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An awareness of fertility and the factors affecting it is crucial to dealing with infertility, though little research has been conducted in the context of rural India. This study assessed Indian women’s perceived causes of, and strategies for coping with, infertility and the associations with levels of reproductive health knowledge in rural areas. Primary data were collected through mapping and listing in high infertility prevalence districts of West Bengal in 2014–15. A total of 159 women aged 20–49 years who had ever experienced infertility were interviewed. A Reproductive Health Knowledge Index (RHKI) was computed to indicate respondent’s level of reproductive health knowledge, and to show its association with perceived causes of infertility and coping with infertility. The highest mean RHKI score was observed among women in the lowest age group (RHKI=5.75, p <0.001), those with a higher level of education (RHKI=9.39, p <0.001) and those who had exposure to any media (RHKI=5.88, p <0.001). Women with a poor wealth index (RHKI=2.11, p <0.01) and those from Scheduled Caste, Scheduled Tribe and Other Backward Class communities (RHKI=4.20, p <0.05) had lower RHKI scores than richer women and those from General Caste communities. Women with a higher RHKI score were more likely to give biology (98.0%, p <0.001), old age (94.1%, p <0.01) and repeated abortions/accident/injury (92.2%, p <0.001) as reasons for infertility, whereas women with a low RHKI were more likely to give religious (73.2%, p <0.001) and old-age-related causes (75.0%, p <0.01) of infertility. Women with a high RHKI score were more likely to opt for modern allopathic treatments (RHKI=7.04, p <0.001), whereas those with a low RHKI score were more likely to seek treatment from religious and superstitious practitioners, use home remedies or receive no treatment at all (RHKI=1.66, p <0.001). Appropriate reproductive health knowledge is crucial if rural Indian women are to correctly assess their infertility problems and choose effective coping strategies.

This study assessed the rate of primary infertility and its associated factors among 402,807 currently married women aged 20–49 years in India using National Family Health Survey-4 data collected in 2015–2016. Dietary patterns and selected morbidities were included as independent variables, and socioeconomic variables were considered as covariates. Bivariate and multivariate analyses were done to estimate the prevalence of primary infertility and assess its association with the selected variables, respectively. The rate of primary infertility among currently married women in India in 2015–16 was 1.9% and this was significantly associated with younger age (<35 years), higher age at marriage (≥18 years), urban residence, higher secondary or above education and poverty. The consumption of dairy products (OR = 0.79, CI = 0.73–0.86), dark green leafy vegetables (OR = 0.57, CI = 0.39–0.81) and fruit (OR = 0.88, CI = 0.77–1.01) significantly reduced the odds of primary infertility. Daily consumption of fish and aerated drinks was related to 1.06–1.21 times higher odds of primary infertility. Overweight/obesity, high blood pressure and high blood glucose levels were associated with 1.08–1.21 times elevated odds of primary infertility. Thyroid disorder (OR = 1.38, CI = 1.21–1.60), heart disease (OR = 1.17, CI = 1.16–1.19) and severe anaemia (OR = 1.24, CI = 1.00–1.53) were associated with an increased likelihood of primary infertility among women (OR 1.17–1.39, CI 1.00–1.60). The findings provide compelling evidence that primary infertility among women is related to dietary patterns and morbidities. Interventions and programmes targeting the promotion of healthy diets and lifestyles could be beneficial in addressing the issue of primary infertility among women.

