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Impact of an integrated nutrition and health programme on neonatal mortality in rural northern India

Abdullah H Baqui ^a, Emma K Williams ^a, Amanda M Rosecrans ^a, Praween K Agrawal ^a, Saifuddin Ahmed ^b, Gary L Darmstadt ^a, Vishwajeet Kumar ^a, Usha Kiran ^c, Dharmendra Panwar ^c, Ramesh C Ahuja ^d, Vinod K Srivastava ^d, Robert E Black ^a, Manthuram Santosham ^a

Introduction

The neonatal period is recognized as a brief, critical time that requires focused interventions to reach the Millennium Development Goal of a two-thirds reduction in child mortality by 2015. In India there are one million neonatal deaths every year, representing approximately a quarter of all global neonatal deaths.^1,2 Neonatal deaths account for about 38% of the annual 10.6 million child deaths recorded worldwide and nearly half of the deaths in children under 5 years in India.^1,3

In developing countries, the primary causes of neonatal deaths are infections (36%), complications of preterm birth (28%) and birth asphyxia (23%), with low birth weight as the primary contributory cause.¹ High coverage of a few simple and cost-effective interventions would reduce neonatal mortality.^4–7 Interventions at the family and community level can save lives, especially where health systems are weak.^4,8 Several community-based efficacy trials have evaluated service delivery strategies to improve newborn survival.^7,9–16 Those trials were conducted under controlled conditions to ensure high programme coverage and usually employed workers who delivered only the intervention being studied. However, population-level data on the impact of family and community-based neonatal care from large-scale programmes is scarce. A need exists to implement proven interventions at scale, across the continuum of care, without losing impact.

Here, we evaluate the effect of a community-based package of maternal and newborn interventions that was implemented at scale using existing government infrastructure through an integrated nutrition and health programme in eight states of India. This evaluation was conducted in two rural districts of the state of Uttar Pradesh, India.

Methods

Programme description

The Integrated Nutrition and Health Programme (INHP) was a partnership of an international nongovernmental organization (NGO), CARE-India, with the Indian government and local NGOs. The programme was implemented through the infrastructure of the government’s Ministry of Women and Child Development’s Integrated Child Development Services and the Ministry of Health and Family Welfare (Fig. 1). The newborn care package aimed to increase the frequency of behaviours during the antenatal, delivery and postnatal periods that have proven benefits for maternal and newborn survival (Table 1). The INHP also included interventions to improve immunization rates and the nutritional status of childbearing women and children under the age of 5 years; these interventions were evaluated separately.

Fig. 1. Conceptual model for promotion of newborn care within the INHP

anganwadi, government child-care and mother-care centre; ICDS, Integrated and Development Services; INHP, Integrated Nutrition and Health Programme; MOHFW, Ministry of Health and Family Welfare; NGO, nongovernmental organization.

In both the INHP and standard government health services, health education and services are provided by two groups of government functionaries: auxiliary nurse-midwives, and maternal and child health promotion (anganwadi) workers. Auxiliary nurse-midwives work in health centres that serve a rural population of about 5000 people. They make home visits to promote home care and care-seeking, attend deliveries, provide immunization and encourage use of family planning methods. Anganwadi workers serve one village (a population of approximately 1000) and operate a facility called an anganwadi centre. They promote maternal, newborn and child health from fixed sites and through home visits, distribute supplementary food to poor families, and provide preschool education.^17–19 The INHP encouraged anganwadi workers to recruit community volunteers called “change agents” to further improve the reach of programmes. The anganwadi workers, auxiliary nurse-midwives, and change agents in the intervention district received a total of 6 days of training on the care of mothers and newborn babies; as a group, we refer to them as community-based workers. In the INHP, information to encourage behaviour change was usually communicated during antenatal and postnatal home visits by the community-based workers (Table 1).

• Table 1. Intervention components of the neonatal care package
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Study location, population and design

Although the programme was implemented in eight states, we collected data from Uttar Pradesh state only. A quasi-experimental design was used and the study design, data collection and analysis were conducted by a team of independent researchers who were not involved in the implementation of the intervention. Two of the authors of this paper (UK and DP) were involved in programme implementation.

