess and identify intervention to improve immunization coverage and can provide information and reference to other states and countries that are aiming to formulate similar action plans.

Aim: To learn how to achieve high-quality, effective coverage of Kangaroo Mother Care (KMC), defined as 8 hours or more of skin-to-skin contact per day and exclusive breastfeeding in district Sonipat in North India, and to develop and evaluate an implementation model. Methods: We conducted implementation research using a mixed-methods approach, including formative research, followed by repeated, rapid cycles of implementation, evaluation and refinement until a model with the potential for high and effective coverage was reached. Evaluation of this model was conducted over a 12-month period. Results: Formative research findings informed the final implementation model. Programme learning was critical to achieve high coverage. The model included improving the identification of small babies, creating KMC wards, modification in hospitalisation criteria, private sector engagement and in-built programme learning to refine implementation progress. KMC was initiated in 87% of eligible babies. At discharge, 85% received skin-to-skin contact care, 60% effective KMC and 80% were exclusively breastfed. At home, 7-day post discharge, 81% received skin-to-skin care and 79% were exclusively breastfed in the previous 24 hours. Conclusion: Achieving high KMC coverage is feasible in the study setting using a model responsive to the local context and led by the Government.

Aim To estimate incremental costs of an implementation model for scaling up Kangaroo Mother Care (KMC) for neonates with birthweight <2000 g. Methods Seven sites across Ethiopia and India collected data for 2018-19 to calculate incremental recurrent costs (of health worker time, supplies, and operations) and start-up costs for KMC scale up. The costs were estimated per live newborn Scaling up KMC in study districts required average incremental costs of US$59 (95% CI US$ 52-67) in Ethiopia and US$72 (95% CI US$ 41-103) in India per eligible newborn in the population. Most of these costs were recurrent; the annualised start-up costs per eligible newborn ranged from 12%-25% of total costs in Ethiopia and 9%-16% in India. The major cost driver was human resources, followed by initial and recurrent training, supplies, and communications costs. Incremental infrastructure costs were only 2%-6% of total costs in both countries. Most of the costs were for activities at the KMC implementing facility, accounting for 79%-88% of the total costs in Ethiopia and 89%-93% of those in India. Conclusion The costs for successful scale up of KMC seem affordable but must be included in programme budgets.

Introduction The WHO recommends oral amoxicillin for 2-59-month-old children with chest-indrawing pneumonia presenting at the health facility. Community-level health workers (CLHWs) are not allowed to treat these children when presented at the community level. This study aimed to evaluate whether CLHWs can safely and effectively treat children 2-59 months-old with chest indrawing with a 5-day course of oral amoxicillin in a few selected countries in Africa and Asia, especially when a referral is not feasible. Methods We conducted a prospective multicountry cluster-randomised, open-label, non-inferiority trial in rural areas of four countries (Bangladesh, Ethiopia, India and Malawi) from September 2016 to December 2018. Children aged 2-59 months having parents/caregivers reported cough and/or difficult breathing presenting to a CLHW were screened for enrolment. CLHWs in the intervention clusters assessed children for hypoxaemia and treated non-hypoxaemic chest-indrawing pneumonia with two times per day oral amoxicillin (50 mg/kg body weight per dose) for 5 days at the community level. CLHWs in the control clusters identified chest indrawing and referred them to a referral-level health facility for treatment. Study supervisors performed pulse oximetry in the control clusters except in Bangladesh. Children were assessed for the primary outcome (clinical treatment failure) up to day 14 after enrolment. The accuracy and impact of pulse oximetry by CLHWs in the intervention clusters were also assessed. Results In 208 clusters, 1688 CLHWs assessed 62 363 children with cough and/or difficulty breathing. Of these, 4013 non-hypoxaemic 2-59-month-old children with chest-indrawing pneumonia were enrolled. We excluded 116 children from analysis, leaving 3897 for intention-to-treat analysis. In the intervention clusters, 4.3% (90/2081) failed treatment, including five deaths, while in the control clusters, 4.4% (79/1816) failed treatment, including five deaths. The adjusted risk difference was -0.01 (95% CI -1.5% to 1.5%), which satisfied the prespecified non-inferiority criterion. CLHWs correctly performed pulse oximetry in 91.1% (2001/2196) of cases in the intervention clusters. Conclusions The community treatment of non-hypoxaemic children with chest-indrawing pneumonia with 5-day oral amoxicillin by trained, equipped and supervised CLHWs is non-inferior to currently recommended facility-based treatment. These findings encourage a review of the existing strategy of community-based management of pneumonia.

