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The reductions in mortality levels among children under five years are observed in most populations, including populations that were lagging the progress in the past. However, the reduction is not uniform across ages during childhood. The mortality declines within the first month have shown relatively slow progress. Early initiation of breastfeeding and discarding pre-lacteal feed protects the newborn from acquiring infection and, thereby, reduces mortality. This paper assesses the change in the prevalence of early initiation of breastfeeding and pre-lacteal feed along with their associated factors, and their association with neonatal mortality in India. We used data from the three rounds of National Family Health Surveys conducted during 2005-06, 2015-16 and 2019-21 in India. We used bivariate and multivariate analyses to examine prevalence rates, risk factors, and relationships between breastfeeding practices, including early initiation of breastfeeding and pre-lacteal feed, and neonatal mortality. Early initiation of breastfeeding within one hour after birth increased rapidly from 25% in 2005-06 to 42% in 2019-21, and the pre-lacteal feeding practice declined from 57% in 2005-06 to 15% in 2019-21. Pre-lacteal feed is lower in states/districts where early breastfeeding initiation is predominant and vice versa. The role of health professionals during pregnancy and the first two days after delivery significantly improved breastfeeding practice. Further, the findings suggest that an early breastfeeding initiation is associated with lower neonatal mortality, whereas pre-lacteal feed is not harmful compared to late breastfeeding initiation. Prevalence of pre-lacteal feed reduced, and initiation of early breastfeeding increased considerably after the launch of the National Rural Health Mission in India. However, after 2015-16, early breastfeeding initiation has stagnated, and the decline in pre-lacteal feed has slowed down. The future program needs special attention to emphasize the availability and accessibility of breastfeeding advisers and observers in health facilities to help mitigate adverse neonatal outcomes.

Asthma is a non-curable but preventable disease, responsible for higher morbidity worldwide. According to recent WHO report, nearly 235 million people are suffering from asthma leading to 383000 deaths in 2015. The burden of asthma morbidity is higher in developed countries and is increasing in developing countries. The present study was aimed at studying the change in prevalence rate of asthma, associated risk factors and estimation of morbidity burden and avoidable cases of asthma in India. The second round of Indian Human Development Survey (IHDS-II), 2011-12, was used for the study. For the present study, asthma was defines as ever diagnosed with asthma or having cough with short breath. Multiple-logistic regression was used to identify the possible risk factors associated with prevalence of reporting asthma. Population attributable fractions (PAFs) were computed to estimate the overall and risk factors specific burden of morbidity due to asthma using the extrapolated population of year 2015 using 2011 census. Overall prevalence rate of asthma increased from 41.9 (per 1000 population) in 2004-05 to 54.9 (per 1000 population) in 2011-12. The prevalence rate of reporting asthma was higher in poorer states compared to richer states, and also varied by sub-geographies, with higher prevalence rate in northern states of the country and lower rates in north-eastern states of the country. The odds of reporting asthma was higher for younger and older ages, individual with fewer years of schooling (OR: 1.41; 95% CI: 1.21-1.64) for individual with zero years of schooling compared to those with 11 or more years of schooling, individual from lower economic status, individual living in household using unclean fuels (OR:1.21; 95% CI: 1.08-1.34) and smokers (OR: 1.34; 95% CI: 1.17-1.55) compared to their counterparts. In the year 2015, the overall morbidity burden of asthma was estimated at nearly 65 million and more than 82 thousand deaths were attributed due to asthma. The burden was highest among individuals living in households using solid fuels (firewood~80%, Kerosene~78%). One-third of the cases could be eliminated by minimising the use of any solid fuels. Around 17% of all the asthma cases in population could be attributed to underweight. Eliminating the modifiable risk factors could help reduce in huge amount of asthma cases for example by providing education, cessation in smoking, and schemes like Pradhan Mantri Ujjwala Yojana (PMUY), by providing clean fuel (LPG) to poor and vulnerable households.