One INHP district, Barabanki, served as the intervention district, while a district receiving standard government health and Integrated Child Development Services, Unnao, was used as a comparison district. From the 15 rural blocks in each district, we used a computer programme to randomly select nine blocks in the intervention district and eight blocks in the comparison district (the difference in the number of blocks selected was due to differences in population size of the blocks in Barabanki and Unnao). One sector, an area with 15–25 anganwadi centres and an estimated population of 20 000 to 25 000 people, was randomly selected from each of the selected blocks. The sample size was calculated to detect a 20% reduction in neonatal mortality following the intervention with 80% power at a 5% significance level.

A baseline household survey was conducted between January and June 2003 to establish rates of programme coverage, maternal knowledge and practices, and neonatal mortality. The newborn component of INHP began in July 2003. Household surveys were repeated at the end of the project, between January and March 2006. All households in the selected sectors were included in both surveys; respondents were women who had had a live birth or stillbirth within the reference period: calendar years 2001–2002 for baseline and 2004–2005 for endline. Only live births were included in this analysis. Data collection included information on household and maternal characteristics, exposure to the intervention, maternal and newborn care practices, and pregnancy history.

Data collection was contracted out to an independent survey research agency (TNS India), which recruited data collectors with at least a 10th grade education who were fluent in the local language and dialect. The data collectors received 7 days of didactic training and 3 days of field practice and were deployed only if they qualified in a post-training test. In addition to the agency’s data quality assurance, investigators set up an independent data quality assurance system that included re-interviewing 5% of households, weekly comparisons of original and re-interview data to identify disagreements, and additional field visits and training to data collectors to resolve discrepancies.

Statistical analysis

Descriptive statistics were calculated with use of standard methods. A household standard-of-living index was constructed as an additive scale of household assets using the same methodology as in India’s National Family Health Survey (NFHS).²⁰ Scores were created by assigning points for household type, sanitation facilities, electricity and water supply, ownership of land and livestock, and household goods. Labels of low, medium and high were assigned based on NFHS categories. χ² analysis was used to test for homogeneity of household socioeconomic and demographic factors and maternal characteristics between the intervention and comparison districts at baseline and endline.

All indicators of exposure to the intervention and behaviour change were based on survey respondents’ self-report. Programme coverage was considered as the proportion of women who reported being visited at home by either an auxiliary nurse-midwife, anganwadi worker or change agent during pregnancy (antenatal coverage) and during the first 28 days after delivery (postnatal coverage). Qualified doctors, nurses, lady health visitors and auxiliary nurse-midwives were considered skilled providers for antenatal, delivery and newborn care. Women were deemed to have had a skilled birth attendant if they reported giving birth at a government, NGO or private health facility or if a skilled provider attended their home delivery. Intervention exposure and behaviour change indicators were analysed using a difference-in-difference test to compare the change from baseline to endline for intervention versus comparison districts.²¹ Linear probability regression models were used with interaction terms for time (baseline versus endline) and intervention district to test the null hypothesis that the difference-in-difference equals zero, controlling for maternal age, education, parity, religion and standard-of-living score. Logistic models were not used due to the problem of using them with interaction terms.²²

Neonatal deaths were those that occurred within 28 days of a live birth. Neonatal mortality rates – i.e. number of neonatal deaths per 1000 live births – were calculated separately for intervention and comparison districts and 95% confidence intervals (CIs) were calculated with binomial estimation method for a variance of proportion.

