Kirti Iyengar - Academia.edu (original) (raw)
Papers by Kirti Iyengar
PLOS ONE, Nov 6, 2019
The objectives of the study were to assess the knowledge and skills of medical interns and nurses... more The objectives of the study were to assess the knowledge and skills of medical interns and nurses regarding family planning (FP) services, and document the prevailing FP practices in the teaching hospitals in India.
The Lancet Global Health, 2018
Journal of Interpersonal Violence, May 15, 2017
In India, physical and psychological abuse perpetrated by a mother-in-law against a daughter-in-l... more In India, physical and psychological abuse perpetrated by a mother-in-law against a daughter-in-law is well documented. However, there is a dearth of literature exploring the perceived frequency and acceptability of mother-inlaw abuse or options available for survivors of this type of abuse. The goal of this qualitative study was to add to the in-law abuse literature by exploring men's and women's perspectives about physical and psychological abuse perpetrated by mothers-in-law against daughters-in-law in northern India. Forty-four women and 34 men residing in rural and urban areas of the Udaipur district in the northwest state of Rajasthan participated in semistructured interviews. Women, but not men, thought mother-in-law abuse was common in their communities. Psychological abuse was accepted in certain situations; however, few male or female participants agreed with physical mother-in-law abuse. Men were described as mediators in the context of mother-in-law abuse, and male participants thought that disrespecting a mother-in-law was
Qualitative Health Research, Mar 5, 2014
Intimate partner violence (IPV) is recognized as a serious medical and public health concern for ... more Intimate partner violence (IPV) is recognized as a serious medical and public health concern for women (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). The World Health Organization (WHO) has defined IPV as behavior within an intimate relationship that causes physical, psychological, or sexual harm such as acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors (Heise & Garcia-Moreno, 2002). Although men can be victims of this type of violence, the majority of IPV globally is perpetrated by men against women (Heise, Ellsberg, & Gottemoeller, 1999). Trauma is a common consequence of IPV, but numerous studies also have shown that victims of IPV are at a higher risk for physical and mental health morbidities. These include unwanted pregnancies, pregnancy loss, and sexually transmitted infections, as well as depression, posttraumatic stress disorder, and anxiety (
Journal of Health Population and Nutrition, Jul 20, 2012
The first postpartum week is a high-risk period for mothers and newborns. Very few community-base... more The first postpartum week is a high-risk period for mothers and newborns. Very few community-based studies have been conducted on patterns of maternal morbidity in resource-poor countries in that first week. An intervention on postpartum care for women within the first week after delivery was initiated in a rural area of Rajasthan, India. The intervention included a rigorous system of receiving reports of all deliveries in a defined population and providing home-level postpartum care to all women, irrespective of the place of delivery. Trained nurse-midwives used a structured checklist for detecting and managing maternal and neonatal conditions during postpartum-care visits. A total of 4,975 women, representing 87.1% of all expected deliveries in a population of 58,000, were examined in their first postpartum week during January 2007-December 2010. Haemoglobin was tested for 77.1% of women (n=3,836) who had a postnatal visit. The most common morbidity was postpartum anaemia-7.4% of women suffered from severe anaemia and 46% from moderate anaemia. Other common morbidities were fever (4%), breast conditions (4.9%), and perineal conditions (4.5%). Life-threatening postpartum morbidities were detected in 7.6% of women-9.7% among those who had deliveries at home and 6.6% among those who had institutional deliveries. None had a fistula. Severe anaemia had a strong correlation with perinatal death [p<0.000, adjusted odds ratio (AOR)=1.99, 95% confidence interval (CI) 1.32-2.99], delivery at home [p<0.000, AOR=1.64 (95% CI 1.27-2.15)], socioeconomically-underprivileged scheduled caste or tribe [p<0.000, AOR=2.47 (95% CI 1.83-3.33)], and parity of three or more [p<0.000, AOR=1.52 (95% CI 1.18-1.97)]. The correlation with antenatal care was not significant. Perineal conditions were more frequent among women who had institutional deliveries while breast conditions were more common among those who had a perinatal death. This study adds valuable knowledge on postpartum morbidity affecting women in the first few days after delivery in a low-resource setting. Health programmes should invest to ensure that all women receive early postpartum visits after delivery at home and after discharge from institution to detect and manage maternal morbidity. Further, health programmes should also ensure that women are properly screened for complications before their discharge from hospitals after delivery.