India's 2011 census revealed a growing imbalance between the numbers of girls and boys aged 0–6 years, which we postulate is due to increased prenatal sex determination with subsequent selective abortion of female fetuses. We aimed to establish the trends in sex ratio by birth order from 1990 to 2005 with three nationally representative surveys and to quantify the totals of selective abortions of girls with census cohort data. We assessed sex ratios by birth order in 0·25 million births in three rounds of the nationally representative National Family Health Survey covering the period from 1990 to 2005. We estimated totals of selective abortion of girls by assessing the birth cohorts of children aged 0–6 years in the 1991, 2001, and 2011 censuses. Our main statistic was the conditional sex ratio of second-order births after a firstborn girl and we used 3-year rolling weighted averages to test for trends, with differences between trends compared by linear regression. The conditional sex ratio for second-order births when the firstborn was a girl fell from 906 per 1000 boys (99% CI 798–1013) in 1990 to 836 (733–939) in 2005; an annual decline of 0·52% (p for trend=0·002). Declines were much greater in mothers with 10 or more years of education than in mothers with no education, and in wealthier households compared with poorer households. By contrast, we did not detect any significant declines in the sex ratio for second-order births if the firstborn was a boy, or for firstborns. Between the 2001 and 2011 censuses, more than twice the number of Indian districts (local administrative areas) showed declines in the child sex ratio as districts with no change or increases. After adjusting for excess mortality rates in girls, our estimates of number of selective abortions of girls rose from 0–2·0 million in the 1980s, to 1·2–4·1 million in the 1990s, and to 3·1–6·0 million in the 2000s. Each 1% decline in child sex ratio at ages 0–6 years implied 1·2–3·6 million more selective abortions of girls. Selective abortions of girls totalled about 4·2–12·1 million from 1980–2010, with a greater rate of increase in the 1990s than in the 2000s. Selective abortion of girls, especially for pregnancies after a firstborn girl, has increased substantially in India. Most of India's population now live in states where selective abortion of girls is common. US National Institutes of Health, Canadian Institute of Health Research, International Development Research Centre, and Li Ka Shing Knowledge Institute.

Data on cause-specific mortality, skilled birth attendance, and emergency obstetric care access are essential to plan maternity services. We present the distribution of India's 2001-2003 maternal mortality by cause and uptake of emergency obstetric care, in poorer and richer states. The Registrar General of India surveyed all deaths occurring in 2001-2003 in 1.1 million nationally representative homes. Field staff interviewed household members about events that preceded the death. Two physicians independently assigned a cause of death. Narratives for all maternal deaths were coded for variables on healthcare uptake. Distribution of number of maternal deaths, cause-specific mortality and uptake of healthcare indicators were compared for poorer and richer states. There were 10,041 all-cause deaths in women age 15-49 years, of which 1096 (11.1%) were maternal deaths. Based on 2004-2006 SRS national MMR estimates of 254 deaths per 100,000 live births, we estimated rural areas of poorer states had the highest MMR (397, 95%CI 385-410) compared to the lowest MMR in urban areas of richer states (115, 95%CI 85-146). We estimated 69,400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India. Most maternal deaths were attributed to direct obstetric causes (82%). There was no difference in the major causes of maternal deaths between poorer and richer states. Two-thirds of women died seeking some form of healthcare, most seeking care in a critical medical condition. Rural areas of poorer states had proportionately lower access and utilization to healthcare services than the urban areas; however this rural-urban difference was not seen in richer states. Maternal mortality and poor access to healthcare is disproportionately higher in rural populations of the poorer states of India.

The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. We extracted GDP, government spending in 184 countries from 1980–2015, and health spend data from 1995–2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. We estimated that global spending on health will increase from US$9·21 trillion in 2014 to $24·24 trillion (uncertainty interval [UI] 20·47–29·72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5·3% (UI 4·1–6·8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4·2% (3·8–4·9). High-income countries are expected to grow at 2·1% (UI 1·8–2·4) and low-income countries are expected to grow at 1·8% (1·0–2·8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133–181) per capita in 2030 and $195 (157–258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157–258) per capita was available for health in 2040 in low-income countries. Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential. Bill & Melinda Gates Foundation.

The provision of affordable health care is generally considered a fundamental goal of a welfare state. In addition to its role in maintaining and improving the health status of individuals and households, it impacts the economic prosperity of a society through its positive effects on labor productivity. Given this context, this paper assesses socioeconomic-differentials in the impact of out-of-pocket-health-expenditure (OOPHE) on impoverishment in China and India, two of the fastest growing economies of the world. The paper uses data from the World Health Organisation's Study on Global Ageing and Adult Health (WHO SAGE), and Bivariate as well as Multivariate analyses for investigating the socioeconomic-differentials in the impact of out-of-pocket-health-expenditure (OOPHE) on impoverishment in China and India. Annually, about 7% and 8% of the population in China and India, respectively, fall in poverty due to OOPHE. Also, the percentage shortfall in income for the population from poverty line due to OOPHE is 2% in China and 1.3% in India. Further, findings from the multivariate analysis indicate that lower wealth status and inpatient as well as outpatient care increase the odds of falling below poverty line significantly (with the extent much higher in the case of in-patient care) due to OOPHE in both China and India. In addition, having at least an under-5 child in the household, living in rural areas and having a household head with no formal education increases the odds of falling below poverty line significantly (compared to a head with college level education) due to OOPHE in China; whereas having at least an under-5 child, not having health insurance and residing in rural areas increases the odds of becoming poor significantly due to OOPHE in India.