Neonatal mortality rates were also calculated after stratification by antenatal and postnatal home visitation status, combining data from both districts. The rates were then adjusted using direct standardization²³ to account for differences in maternal age, education, parity, religion and standard-of-living score. Using coefficients from adjusted logistic regression, we estimated the marginal changes in neonatal mortality for various levels of coverage of antenatal and postnatal home visits. The effect of antenatal visits was assessed by varying the antenatal coverage levels from 0% to 100% assuming no postnatal visits had occurred. Coverage of postnatal visitation within 28 days was varied between 0% and 100% keeping antenatal coverage at the same level. For example, if postnatal coverage was estimated at 50%, we estimated that antenatal coverage was also 50%. We used Stata, version 8 (StataCorp. LP, College Station, TX, United States of America) for statistical analysis.²⁴

Results

Baseline sociodemographic characteristics of study participants are shown in Table 2. Increases in coverage were measured in the intervention district for the proportion of women who received only an antenatal home visit (from 14% to 22%) and the proportion who received an antenatal and a postnatal visit within 28 days (from 2% to 34%), while these indicators showed little change in the comparison district (P < 0.001; Table 3). At endline, coverage of antenatal visits was 56% for the intervention district and 21% for the comparison district, while coverage of postnatal visits within 28 days was 39% for the intervention district and 6% for the comparison district. Those who received a home visit were slightly more likely to be Hindu, or to have a middle or high standard of living; these differences were adjusted for in subsequent analyses.

The behaviours that were promoted through the programme showed greater increases in frequency in the intervention district than in the comparison district, after controlling for maternal and household characteristics, although the size of the changes varied (Table 3). For example, the proportion of households that practiced clean cord care more than doubled in the intervention district (from 32% at baseline to 68% at endline), while coverage of skilled birth attendance increased from 16% to 22%.

Adjusted baseline neonatal mortality rates did not differ between the intervention (46.4 deaths per 1000 live births, 95% CI: 42.0–50.8) and comparison districts (45.8 deaths per 1000 live births, 95% CI: 40.6–51.0) and showed no evidence of change from baseline to endline (Table 4). At endline, neonates of women in both districts who received a visit from a community-based worker during the antenatal period only, did not have a lower neonatal mortality rate (54.0 deaths per 1000 live births, 95% CI: 45.9–62.1) than those of women who received no visit (53.8 deaths per 1000 live births, 95% CI: 48.9–58.8; Table 4). However, in the group of women who received a postnatal visit within 28 days, the neonatal mortality rate of 35.7 deaths per 1000 live births (95% CI: 29.2–42.1) was significantly lower than that in the group who received either no visit (53.8, 95% CI: 48.9–58.8) or only an antenatal visit (54.0, 95% CI: 45.9–62.1). Women who received a postnatal visit within 3 days of delivery had a 25% lower neonatal mortality rate than did those who received no visit, which was also statistically significant (Table 4). Since neonates who died in the first few hours of life might have a lower probability of receiving a postnatal visit, we repeated the analysis excluding deaths that occurred on the day of birth. In this subset, the reduction due to postnatal visits was still statistically significant at 28%, compared to those who received no antenatal or postnatal visit (data not shown).

The predicted model indicated that increasing coverage of antenatal and postnatal visits during the first 28 days from 10% to 50%, would reduce the neonatal mortality rate by 19%; increasing coverage from 10% to 90% would yield a 34% reduction (Fig. 2; available at: http://www.who.int/bulletin/volumes/10/07-042226/en/index.html).

Fig. 2. Predicted neonatal mortality rates varying antenatal and postnatal programme coverage equally^a

^a Using coefficients from adjusted logistic regression, the marginal changes in neonatal mortality were estimated for various levels of coverage of antenatal and postnatal home visits; the effect of antenatal visits was assessed by varying the antenatal coverage levels from 0% to 100% assuming no postnatal visitation. Coverage of postnatal visitation within 28 days was varied between 0% and 100% keeping antenatal coverage at the same level. For example, if postnatal coverage was estimated at 50%, antenatal was also estimated at 50%.