Title Competency assessment of the medical interns and nurses and prevailing practices to provide... more Title Competency assessment of the medical interns and nurses and prevailing practices to provide family planning services in teaching hospitals in three states of India.
Journal of Health Population and Nutrition, Jul 20, 2012
Maternal complications are common during and following childbirth. However, little information is... more Maternal complications are common during and following childbirth. However, little information is available on the psychological, social and economic consequences of maternal complications on women's lives, especially in a rural setting. A prospective cohort study was conducted in southern Rajasthan, India, among rural women who had a severe or less-severe, or no complication at the time of delivery or in the immediate postpartum period. In total, 1,542 women, representing 93% of all women who delivered in the field area over a 15-month period and were examined in the first week postpartum by nurse-midwives, were followed up to 12 months to record maternal and child survival. Of them, a subset of 430 women was followed up at 6-8 weeks and 12 months to capture data on the physical, psychological, social, or economic consequences. Women with severe maternal complications around the time of delivery and in the immediate postpartum period experienced an increased risk of mortality and morbidity in the first postpartum year: 2.8% of the women with severe complications died within one year compared to none with uncomplicated delivery. Women with severe complications also had higher rates of perinatal mortality [adjusted odds ratio (AOR)=3.98, confidence interval (CI) 1.96-8.1, p=0.000] and mortality of babies aged eight days to 12 months (AOR=3.14, CI 1.4-7.06, p=0.004). Compared to women in the uncomplicated group, women with severe complications were at a higher risk of depression at eight weeks and 12 months with perceived physical symptoms, had a greater difficulty in completing daily household work, and had important financial repercussions. The results suggest that women with severe complications at the time of delivery need to be provided regular follow-up services for their physical and psychological problems till about 12 months after childbirth. They also might benefit from financial support during several months in the postpartum period to prevent severe economic consequences. Further research is needed to identify an effective package of services for women in the first year after delivery.
Background Even in countries where abortion is legal, many women suffer mortality and morbidity f... more Background Even in countries where abortion is legal, many women suffer mortality and morbidity from unsafe abortion. When faced with an unwanted pregnancy, women encounter many social, geographical, and health system level barriers in accessing safe abortion. Medical methods are far more amenable to be provided in primary care rural settings, however, in practice, women are required to make multiple clinic visits to receive medical abortion services. Two important measures to reduce the number of clinic visits after an early medical abortion, are eliminating the second visit by allowing home use of misoprostol and eliminating the third visit by allowing women to assess the outcome of their abortion on their own. However, most research on home use of misoprostol and on alternatives to routine clinic follow-up visits has been done in high-income countries or in urban areas of developing countries. There is little evidence on efficacy, safety and acceptability of home use of misoprostol and self-assessment approaches from rural areas of low resource settings. Objectives The aims of this research were: (a) to assess the efficacy, feasibility, safety and acceptability of self assessment as compared to the routine clinic follow-up after early medical abortion, (b) to assess efficacy, safety and acceptability of home administration of misoprostol as compared to clinic use of misoprostol, and (c) to explore women's experiences and perceptions of home use of misoprostol and of self-assessment of outcome of early medical abortion. Methods The study was conducted in southern part of Rajasthan state in India, where 75% population is rural and only about half the women are literate. A randomised controlled, noninferiority trial was conducted at 6 health centres (3 rural, 3 urban) in 2013-14. Women seeking early medical abortion up to 9 weeks gestation were randomly assigned either to routine clinic follow-up or to self-assessment using a low-sensitivity pregnancy test at home. They were contacted through a home visit or phone call, 10-15 days later, to record the outcome of the abortion. The primary outcome was complete abortion without continuing pregnancy or need for surgical evacuation or additional mifepristone /misoprostol. The non-inferiority margin for the risk difference was 5%. Secondary outcomes included safety, feasibility, interim visits, and acceptability. A secondary analysis of the data was carried out to compare the outcomes among women with home and clinic administration of misoprostol. 