Under the prevailing conditions of imbalanced life table and historic gender discrimination in India, our study examines crossover between life expectancies at ages zero, one and five years for India and quantifies the relative share of infant and under-five mortality towards this crossover. We estimate threshold levels of infant and under-five mortality required for crossover using age specific death rates during 1981-2009 for 16 Indian states by sex (comprising of India's 90% population in 2011). Kitagawa decomposition equations were used to analyse relative share of infant and under-five mortality towards crossover. India experienced crossover between life expectancies at ages zero and five in 2004 for menand in 2009 for women; eleven and nine Indian states have experienced this crossover for men and women, respectively. Men usually experienced crossover four years earlier than the women. Improvements in mortality below ages five have mostly contributed towards this crossover. Life expectancy at age one exceeds that at age zero for both men and women in India except for Kerala (the only state to experience this crossover in 2000 for men and 1999 for women). For India, using life expectancy at age zero and under-five mortality rate together may be more meaningful to measure overall health of its people until the crossover. Delayed crossover for women, despite higher life expectancy at birth than for men reiterates that Indian women are still disadvantaged and hence use of life expectancies at ages zero, one and five become important for India. Greater programmatic efforts to control leading causes of death during the first month and 1-59 months in high child mortality areas can help India to attain this crossover early.

Clinical studies demonstrate the efficacy of interventions to reduce neonatal deaths, but there are fewer studies of their real-life effectiveness. In India, women often seek facility delivery after complications arise, rather than to avoid complications. Our objective was to quantify the association of facility delivery and postnatal checkups with neonatal mortality while examining the \"reverse causality\" in which the mothers deliver at a health facility due to adverse perinatal events. We conducted nationally representative case-control studies of about 300,000 live births and 4,000 neonatal deaths to examine the effect of, place of delivery and postnatal checkup on neonatal mortality. We compared neonatal deaths to all live births and to a subset of live births reporting excessive bleeding or obstructed labour that were more comparable to cases in seeking care. In the larger study of 2004-8 births, facility delivery without postnatal checkup was associated with an increased odds of neonatal death (Odds ratio = 2.5; 99% CI 2.2-2.9), especially for early versus late neonatal deaths. However, use of more comparable controls showed marked attenuation (Odds ratio = 0.5; 0.4-0.5). Facility delivery with postnatal checkup was associated with reduced odds of neonatal death. Excess risks were attenuated in the earlier study of 2001-4 births. The combined effect of facility deliveries with postnatal checks ups is substantially higher than just facility delivery alone. Evaluation of the real-life effectiveness of interventions to reduce child and maternal deaths need to consider reverse causality. If these associations are causal, facility delivery with postnatal check up could avoid about 1/3 of all neonatal deaths in India (~100,000/year).