ObjectiveEquitable and affordable access to improved sanitation facilities is linked to health and is among the priority areas of development programmes in a country like India. This study assesses the level of different sanitation facilities accessed by households and attempts to understand the socioeconomic characteristics of the households that received financial benefits from the Swachh Bharat Mission (Swachh Bharat Abhiyan), a Government of India flagship programme.DesignCross-sectional study.Setting and participantsThe study extracted data from the 76th round (2018) of the National Sample Survey, consisting of 106 837 households in India.Outcome measuresSanitation services and benefits received from the Swachh Bharat Mission in the last 3 years preceding the survey were the two outcome variables of this study. Bivariate and multinomial logistic regression analysis were performed to identify factors associated with the outcome variables.ResultsFindings show the existence of state and regional disparities, along with rural–urban gaps, in the accessibility of sanitation facilities. Half of the households (52%, n=55 555) had access to safely managed sanitation facilities, followed by basic services (14.8%, n=15 812), limited services (11.4%, n=12 179) and unimproved services/open defecation (21.8%, n=23 290). Limited and unimproved facilities decreased significantly (p<0.001) with increase in economic status, although poor and less educated households received the maximum benefit from the Swachh Bharat Mission.ConclusionThe mission has been successful in increasing access overall; however, many people continue to lack access to improved sanitation and there remains a need to follow up poor and rural households to determine their usage of and the current state of their sanitation facilities.

Continuum of care throughout pregnancy, delivery and post-delivery has proved to be a critical health intervention for improving the health of mothers and their newborn children. Using data from the fourth wave of the National Family Health Survey (NFHS-4) conducted in 2015–16, this study examined the correlates of utilization of maternal health care services and child immunization following the continuum of care approach in India. The study also assessed whether the continuity in utilizing maternal health care services affects the immunization of children. A total of 33,422 survey women aged 15–49 were included in the analysis of maternal health care indicators, and 8246 children aged 12–23 months for the analysis of child immunization. The results indicated that about 19% of the women had completed the maternal health continuum, i.e. received full antenatal care, had an institutional delivery and received postnatal care. Women with a higher level of education and of higher economic status were more likely to have complete continuum of care. Continuity of maternal health care was found to be associated with an increase in the immunization level of children. It was observed that 76% of the children whose mothers had complete continuum of care were fully immunized. Furthermore, the results from propensity score matching revealed that if mothers received continuum of care, the chance of their child being fully immunized increased by 17 percentage points. The results suggest that promotion of the continuum of maternal health care approach could help reduce not only the burden of maternal deaths in India, but also that of child deaths by increasing the immunization level of children.

Large scale surveys are the main source of data pertaining to all the social and demographic indicators, hence its quality is also of great concern. In this paper, we discuss the indicators used to examine the quality of data. We focus on age misreporting, incompleteness and inconsistency of information; and skipping of questions on reproductive and sexual health related issues. In order to observe the practical consequences of errors in a survey; the District Level Household and Facility Survey (DLHS-3) is used as an example dataset. Whipple's and Myer's indices are used to identify age misreporting. Age displacements are identified by estimating downward and upward transfers for women from bordering age groups of the eligible age range. Skipping pattern is examined by recording the responses to the questions which precede the sections on birth history, immunization, and reproductive and sexual health. The study observed errors in age reporting, in all the states, but the extent of misreporting differs by state and individual characteristics. Illiteracy, rural residence and poor economic condition are the major factors that lead to age misreporting. Female were excluded from the eligible age group, to reduce the duration of interview. The study further observed that respondents tend to skip questions on HIV/RTI and other questions which follow a set of questions. The study concludes that age misreporting, inconsistency and incomplete response are three sources of error that need to be considered carefully before drawing conclusions from any survey. DLHS-3 also suffers from age misreporting, particularly for female in the reproductive ages. In view of the coverage of the survey, it may not be possible to control age misreporting completely, but some extra effort to probe a better answer may help in improving the quality of data in the survey.