4.3. Experiences and perceptions of simplified medical abortion (paper IV) 5. Discussion 5.1. How effective, safe, feasible and acceptable is selfassessment as an alternative to clinic follow-up for women having early medical abortion? 5.2. Can women in low resource settings safely administer misoprostol at home for early medical abortion? 5.3. What are experiences and perceptions of women regarding home use of misoprostol and self-assessment? 5.4. Advantages of self-managed medical abortion 5.5. What other measures are needed to simplify medical abortion? 5.6. What is needed to allow task shifting to women in health care? 5.5. Study strengths and limitations 6. Conclusions 7. Practice and policy implications 8. Implications for research 9. Acknowledgements 10. References vii
Acceptability and feasability of home assessment using low-sensitivity pregnancy test in a low re... more Acceptability and feasability of home assessment using low-sensitivity pregnancy test in a low resource setting Rajasthan, India
Qualitative Health Research, Mar 15, 2016
Although more maternal deaths occur in the postpartum period, this period receives far less atten... more Although more maternal deaths occur in the postpartum period, this period receives far less attention from the program managers. To understand how the women and their families perceive postpartum health problems, the culturally derived restrictions, and precautions controlling diets and behavior patterns, we conducted a mixed-method study in Rajasthan, India. The study methods included free listing of maternal morbidity conditions, interviews with 81 recently delivered women, case interviews with eight cases of huwa rog (postpartum illness), and interviews with nine key informants. The study showed that huwa rog refers to a broad category of serious postpartum illness, thought to affect women a few weeks to several months after delivery. Prevention of the illness involves a system of precautions referred to as parhej, which includes a distinctive set of “medicinal dietary items” referred to as desi dawai, or “country medicine,” and restrictions about mobility and work patterns of a postpartum woman. This cultural framework around the concept of huwa rog and peoples’ beliefs about it are of central importance for planning postpartum health interventions, including place of contact and communication messages.
BMC Women's Health, May 25, 2017
Background: Despite being legally available in India since 1971, barriers to safe and legal abort... more Background: Despite being legally available in India since 1971, barriers to safe and legal abortion remain, and unsafe and/or illegal abortion continues to be a problem. Community health workers have been involved in improving access to health information and care for maternal and child health in resource poor settings, but their role in facilitating accurate information about and access to safe abortion has been relatively unexplored. A qualitative study was conducted in Rajasthan, India to study acceptability, perspectives and preferences of women and community health workers, regarding the involvement of community health workers in medical abortion referrals. Methods: In-depth interviews were conducted with 24 women seeking early medical abortion at legal abortion facilities or presenting at these facilities for a follow-up assessment after medical abortion. Ten community health workers who were trained to assess eligibility for early medical abortion and/or to assess whether women needed a follow-up visit after early medical abortion were also interviewed. The transcripts were coded using ATLAS-ti 7 (version 7.1.4) in the local language and reports were generated for all the codes, emerging themes were identified and the findings were analysed. Results: Community health workers (CHWs) were willing to play a role in assessing eligibility for medical abortion and in identifying women who are in need of follow-up care after early medical abortion, when provided with appropriate training, regular supplies and job aids. Women however had apprehensions about contacting CHWs in relation to abortions. Important barriers that prevented women from seeking information and assistance from community health workers were fear of breach of confidentiality and a perception that they would be pressurised to undergo sterilisation. Conclusions: Our findings support a potential for greater role of CHWs in making safe abortion information and services accessible to women, while highlighting the need to address women's concerns about approaching CHWs in case of unwanted pregnancy. Further intervention research would be needed to shed light on the effectiveness of role of CHWs in facilitating access to safe abortion and to outline specific components in a programme setting. Trial registration: Not applicable.