• Table 2. Selected maternal and household characteristics of recently delivered women by study district: baseline (2001–2002) and endline (2004–2005) surveys
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• Table 3. Programme exposure and behaviour change in recently delivered women by study district: baseline (2001–2002) and endline (2004–2005)
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• Table 4. Neonatal mortality rate by study district and by postnatal visit status: baseline (2001–2002) and endline (2004–2005) surveys
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Discussion

We have shown that an INHP with a newborn component increased coverage of antenatal and postnatal health-promotion visits, and improved some neonatal-care practices. However, most of the gain in coverage was in the antenatal period, and fewer than one in four neonates received a home visit within the crucial first 3 days of life, when half of all neonatal deaths occurred.²⁵ Moreover, only three of the selected behaviours – receiving two tetanus toxoid immunizations, saving money for childbirth and maintaining clean cord care – were adopted by most women in the intervention district.

Although the programme failed to reduce neonatal mortality, those women who received a postnatal visit were significantly less likely to have their neonate die, and our simulation analysis suggested that 90% programme coverage with an antenatal visit and a postnatal home visit within the first 28 days could reduce the neonatal mortality rate by 34% from baseline.

Most of the reduction in mortality was in the group who were visited within the first 3 days of birth. To check for survivor bias, we re-analysed the data excluding babies who died on the first day of life and noted that the effect on mortality remained statistically significant. The effect of postnatal visits on rates of neonatal deaths was most likely due to promotion of essential newborn care practices including early and exclusive breastfeeding, thermal care and clean cord care as well as through identification and referral of neonates with signs of illness. Because the number of women who received a postnatal visit but no antenatal visit was so small, our ability to draw conclusions about the effect of a postnatal visit without a preceding antenatal visit was hampered; however, in practice antenatal visits would be necessary to establish contact with pregnant women to plan for postnatal visits.

To our knowledge, this is the first study to assess the impact on mortality of a large-scale community-based neonatal health programme implemented with use of multipurpose government health workers. Few large-scale programmes are rigorously evaluated with mortality as the outcome. Furthermore, our study was conducted by a team that was independent of programme implementation. This study shows the value of large-scale programme evaluations and our findings reinforce the need to not only validate existing methods but also develop new methods to assess the quality, coverage, and impact of programmes.

This study has limitations. Although CARE-India implemented the INHP at scale in 70 districts of eight states of India, this evaluation was conducted only in Uttar Pradesh. A quasi-experimental design was selected because a cluster-randomized trial was not feasible. Assessment of behaviours was based on respondents’ report, which might have led to some recall error. However, an independent data quality-assurance system was established to improve data quality, and the rate of recall error should not have differed between the intervention and comparison groups.

Most deaths in children younger than 5 years – including neonatal deaths – could be prevented if simple, proven interventions were implemented at scale.^4,6 Our simulation analysis finding was consistent with modelled results from the Lancet Neonatal Survival Series, which suggested that a package of family-community care at 90% coverage could reduce neonatal mortality by 18–37%.⁴ Seminal work on child health and nutrition in rural India also showed an inverse relationship between the intensity of services received from auxiliary health workers and mortality rates.²⁶ The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) also found varying degrees of effectiveness,^27–31 largely due to variations in the health system contexts and how well the programme had been implemented.³² While the training of health workers improved quality of care,^28,31,33 coverage of community activities remained low and researchers noted little effect on care-seeking or health services coverage.^8,29–31 In previous evaluations of programmes from the Integrated Child Development Services, nutritional supplementation to children and mothers was increased, but only to 53% and 26%, respectively, after almost 10 years of implementation.¹⁷ By comparison, coverage of childhood immunization reached more than 60% after 5 years.³⁴

We suspect that the lack of a population-level effect on mortality was related to the degree of scale-up of the intervention. The intervention was scaled up to an extent in that the community-based workers were present throughout the study area, and 43% of auxiliary nurse-midwives, 91% of anganwadi workers and 98% of the change agents received the training in neonatal care. However, scale-up was limited in the sense that coverage was not as good as it could have been.