Background Commercial surrogacy is a highly controversial issue that leads to heated debates in the feminist literature, especially when surrogacy takes place in developing countries and when it is performed by local women for wealthy international individuals. The objective of this article is to confront common assumptions with the narratives and experiences described by Indian surrogates themselves. Methods This qualitative study included 33 surrogates interviewed in India (Mumbai, Chennai and New Delhi) who were at different stages of the surrogacy process. They were recruited through five clinics and agencies. This 2-year field study was conducted before the 2018 surrogacy law. Results Surrogates met the criteria fixed by the national guidelines in terms of age and marital and family situation. The commitment to surrogacy had generally been decided with the husband. Its aim was above all to improve the socioeconomic condition of the family. Women described surrogacy as offering better conditions than their previous paid activity. They had clear views on the child and their work. However, they declared that they faced difficulties and social condemnation as surrogacy is associated with extra-marital relationships. They also described a medical process in which they had no autonomy although they did not express complaints. Overall, surrogates did not portray themselves as vulnerable women and victims, but rather as mothers and spouses taking control of their destiny. Conclusions The reality of surrogacy in India embraces antagonistic features that we analyze in this paper as “paradoxes”. First, while women have become surrogates in response to gender constraints as mothers and wives, yet in so doing they have gone against gender norms. Secondly, while surrogacy was socially perceived as dirty work undertaken in order to survive, surrogates used surrogacy as a means to upward mobility for themselves and their children. Finally, while surrogacy was organized to counteract accusations of exploitation, surrogates were under constant domination by the medical system and had no decision-making power in the surrogacy process. This echoes their daily life as women. Although the Indian legal framework has changed, surrogacy still challenges gender norms, particularly in other developing countries where the practice is emerging.

Women’s empowerment is fundamental for realizing unalienable human rights and is vital to sustainable development outcomes. In India, the SWABHIMAAN intervention program was an integrated multi-sectoral strategy to improve girls’ and women’s nutrition before conception, during pregnancy, and after childbirth. This study assesses the role of self-help-group (SHGs) in improving the effectiveness of community health interventions and its impact on their self-empowerment. Qualitative data gathered through in-depth interviews (IDI) with community-based SHG members involved as Nutrition Friend (Poshan Sakhi-PS) in the SWABHIMAAN program in 2018 was used for analysis. Informed consent procedures were followed, and only those who voluntarily consented to the interview were interviewed. Twenty-five IDIs of purposively selected PSs in three states (Bihar, n = 9; Chhattisgarh, n = 8; and Odisha, n = 8) were analyzed thematically, according to Braun & Clarke (2006). NVivo 12 software was used for organizing and coding data. Three central themes that emerged to explain women’s empowerment were (1) Barriers & redressal mechanisms adopted by PS, (2) PS as a change-maker, and (3) Changes in the life of PS. The study found that women perceive themselves as more empowered through involvement in the SWABHIMAN intervention program, besides improving the community’s and their households’ nutritional status. The results suggest that policies and programs on health and nutrition interventions need to involve peer women from the community, leading to more effective outcomes. Empowering women and closing gender gaps in employment/work are critical to achieving the 2030 Sustainable Development Goals.

(i) To assess diagnostic accuracy of mid-upper arm circumference (MUAC) for screening thinness and severe thinness in Indian adolescent girls aged 10-14 and 15-19 years compared with BMI-for-age Z-score (BAZ) <-2 and <-3 as the gold standard and (ii) to identify appropriate MUAC cut-offs for screening thinness and severe thinness in Indian girls aged 10-14 and 15-19 years. Cross-sectional, conducted October 2016-April 2017. Four tribal blocks of two eastern India states, Chhattisgarh and Odisha. Girls (n 4628) aged 10-19 years. Measurements included height, weight and MUAC to calculate BAZ. Standard diagnostic accuracy tests, receiver-operating characteristic curves and Youden index helped arrive at MUAC cut-offs at BAZ < -2 and <-3, as gold standard. Mean MUAC and BMI correlation was positive (0·78, P = 0·001 and r 2 = 0·61). Among 10-14 years, MUAC cut-off corresponding to BAZ < -2 and BAZ < -3 was ≤19·4 and ≤18·9 cm. Among 15-19 years, corresponding values were ≤21·6 and ≤20·7 cm. For both BAZ < -2 and BAZ < -3, specificity was higher in 15-19 v. 10-14 years. State-wise variations existed. MUAC cut-offs ranged from 17·7 cm (10 years) to 22·5 cm (19 years) for BAZ < -2, and from 17·0 cm (10 years) to 21·5 cm (19 years) for BAZ < -3. Single-age area under the curve range was 0·82-0·97. Study provides a case for use of year-wise and sex-wise context-specific MUAC-cut-offs for screening thinness/severe thinness in adolescents, rather than one MUAC cut-off across 10-19 years, depending on purpose and logistic constraints.