The Lancet Global Health, Jun 1, 2016
Reproductive Health Matters, 2000
High unmet need for limiting contraception persists in most states of India despite wide access t... more High unmet need for limiting contraception persists in most states of India despite wide access to sterilisation. Qualitative evidence from a rural community in which child mortality is high and women's autonomy is low suggests that women may seek reversibility in a contraceptive even if they have finished childbearing. This paper describes the introduction of the Copper-T 380A--a contraceptive with an effective life span of ten years--as an alternative to female sterilisation in a rural area of the state of Rajasthan, in a clinic linked to an outreach programme. The intervention addressed women's apprehensions, ensured service standards and guaranteed women's right to have the Copper-T removed at will. Data on 216 insertions over 34 months revealed a preference for the Copper-T 380A among older women and women who had achieved desired family size, especially among tribal women. More than a quarter of the 30 removals in that period were for non-medical reasons, such as family opposition, child death or remarriage. As a long-term but reversible option, the Copper-T 380A allows women room to change their minds in relation to future childbearing until they have reached menopause. Including this option in family planning services can help to meet a portion of the unmet need for contraception among women not willing to choose sterilisation, while reducing dependence on doctors and expensive equipment.
Global Health: Science and Practice
In the study medical schools, we observed providers using several harmful or unnecessary practice... more In the study medical schools, we observed providers using several harmful or unnecessary practices on pregnant women in labor, including routine pubic shaving, enema on admission, routine episiotomy, application of fundal pressure, delivery in the lithotomy position, and unindicated augmentation. n Barriers to adherence to the recommended evidencebased intrapartum practices included fear of perineal tear/injury to the baby in different birthing positions; lack of physical space, resources, and time; and outdated knowledge and beliefs of faculty and labor room staff.
The Lancet Global Health, 2015
Can women themselves assess the outcome of an early medical abortion as safely and effectively as... more Can women themselves assess the outcome of an early medical abortion as safely and effectively as a clinic follow-up visit? : A randomised controlled, non-inferiority trial in India
Journal of Perinatology, 2008
In a rural community of Rajasthan in north India, we explored family, community and provider prac... more In a rural community of Rajasthan in north India, we explored family, community and provider practices during labor and childbirth, which are likely to influence newborn health outcomes. A range of qualitative datagathering methods was applied in two rural clusters of Udaipur district. This paper reports on the key findings from eight direct observations of labor and childbirth at home and in primary health facilities, as well as 10 focus group discussions, 18 case interviews with recently delivered women and 39 key informant interviews carried out within the community. Although most families preferred home delivery, health-facility deliveries were preferred for first births, especially among adolescents. A team of birth attendants led by a traditional birth attendant or an elder female relative took decisions and performed key functions during home childbirth. Modern providers were commonly invited to administer intramuscular oxytocin injections to hasten home delivery, whereas health staff tended to do the same during facility deliveries. The practice of applying forceful fundal pressure, stemming from overriding concern about the woman's inability to deliver spontaneously, was near universal in both situations. In both facilities and homes, monitoring of labor was largely restricted to repeated unhygienic vaginal examinations with little or no monitoring of fetal or maternal well-being. Babies born at home remained lying on the wet floor till the placenta was delivered. The cord was usually tied using available twine or ceremonial thread and cut using a new blade. In facility settings, drying and wrapping of the baby after birth was delayed and preparedness for resuscitation was minimal. Families believed in delaying breast-feeding till 3 days after birth, when they believed breast milk became available. Even hospital staff discharged the mother and newborn without efforts to initiate breastfeeding. A combination of traditional and modern practices, rooted in the concept of inducing heat to facilitate labor, occurred in both home and facility delivery settings. Programs to improve neonatal survival in such rural settings will need to invest both in strengthening primary health services provided during labor and delivery through training and monitoring, and in community promotion of improved newborn care practices.
Global qualitative nursing research
The aim of this study is to explore women's experiences and perceptions of home use of misopr... more The aim of this study is to explore women's experiences and perceptions of home use of misoprostol and of the self-assessment of the outcome of early medical abortion in a low-resource setting in India. In-depth interviews were conducted with 20 women seeking early medical abortion, who administered misoprostol at home and assessed their own outcome of abortion using a low-sensitivity pregnancy test. With home use of misoprostol, women were able to avoid inconvenience of travel, child care, and housework, and maintain confidentiality. The use of a low-sensitivity pregnancy test alleviated women's anxieties about retained products. Majority said they would prefer medical abortion involving a single visit in future. This study provides nuanced understanding of how women manage a simplified medical abortion in the context of low literacy and limited communication facilities. Service delivery guidelines should be revised to allow women to have medical abortion with fewer visits.