Anemia is a public health problem in women of reproductive age in many low- and medium-income countries including India. Maternal anemia can cause low birth weight, impaired fetal growth, and preterm birth. We assessed the baseline prevalence of anemia, iron deficiency (ID), iron deficiency anemia (IDA), and inflammation using c-reactive protein (CRP) among non-pregnant, non-lactating women of reproductive age living in the Ambala District, Haryana, India prior to the start of a wheat flour fortification program. We conducted a multistage cluster probability household and biomarker survey and analyzed venous blood samples from non-pregnant, non-lactating women aged 18–49 years residing in rural areas of two subdistricts in the Ambala District. Factors of interest were: anemia, hemoglobin < 12.0 g/dL; ID, serum ferritin < 15μg/L; IDA, presence of both anemia and iron deficiency; inflammation, CRP > 5 mg/L. We used the BRINDA regression adjustment for ferritin to account for inflammation. Prevalence and 95% confidence intervals (CI) for anemia, ID, IDA, and CRP were estimated. Among 775 non-pregnant, non-lactating women of reproductive age, 54.3% (95% CI; 50.7, 58.0) had anemia, 86.9% (95% CI; 84.3, 89.2) were iron deficient, and 15.1% (95% CI; 12.5, 18.1) had inflammation. Among those with anemia, 58.2% (95 CI; 54.3, 62.0) had iron deficiency anemia. Anemia, iron deficiency, and iron deficiency anemia among non-pregnant, non-lactating women of reproductive age in Haryana are significant public health concerns. The findings from the survey helped quantify the burden of inadequate iron intake and informed the Haryana government's prevention strategy aimed at reducing micronutrient deficiencies through a wheat flour fortification program. Centers for Disease Control and Prevention.

Background Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality. Methodology The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0–59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs). Findings A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0–6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7–59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI. Conclusion The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7–59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7–59 days old fast breathers and recommend a review of the current national policy.

INTRODUCTION:In 2014, the Government of India (GOI) released operational guidelines on the use of antenatal corticosteroids (ACS) in preterm labor. However, without ensuring the quality of childbirth and newborn care at facilities, the use of ACS in low- and middle-income countries is potentially harmful. This study assessed the readiness to provide ACS at primary and secondary care public health facilities in northern India.METHODS:A cross-sectional study was conducted in 37 public health facilities in 2 districts of Haryana, India. Facility processes and program implementation for ACS delivery were assessed using pretested study tools developed from the World Health Organization (WHO) quality of care standards and WHO guidelines for threatened preterm birth.RESULTS:Key gaps in public health facilities' process of care to provide ACS for threatened preterm birth were identified, particularly concerning evidence-based practices, competent workforce, and actionable health information system. Emphasis on accurate gestational age estimation, quality of childbirth care, and quality of preterm care were inadequate. Shortage of trained staff was widespread, and a disconnect was found between knowledge and attitudes regarding ACS use. ACS administration was provided only at district or subdistrict hospitals, and these facilities did not uniformly record ACS-specific indicators. All levels lacked a comprehensive protocol and job aids for identifying and managing threatened preterm birth.CONCLUSIONS:ACS operational guidelines were not widely disseminated or uniformly implemented. Facilities require strengthened supervision and standardization of threatened preterm birth care. Facilities need greater readiness to meet required conditions for ACS use. Increasing uptake of a single intervention without supporting it with adequate quality of maternal and newborn care will jeopardize improvement in preterm birth outcomes. We recommend updating and expanding the existing GOI ACS operational guidelines to include specific actions for the safe and effective use of ACS in line with recent scientific evidence.