CONTEXT: Little evidence from India is available regarding the ways in which early marriage may compromise young women's lives and their reproductive health and choices. METHODS: Data from 8,314 married women aged 20-24 living in five Indian states, obtained from a subnationally representative study of transitions experienced by youth, were used to compare marital, reproductive and other outcomes between young women who had married before age 18 and those who had married later. Logistic regression analyses were conducted to identify associations between timing of marriage and the outcomes of interest. RESULTS: Young women who had married at age 18 or older were more likely than those who had married before age 18 to have been involved in planning their marriage (odds ratio, 1.4), to reject wife beating (1.2), to have used contraceptives to delay their first pregnancy (1.4) and to have had their first birth in a health facility (1.4). They were less likely than women who had married early to have experienced physical violence (0.6) or sexual violence (0.7) in their marriage or to have had a miscarriage or stillbirth (0.6). CONCLUSIONS: Findings underscore the need to build support among youth and their families for delaying marriage, to enforce existing laws on the minimum age at marriage and to encourage school, health and other authorities to support young women in negotiating with their parents to delay marriage. Contexto: Hay muy poca evidencia disponible de India sobre las formas en que el matrimonio temprano puede poner en riesgo el futuro, la salud reproductiva y las opciones de maternidad de las mujeres jóvenes. Métodos: Datos sobre 8,314 mujeres casadas en edades de 20-24 años de cinco estados indios, obtenidos a partir de un estudio representativo a nivel sub-nacional, se usaron para comparar los resultados maritales y reproductivos en mujeres jóvenes que se habían casado antes de los 18 años y en las que se casaron a una mayor edad. Se condujeron análisis de regresión logística para identificar asociaciones entre el momento del matrimonio y los resultados de interés. Resultados: Comparadas con las mujeres que casaron antes de los 18, las jóvenes que se había casado a mayor edad tenían mayor probabilidad de haber participado en la planificación de su matrimonio (razón de momios, 1.4), de rechazar la violencia contra la mujer (1.2), de haber usado anticonceptivos para posponer su primer embarazo (1.4) y de haber tenido su primer parto en una institución de salud (1.4). Y tuvieron menor probabilidad de haber experimentado violencia física o sexual en su matrimonio (0.6-0.7), y de haber tenido un aborto espontáneo o muerte fetal (0.6), que las mujeres que se casaron a menor edad. Conclusiones: Los hallazgos subrayan la necesidad de fortalecer el apoyo entre las jóvenes y sus familias para retrasar el matrimonio, y aplicar las leyes existentes relativas a la edad mínima al casarse. También indican la importancia de alentar a las autoridades escolares, sanitarias y de otros sectores de que apoyen a las mujeres jóvenes en la negociación con sus padres para retrasar el matrimonio. Contexte: Les données probantes sont rares, en Inde, concernant les effets préjudiciables du mariage précoce sur la vie et sur la santé et les choix génésiques des jeunes femmes. Méthodes: Les données relatives à 8.314 femmes mariées de 20 à 24 ans vivant dans cinq états du pays, obtenues d'une étude sous-nationale des transitions vécues par les jeunes, servent à comparer les issues matrimoniales, génésiques et autres entre les jeunes femmes mariées avant l'âge de 18 ans et celles mariées plus tard. Les associations entre le moment du mariage et les issues considérées sont identifiées par analyses de régression logistique. Résultats: Les jeunes femmes mariées à l'âge de 18 ans ou audelà sont plus susceptibles que celles mariées avant l'âge de 18 ans d'avoir participé à la planification de leur mariage (rapport de probabilités, 1,4), de rejeter la violence conjugale (1,2), d'avoir pratiqué la contraception pour différer leur première grossesse (1,4) et d'avoir accouché de leur premier enfant dans un établissement de santé (1,4). Elles sont moins susceptibles que leurs homologues mariées à un âge précoce d'avoir subi de violences physiques (0,6) ou sexuelles (0,7) au sein de leur mariage ou d'avoir fait une fausse couche ou accouché d'un mortné (0,6). Conclusions: Les observations de l'étude soulignent la nécessité de renforcer parmi les jeunes et leurs familles la volonté de repousser l'âge du mariage. Elles mettent aussi en évidence le besoin de faire respecter les lois existantes sur l'âge minimum au moment du mariage et d'encourager les autorités scolaires, sanitaires et autres à soutenir les jeunes femmes dans leurs négociations avec leurs parents en faveur de mariages différés.

A prospective, multicenter study was initiated by the Government of Maharashtra, India, to determine predictors of long-term outcomes of percutaneous coronary intervention (PCI) for coronary artery disease, and to compare the effectiveness of drug-eluting stents (DESs) and bare-metal stents (BMSs) in patients undergoing PCI under government-funded insurance. The present analysis included 4595 patients managed between August 2012 and November 2016 at any of 110 participating centers. Using the classical multivariable regression and propensity-matching approach, we found age to be the most important predictor of 1-year mortality and target lesion revascularization at 1 year post-PCI. However, using machine learning methods to account for unmeasured confounders and bias in this large observational study, we determined total stent length and number of stents deployed as the most important predictors of 1-year survival, followed by age and employment status. The unadjusted death rates were 5.0% and 3.8% for the BMS and DES groups, respectively (p = 0.185, log-rank test). The rate of re-hospitalization (p<0.001) and recurrence of unstable angina (p = 0.08) was significantly lower for DESs than for BMSs. Increased use of DES after 2015 (following establishment of a price cap on DESs) was associated with a sharp decrease in adjusted hazard ratios of DESs versus BMSs (from 0.94 in 2013 to 0.58 in 2016), suggesting that high price was limiting DES use in some high-risk patients. Since stented length and stent number were the most important predictors of survival outcomes, adopting an ischemia-guided revascularization strategy is expected to help improve outcomes and reduce procedural costs. In the elderly, PCI should be reserved for cases where the benefits outweigh the higher risk of the procedure. As unemployed patients had poorer long-term outcomes, we expect that implementation of a post-PCI cardiovascular rehabilitation program may improve long-term outcomes.