PLOS ONE, Nov 6, 2019
The objectives of the study were to assess the knowledge and skills of medical interns and nurses... more The objectives of the study were to assess the knowledge and skills of medical interns and nurses regarding family planning (FP) services, and document the prevailing FP practices in the teaching hospitals in India.
The Lancet Global Health, 2018
Journal of Interpersonal Violence, May 15, 2017
In India, physical and psychological abuse perpetrated by a mother-in-law against a daughter-in-l... more In India, physical and psychological abuse perpetrated by a mother-in-law against a daughter-in-law is well documented. However, there is a dearth of literature exploring the perceived frequency and acceptability of mother-inlaw abuse or options available for survivors of this type of abuse. The goal of this qualitative study was to add to the in-law abuse literature by exploring men's and women's perspectives about physical and psychological abuse perpetrated by mothers-in-law against daughters-in-law in northern India. Forty-four women and 34 men residing in rural and urban areas of the Udaipur district in the northwest state of Rajasthan participated in semistructured interviews. Women, but not men, thought mother-in-law abuse was common in their communities. Psychological abuse was accepted in certain situations; however, few male or female participants agreed with physical mother-in-law abuse. Men were described as mediators in the context of mother-in-law abuse, and male participants thought that disrespecting a mother-in-law was
Qualitative Health Research, Mar 5, 2014
Intimate partner violence (IPV) is recognized as a serious medical and public health concern for ... more Intimate partner violence (IPV) is recognized as a serious medical and public health concern for women (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). The World Health Organization (WHO) has defined IPV as behavior within an intimate relationship that causes physical, psychological, or sexual harm such as acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors (Heise & Garcia-Moreno, 2002). Although men can be victims of this type of violence, the majority of IPV globally is perpetrated by men against women (Heise, Ellsberg, & Gottemoeller, 1999). Trauma is a common consequence of IPV, but numerous studies also have shown that victims of IPV are at a higher risk for physical and mental health morbidities. These include unwanted pregnancies, pregnancy loss, and sexually transmitted infections, as well as depression, posttraumatic stress disorder, and anxiety (
Journal of Health Population and Nutrition, Jul 20, 2012
The first postpartum week is a high-risk period for mothers and newborns. Very few community-base... more The first postpartum week is a high-risk period for mothers and newborns. Very few community-based studies have been conducted on patterns of maternal morbidity in resource-poor countries in that first week. An intervention on postpartum care for women within the first week after delivery was initiated in a rural area of Rajasthan, India. The intervention included a rigorous system of receiving reports of all deliveries in a defined population and providing home-level postpartum care to all women, irrespective of the place of delivery. Trained nurse-midwives used a structured checklist for detecting and managing maternal and neonatal conditions during postpartum-care visits. A total of 4,975 women, representing 87.1% of all expected deliveries in a population of 58,000, were examined in their first postpartum week during January 2007-December 2010. Haemoglobin was tested for 77.1% of women (n=3,836) who had a postnatal visit. The most common morbidity was postpartum anaemia-7.4% of women suffered from severe anaemia and 46% from moderate anaemia. Other common morbidities were fever (4%), breast conditions (4.9%), and perineal conditions (4.5%). Life-threatening postpartum morbidities were detected in 7.6% of women-9.7% among those who had deliveries at home and 6.6% among those who had institutional deliveries. None had a fistula. Severe anaemia had a strong correlation with perinatal death [p<0.000, adjusted odds ratio (AOR)=1.99, 95% confidence interval (CI) 1.32-2.99], delivery at home [p<0.000, AOR=1.64 (95% CI 1.27-2.15)], socioeconomically-underprivileged scheduled caste or tribe [p<0.000, AOR=2.47 (95% CI 1.83-3.33)], and parity of three or more [p<0.000, AOR=1.52 (95% CI 1.18-1.97)]. The correlation with antenatal care was not significant. Perineal conditions were more frequent among women who had institutional deliveries while breast conditions were more common among those who had a perinatal death. This study adds valuable knowledge on postpartum morbidity affecting women in the first few days after delivery in a low-resource setting. Health programmes should invest to ensure that all women receive early postpartum visits after delivery at home and after discharge from institution to detect and manage maternal morbidity. Further, health programmes should also ensure that women are properly screened for complications before their discharge from hospitals after delivery.