INTRODUCTION:Improving quality of care (QoC) for childbirth and sick newborns is critical for maternal and neonatal mortality reduction. Information on the process and impact of quality improvement at district and sub-district hospitals in India is limited. This implementation research was prioritized by the Haryana State (India) to improve the QoC for maternal and newborn care at the busy hospitals in districts. METHODS:This study at nine district and sub-district referral hospitals in three districts (Faridabad, Rewari and Jhajjar) during April 2017-March 2019 adopted pre-post, quasi-experimental study design and plan-do-study-act quality improvement method. During the six quarterly plan-do-study-act cycles, the facility and district quality improvement teams led the gap identification, solution planning and implementation with external facilitation. The external facilitators monitored and collected data on indicators related to maternal and newborn service availability, patient satisfaction, case record quality, provider's knowledge and skills during the cycles. These indicators were compared between baseline (pre-intervention) and endline (post-intervention) cycles for documenting impact. RESULTS:The interventions closed 50% of gaps identified, increased the number of deliveries (1562 to 1631 monthly), improved care of pregnant women in labour with hypertension (1.2% to 3.9%, p<0.01) and essential newborn care services at birth (achieved ≥90% at most facilities). Antenatal identification of high-risk pregnancies increased from 4.1% to 8.8% (p<0.01). Hand hygiene practices improved from 35.7% to 58.7% (p<0.01). The case record completeness improved from 66% to 87% (p<0.01). The time spent in antenatal clinics declined by 19-42 minutes (p<0.01). The pooled patient satisfaction scores improved from 82.5% to 95.5% (p<0.01). Key challenges included manpower shortage, staff transfers, leadership change and limited orientation for QoC. CONCLUSION:This multipronged quality improvement strategy improved the maternal and newborn services, case documentation and patient satisfaction at district and sub-district hospitals. The processes and lessons learned shall be useful for replicating and scaling up.

ObjectivesKangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage.DesignThis study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge.Participants3804 infants of birth weight under 2000g who survived the first 3days, were available in the study area and whose mother resided in the study area.Main outcome measuresThe primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7days postdischarge.ResultsKey barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%-86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7days postdischarge, KMC was provided to 53%-65% of infants in all sites, except Oromia (38%) and Karnataka (36%).ConclusionsThis study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers' conviction that KMC is the standard of care, women's and families' acceptance of KMC, and changes in infrastructure, policy, skills and practice.Trial registration numbersISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

Objectives: The aim of the study is to understand antibiotic prescribing patterns and to understand knowledge of antibiotic resistance amongst the doctors working at public health facilities of a northern Indian state. Methodology: A cross-sectional study among doctors of the civil hospitals of Haryana state of India was conducted 2019. Data were collected by self-administered questionnaire from a total of 215 doctors posted at the 22 district hospitals. Results: The response rate was 98%. Doctors (66%) perceived antibiotic resistance as a very important global problem, a very important problem in India (68%) and as an important problem in their hospital (31%). Experience in years was significantly associated with considering hand hygiene (OR, 5.78; 95% CI, 1.6420.3; P = 0.005) and treatment of bacteria as per susceptibility report of the organism (OR, 0.54; 95% CI, 0.310.93; P = 0.03).Surgeons reported piperacillin-tazobactam (17%), cloxacillin (17%), and cephazolin (12.05%) and others (54.2%) as the first choice of antibiotics for infection after surgery. Doctors (52.3%) reported that they started antibiotics 12 hours before surgery; 15 (17%) prescribed antibiotics 6 hours before surgery; and 23 (27%) 1 day before the surgery. Time for stopping antibiotics after surgery, as reported by participants, was 1 day (15%), 23 days (35%), 57 days (44%), respectively. A total of 71 (83%) doctors thought that surgical incision could lead to post-surgical site infection. Conclusion: Findings of study can be utilized to enhance education on antimicrobial prescribing, antimicrobial surveillance, and prescribing patterns among doctors in our settings.