Undernutrition-before, during and after pregnancy endangers the health and well-being of the mother and contributes to sub-optimal fetal development and growth. A non-randomized controlled evaluation was undertaken to assess the impact of engaging federations of women's group on coverage of nutrition interventions and on nutrition status of women in the designated poverty pockets of three Indian states-Bihar, Chhattisgarh, and Odisha. The impact evaluation is based on two rounds of cross-sectional data from 5 resource poor blocks across 3 States, assigning 162 villages to the intervention arm and 151 villages to the control arm. The cross-sectional baseline (2016-17) and endline survey (2021-22) covered a total of 10491 adolescent girls (10-19 years), 4271 pregnant women (15-49 years) and 13521 mothers of children under age two years (15-49 years). Exposure was defined based on participation in the participatory learning and action meetings, and fixed monthly health camps (Adolescent Health Days (AHDs) and Village Health Sanitation and Nutrition Days (VHSNDs)). Logistic regression models were applied to establish the association between exposure to programme activities and improvement in coverage of nutrition interventions and outcomes. In the intervention area at endline, 27-38% of women participated in the participatory learning and action meetings organized by women's groups. Pregnant women participating in programme activities were two times more likely to receive an antenatal care visit in the first trimester of pregnancy (Odds ratio: 2.55 95% CI-1.68-3.88), while mothers of children under 2 were 60% more likely to receive 4 ANC visits (Odds ratio: 1.61, 95% CI- 1.30-2.02). Odds of consuming a diversified diet was higher among both pregnant women (Odds ratio: 2.05, 95% CI- 1.41-2.99) and mother of children under 2 years of age (Odds ratio: 1.38, 95% CI- 1.08-1.77) among those participating in programme activities in the intervention arm. Access to commodities for WASH including safe sanitation services (Odds ratio: 1.80, 95% CI- 1.38-2.36) and sanitary pads (Odds ratio: 1.64, 95% CI- 1.20-2.22) was higher among adolescent girls participating in programme activities. Women's groups led participatory learning and action approaches coupled with strengthening of the supply side delivery mechanisms resulted in higher coverage of health and nutrition services. However, we found that frequency of participation was low and there was limited impact on the nutritional outcomes. Therefore, higher frequency of participation in programme activities is recommended to modify behaviour and achieve quick gains in nutritional outcomes.

Commercial surrogacy in emerging countries such as India is often associated with exploitation of vulnerable women, the assumption being that it is performed by poor and uneducated women for rich intended parents. However, the hypothesis that surrogates are poor women has rarely been confronted with field data. The objective was to compare the socioeconomic characteristics of Indian surrogates interviewed in social studies with those of Indian women in the general population in order to provide preliminary data on whether surrogates have a specific profile and are indeed disadvantaged compared with their counterparts. The study analyzes the data from four cross-sectional studies carried out in India among surrogates between 2006 and 2014. Surrogates were recruited through clinics, agencies and agents. Data were collected during face-to-face interviews. The resulting convenience sample included 96 Indian surrogates. Their sociodemographic characteristics were compared with those of the general population extracted from Indian national surveys. The surrogates interviewed had their first child at a younger age than women in the general population, but they tended to have a smaller family. Their social situation tended to be better than that of the general population in terms of education, employment and family income. These results provide first empirical evidence moderating the common assumption that Indian surrogates are the poorest and least educated women. This does not mean, however, that exploitation does not exist. More studies are needed to confirm these results and to explore the issue in new international destinations for surrogacy.