Title Competency assessment of the medical interns and nurses and prevailing practices to provide... more Title Competency assessment of the medical interns and nurses and prevailing practices to provide family planning services in teaching hospitals in three states of India.
Journal of Health Population and Nutrition, Jul 20, 2012
Maternal complications are common during and following childbirth. However, little information is... more Maternal complications are common during and following childbirth. However, little information is available on the psychological, social and economic consequences of maternal complications on women's lives, especially in a rural setting. A prospective cohort study was conducted in southern Rajasthan, India, among rural women who had a severe or less-severe, or no complication at the time of delivery or in the immediate postpartum period. In total, 1,542 women, representing 93% of all women who delivered in the field area over a 15-month period and were examined in the first week postpartum by nurse-midwives, were followed up to 12 months to record maternal and child survival. Of them, a subset of 430 women was followed up at 6-8 weeks and 12 months to capture data on the physical, psychological, social, or economic consequences. Women with severe maternal complications around the time of delivery and in the immediate postpartum period experienced an increased risk of mortality and morbidity in the first postpartum year: 2.8% of the women with severe complications died within one year compared to none with uncomplicated delivery. Women with severe complications also had higher rates of perinatal mortality [adjusted odds ratio (AOR)=3.98, confidence interval (CI) 1.96-8.1, p=0.000] and mortality of babies aged eight days to 12 months (AOR=3.14, CI 1.4-7.06, p=0.004). Compared to women in the uncomplicated group, women with severe complications were at a higher risk of depression at eight weeks and 12 months with perceived physical symptoms, had a greater difficulty in completing daily household work, and had important financial repercussions. The results suggest that women with severe complications at the time of delivery need to be provided regular follow-up services for their physical and psychological problems till about 12 months after childbirth. They also might benefit from financial support during several months in the postpartum period to prevent severe economic consequences. Further research is needed to identify an effective package of services for women in the first year after delivery.
Background Even in countries where abortion is legal, many women suffer mortality and morbidity f... more Background Even in countries where abortion is legal, many women suffer mortality and morbidity from unsafe abortion. When faced with an unwanted pregnancy, women encounter many social, geographical, and health system level barriers in accessing safe abortion. Medical methods are far more amenable to be provided in primary care rural settings, however, in practice, women are required to make multiple clinic visits to receive medical abortion services. Two important measures to reduce the number of clinic visits after an early medical abortion, are eliminating the second visit by allowing home use of misoprostol and eliminating the third visit by allowing women to assess the outcome of their abortion on their own. However, most research on home use of misoprostol and on alternatives to routine clinic follow-up visits has been done in high-income countries or in urban areas of developing countries. There is little evidence on efficacy, safety and acceptability of home use of misoprostol and self-assessment approaches from rural areas of low resource settings. Objectives The aims of this research were: (a) to assess the efficacy, feasibility, safety and acceptability of self assessment as compared to the routine clinic follow-up after early medical abortion, (b) to assess efficacy, safety and acceptability of home administration of misoprostol as compared to clinic use of misoprostol, and (c) to explore women's experiences and perceptions of home use of misoprostol and of self-assessment of outcome of early medical abortion. Methods The study was conducted in southern part of Rajasthan state in India, where 75% population is rural and only about half the women are literate. A randomised controlled, noninferiority trial was conducted at 6 health centres (3 rural, 3 urban) in 2013-14. Women seeking early medical abortion up to 9 weeks gestation were randomly assigned either to routine clinic follow-up or to self-assessment using a low-sensitivity pregnancy test at home. They were contacted through a home visit or phone call, 10-15 days later, to record the outcome of the abortion. The primary outcome was complete abortion without continuing pregnancy or need for surgical evacuation or additional mifepristone /misoprostol. The non-inferiority margin for the risk difference was 5%. Secondary outcomes included safety, feasibility, interim visits, and acceptability. A secondary analysis of the data was carried out to compare the outcomes among women with home and clinic administration of misoprostol. 