BACKGROUND:WHO does not recommend community-level health workers (CLHWs) using integrated community case management (iCCM) to treat 7-59 days old infants with fast breathing with oral amoxicillin, whereas World Health Organization (WHO) integrated management of childhood illness (IMCI) recommends it. We want to collect evidence to help harmonization of both protocols. METHODS:A cluster, randomized, open-label trial will be conducted in Africa and Asia (Ethiopia, Malawi, Bangladesh and India) using a common protocol with the same study design, inclusion criteria, intervention, comparison, and outcomes to contribute to the overall sample size. This trial will also identify hypoxaemia in young infants with fast breathing. CLHWs will assess infants for fast breathing, which will be confirmed by a study supervisor. Enrolled infants in the intervention clusters will be treated with oral amoxicillin, whereas in the control clusters they will be managed as per existing iCCM protocol. An independent outcome assessor will assess all enrolled infants on days 6 and 14 of enrolment for the study outcomes in both intervention and control clusters. Primary outcome will be clinical treatment failure by day 6. This trial will obtain approval from the WHO and site institutional ethics committees. CONCLUSIONS:If the research shows that CLHWs can effectively and safely treat fast breathing pneumonia in 7-59 days old young infants, it will increase access to pneumonia treatment substantially for infants living in communities with poor access to health facilities. Additionally, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with IMCI protocol. TRIAL REGISTRATION:The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.

Background In a randomized controlled trial (RCT) with 8402 stable low birthweight (LBW) infants, majority being late preterm or term small for gestational age, community-initiated KMC (ciKMC) showed a significant improvement in survival. However, the effect of ciKMC on neurodevelopment is unclear. This is important to elucidate as children born with low birth weight are at high risk of neurodevelopmental deficits. In the first 552 stable LBW infants enrolled in the above trial, we evaluated the effect of ciKMC on neurodevelopmental outcomes during infancy. Method This RCT was conducted among 552 stable LBW infants, majorly late preterm or term small for gestational age infants without any problems at birth and weighing 1500–2250 g at birth. The intervention comprised of promotion of skin-to-skin contact and exclusive breastfeeding by trained intervention delivery team through home visits. The intervention group mother-infant-dyads were supported to practice ciKMC till day 28 after birth or until the baby wriggled-out. All infants in the intervention and control groups received Home Based Post Natal Care (HBPNC) visits by government health workers. Cognitive, language, motor and socio-emotional outcomes were assessed at infant-ages 6- and 12-months using Bayley Scale of Infant Development (BSID-III). Other outcomes measured were infant temperament, maternal depression, maternal sense of competence, mother-infant bonding and home-environment. We performed post-hoc equivalence testing using two one-sided tests of equivalence (TOST) to provide evidence that ciKMC does not do harm in terms of neurodevelopment. Results In the intervention arm, the median (IQR) time to initiate ciKMC was 48 (48 to 72) hours after birth. The mean (SD) duration of skin-to-skin-contact was 27.9 (3.9) days with a mean (SD) of 8.7 (3.5) hours per day. We did not find significant effect of ciKMC on any of the child developmental outcomes during infancy. The TOST analysis demonstrated that composite scores for cognitive, language and motor domains at 12 months among the study arms were statistically equivalent. Conclusion Our study was unable to capture any effect of ciKMC on neurodevelopment during infancy in this sample of stable late preterm or term small for gestational age infants. Long term follow-up may provide meaningful insights. Trial registration The trial is registered at clinicaltrials.gov NCT02631343 dated February 17, 2016; Retrospectively registered.

Centers for Disease Control and Prevention.

Trained Accredited Social Health Activists can treat uncomplicated childhood illnesses and are accepted by the community in this role.