4.3. Experiences and perceptions of simplified medical abortion (paper IV) 5. Discussion 5.1. How effective, safe, feasible and acceptable is selfassessment as an alternative to clinic follow-up for women having early medical abortion? 5.2. Can women in low resource settings safely administer misoprostol at home for early medical abortion? 5.3. What are experiences and perceptions of women regarding home use of misoprostol and self-assessment? 5.4. Advantages of self-managed medical abortion 5.5. What other measures are needed to simplify medical abortion? 5.6. What is needed to allow task shifting to women in health care? 5.5. Study strengths and limitations 6. Conclusions 7. Practice and policy implications 8. Implications for research 9. Acknowledgements 10. References vii
Acceptability and feasability of home assessment using low-sensitivity pregnancy test in a low re... more Acceptability and feasability of home assessment using low-sensitivity pregnancy test in a low resource setting Rajasthan, India
Qualitative Health Research, Mar 15, 2016
Although more maternal deaths occur in the postpartum period, this period receives far less atten... more Although more maternal deaths occur in the postpartum period, this period receives far less attention from the program managers. To understand how the women and their families perceive postpartum health problems, the culturally derived restrictions, and precautions controlling diets and behavior patterns, we conducted a mixed-method study in Rajasthan, India. The study methods included free listing of maternal morbidity conditions, interviews with 81 recently delivered women, case interviews with eight cases of huwa rog (postpartum illness), and interviews with nine key informants. The study showed that huwa rog refers to a broad category of serious postpartum illness, thought to affect women a few weeks to several months after delivery. Prevention of the illness involves a system of precautions referred to as parhej, which includes a distinctive set of “medicinal dietary items” referred to as desi dawai, or “country medicine,” and restrictions about mobility and work patterns of a postpartum woman. This cultural framework around the concept of huwa rog and peoples’ beliefs about it are of central importance for planning postpartum health interventions, including place of contact and communication messages.
BMC Women's Health, May 25, 2017
Background: Despite being legally available in India since 1971, barriers to safe and legal abort... more Background: Despite being legally available in India since 1971, barriers to safe and legal abortion remain, and unsafe and/or illegal abortion continues to be a problem. Community health workers have been involved in improving access to health information and care for maternal and child health in resource poor settings, but their role in facilitating accurate information about and access to safe abortion has been relatively unexplored. A qualitative study was conducted in Rajasthan, India to study acceptability, perspectives and preferences of women and community health workers, regarding the involvement of community health workers in medical abortion referrals. Methods: In-depth interviews were conducted with 24 women seeking early medical abortion at legal abortion facilities or presenting at these facilities for a follow-up assessment after medical abortion. Ten community health workers who were trained to assess eligibility for early medical abortion and/or to assess whether women needed a follow-up visit after early medical abortion were also interviewed. The transcripts were coded using ATLAS-ti 7 (version 7.1.4) in the local language and reports were generated for all the codes, emerging themes were identified and the findings were analysed. Results: Community health workers (CHWs) were willing to play a role in assessing eligibility for medical abortion and in identifying women who are in need of follow-up care after early medical abortion, when provided with appropriate training, regular supplies and job aids. Women however had apprehensions about contacting CHWs in relation to abortions. Important barriers that prevented women from seeking information and assistance from community health workers were fear of breach of confidentiality and a perception that they would be pressurised to undergo sterilisation. Conclusions: Our findings support a potential for greater role of CHWs in making safe abortion information and services accessible to women, while highlighting the need to address women's concerns about approaching CHWs in case of unwanted pregnancy. Further intervention research would be needed to shed light on the effectiveness of role of CHWs in facilitating access to safe abortion and to outline specific components in a programme setting. Trial registration: Not applicable.
The Lancet Global Health, Jun 1, 2016
Reproductive Health Matters, 2000
High unmet need for limiting contraception persists in most states of India despite wide access t... more High unmet need for limiting contraception persists in most states of India despite wide access to sterilisation. Qualitative evidence from a rural community in which child mortality is high and women's autonomy is low suggests that women may seek reversibility in a contraceptive even if they have finished childbearing. This paper describes the introduction of the Copper-T 380A--a contraceptive with an effective life span of ten years--as an alternative to female sterilisation in a rural area of the state of Rajasthan, in a clinic linked to an outreach programme. The intervention addressed women's apprehensions, ensured service standards and guaranteed women's right to have the Copper-T removed at will. Data on 216 insertions over 34 months revealed a preference for the Copper-T 380A among older women and women who had achieved desired family size, especially among tribal women. More than a quarter of the 30 removals in that period were for non-medical reasons, such as family opposition, child death or remarriage. As a long-term but reversible option, the Copper-T 380A allows women room to change their minds in relation to future childbearing until they have reached menopause. Including this option in family planning services can help to meet a portion of the unmet need for contraception among women not willing to choose sterilisation, while reducing dependence on doctors and expensive equipment.
Global Health: Science and Practice
In the study medical schools, we observed providers using several harmful or unnecessary practice... more In the study medical schools, we observed providers using several harmful or unnecessary practices on pregnant women in labor, including routine pubic shaving, enema on admission, routine episiotomy, application of fundal pressure, delivery in the lithotomy position, and unindicated augmentation. n Barriers to adherence to the recommended evidencebased intrapartum practices included fear of perineal tear/injury to the baby in different birthing positions; lack of physical space, resources, and time; and outdated knowledge and beliefs of faculty and labor room staff.
The Lancet Global Health, 2015
Can women themselves assess the outcome of an early medical abortion as safely and effectively as... more Can women themselves assess the outcome of an early medical abortion as safely and effectively as a clinic follow-up visit? : A randomised controlled, non-inferiority trial in India
Journal of Perinatology, 2008
In a rural community of Rajasthan in north India, we explored family, community and provider prac... more In a rural community of Rajasthan in north India, we explored family, community and provider practices during labor and childbirth, which are likely to influence newborn health outcomes. A range of qualitative datagathering methods was applied in two rural clusters of Udaipur district. This paper reports on the key findings from eight direct observations of labor and childbirth at home and in primary health facilities, as well as 10 focus group discussions, 18 case interviews with recently delivered women and 39 key informant interviews carried out within the community. Although most families preferred home delivery, health-facility deliveries were preferred for first births, especially among adolescents. A team of birth attendants led by a traditional birth attendant or an elder female relative took decisions and performed key functions during home childbirth. Modern providers were commonly invited to administer intramuscular oxytocin injections to hasten home delivery, whereas health staff tended to do the same during facility deliveries. The practice of applying forceful fundal pressure, stemming from overriding concern about the woman's inability to deliver spontaneously, was near universal in both situations. In both facilities and homes, monitoring of labor was largely restricted to repeated unhygienic vaginal examinations with little or no monitoring of fetal or maternal well-being. Babies born at home remained lying on the wet floor till the placenta was delivered. The cord was usually tied using available twine or ceremonial thread and cut using a new blade. In facility settings, drying and wrapping of the baby after birth was delayed and preparedness for resuscitation was minimal. Families believed in delaying breast-feeding till 3 days after birth, when they believed breast milk became available. Even hospital staff discharged the mother and newborn without efforts to initiate breastfeeding. A combination of traditional and modern practices, rooted in the concept of inducing heat to facilitate labor, occurred in both home and facility delivery settings. Programs to improve neonatal survival in such rural settings will need to invest both in strengthening primary health services provided during labor and delivery through training and monitoring, and in community promotion of improved newborn care practices.
Global qualitative nursing research
The aim of this study is to explore women's experiences and perceptions of home use of misopr... more The aim of this study is to explore women's experiences and perceptions of home use of misoprostol and of the self-assessment of the outcome of early medical abortion in a low-resource setting in India. In-depth interviews were conducted with 20 women seeking early medical abortion, who administered misoprostol at home and assessed their own outcome of abortion using a low-sensitivity pregnancy test. With home use of misoprostol, women were able to avoid inconvenience of travel, child care, and housework, and maintain confidentiality. The use of a low-sensitivity pregnancy test alleviated women's anxieties about retained products. Majority said they would prefer medical abortion involving a single visit in future. This study provides nuanced understanding of how women manage a simplified medical abortion in the context of low literacy and limited communication facilities. Service delivery guidelines should be revised to allow women to have medical abortion with fewer visits.