CONTEXT:"Integrated Management of Neonatal and Childhood Illnesses" (IMNCI) needs regular supportive supervision (SS). AIMS:The aim of this study was to find suitable SS model for implementing IMNCI. SETTINGS AND DESIGN:This was a prospective interventional study in 10 high-focus districts of Haryana. SUBJECTS AND METHODS:Two methods of SS were used: (a) visit to subcenters and home visits (model 1) and (b) organization of IMNCI clinics/camps at primary health center (PHC) and community health center (CHC) (model 2). Skill scores were measured at different time points. Routine IMNCI data from study block and randomly selected control block of each district were retrieved for 4 months before and after the training and supervision. STATISTICAL ANALYSIS USED:Change in percentage mean skill score difference and percentage difference in median number of children were assessed in two areas. RESULTS:Mean skill scores increased significantly from 2.1 (pretest) to 7.0 (posttest 1). Supportive supervisory visits sustained and improved skill scores. While model 2 of SS could positively involve health system officials, model 1 was not well received. Outcome indicator in terms of number of children assessed showed a significant improvement in intervention areas. CONCLUSIONS:SS in IMNCI clinics/camps at PHC/CHC level and innovative skill scoring method is a promising approach.

AIMThis implementation research aims to improve quality of care for mothers and newborns in three districts of Haryana, India at different public health facilities.BACKGROUNDThe decline in key maternal and newborn health indicators in India is relatively slower than expected and missed the millennium development goals. The multifold rise in institutional delivery in last decade has limited impact on neonatal and maternal mortality. Despite investments in infrastructure, equipment, supplies, monitoring tools, and also manpower, suboptimal gains in indicators point towards potential challenge in quality of care.DESIGNThis study adopts pre-post, quasi-experimental study design with repeated observations using mixed research methods to document the impact of the plan-do-study-act implementation cycles.METHODSThe quality improvement interventions shall be implemented at three district hospitals and six-first referral unit hospitals in three districts of Haryana targeting the antenatal, delivery, newborn care services with nurses as the key partners. Formative research, situational analysis, and root-cause analysis shall inform the contextualization, prioritization of interventions. Incremental plan-do-study-act cycles over 15 months shall be implemented. The changes in adherence to protocols, appropriate documentation, reduction in delays, and client satisfaction shall be documented for 16 indicators across delivery, antenatal, and sick newborn care domains.DISCUSSIONThe successful implementation of the quality improvement processes has the potential of improving the pregnancy outcomes in terms of stillbirths, maternal, and newborn mortality and sick newborn outcomes. The feasibility and learning of coimplementation in the public health system shall inform integration into standards and scaling up.

Background: The immunization coverage in India is far away from satisfactory with full immunization coverage being only 62% at national level. Targeting the intensive efforts to poor performing areas and addressing the determinants of nonimmunization and dropouts offers a quick solution. In this paper, we assess the inter-district variations in Haryana state, and the association of social determinants with partial and no immunization. Methodology: This analysis is based on data collected as part of a large household survey undertaken in the state of Haryana to measure the extent of Universal Health Coverage. A multistage stratified random sampling design was used to select primary sampling units (i.e., subcenters), villages, and households. A total of 11,594 mothers with a child between 12 and 23 months were interviewed on receipt of immunization services. Determinants of nonimmunization and partial immunization were assessed using multiple logistic regression. Results: About 21% of children aged 12–23 months were partially immunized, while 4.3% children aged 12–23 months had received “no immunization.” While the coverage of full immunization was 74.7% at the state level, it varied from 95% in best performing district to 38% in poorest performing district. Odds of a partially immunized child were significantly higher in urban area (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.1–1.38), among Muslim household (OR = 3.52; 95% CI = 3.03–4.11), children of illiterate parents (OR = 1.58; 95% CI = 1.22–2.05), and poorest quintile (OR = 1.61; 95% CI = 1.36–1.89). Conclusions: Wide interdistrict variations call for a need to consider changes in resource allocation and strengthening of the government initiatives to improve routine immunization in these districts.