Through interviews with programme managers and community-based workers, we identified that the workers’ competency in the new neonatal component of the programme, their workload and inadequate management and supervision were possible barriers to higher coverage. CARE-India conducted an evaluation and noted that change agents’ reach was lower than expected. Further, they identified that anganwadi workers and auxiliary nurse-midwives needed simple systems to prioritize their competing job priorities, more frequent and effective field supervision and more intensive trainings with better field-based assessment of skills.³⁵

Reaching newborn babies at the community level is crucial in settings where the availability and utilization of facility-based care is low. While the training of multipurpose health and nutrition workers in essential newborn care is necessary, systems must also be put in place to ensure that these workers visit neonates at home during the first hours and days after birth and that they can provide a link to competent health services. ■

Acknowledgements

We thank the residents of the study districts who gave their time generously; the Government of India and CARE-India colleagues for their cooperation and support; and special thanks to Massee Bateman and Neal Brandes of the United States Agency for International Development (USAID) for their support, valuable insights and guidance. The study would not have been possible without the hard work and dedication of project staff of CARE-India, TNS India and the Johns Hopkins University.

Funding: This project was funded by USAID, India Mission, through Global Research Activity Award # HRN-A-00-96-90006-00 to the Johns Hopkins Bloomberg School of Public Health.

Competing interests: Usha Kiran and Dharmendra Panwar managed the intervention but were not directly involved in the evaluation. All other authors declare no conflict of interest.

References

• Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891-900 doi: 10.1016/S0140-6736(05)71048-5 pmid: 15752534.
• Improving neonatal health in south-east asia region: report of a regional consultation. New Delhi: WHO; 2002.
• Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226-34 doi: 10.1016/S0140-6736(03)13779-8 pmid: 12842379.
• Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005; 365: 977-88 doi: 10.1016/S0140-6736(05)71088-6 pmid: 15767001.
• Darmstadt GL, Lawn JE, Costello A. Advancing the state of the world’s newborns. Bull World Health Organ 2003; 81: 224-5 pmid: 12764520.
• Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet 2003; 362: 65-71 doi: 10.1016/S0140-6736(03)13811-1 pmid: 12853204.
• Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics 2005; 115: 519-617 pmid: 15866863.
• Bryce J, Arifeen SE, Pariyo G, Lanata C, Gwatkin D, Habicht JP. Reducing child mortality: can public health deliver? Lancet 2003; 362: 159-64 doi: 10.1016/S0140-6736(03)13870-6 pmid: 12867119.
• Bang AT, Bang RA, Reddy HM. Home-based neonatal care: summary and applications of the field trial in rural Gadchiroli, India (1993 to 2003). J Perinatol 2005; 25: S108-22 doi: 10.1038/sj.jp.7211278 pmid: 15791272.
• Bartlett AV, Paz de Bocaletti ME, Bocaletti MA. Neonatal and early postneonatal morbidity and mortality in a rural Guatemalan community: the importance of infectious diseases and their management. Pediatr Infect Dis J 1991; 10: 752-7 pmid: 1945577.
• Berggren GG, Berggren W, Verly A, Garnier N, Peterson W, Ewbank D, et al., et al. Traditional midwives, tetanus immunization, and infant mortality in rural Haiti. Trop Doct 1983; 13: 79-87 pmid: 6679403.
• Daga SR, Daga AS, Dighole RV, Patil RP, Dhinde HL. Rural neonatal care: Dahanu experience. Indian Pediatr 1992; 29: 189-93 pmid: 1592499.
• Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al., et al. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004; 364: 970-9 doi: 10.1016/S0140-6736(04)17021-9 pmid: 15364188.
• Pratinidhi A, Shah U, Shrotri A, Bodhani N. Risk approach strategy in neonatal care. Bull World Health Organ 1986; 64: 291-7 pmid: 3488845.
• Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005; 352: 2091-9 doi: 10.1056/NEJMsa042830 pmid: 15901862.
• Darmstadt G, Kumar V, Mohanty S, Kumar A, Mishra R, Santosham M, et al., et al. Impact of community-based behaviour change management on neonatal mortality: a cluster-randomized, controlled trial in Shivgarh, Uttar Pradesh, India. Lancet 2008.
• Avsm YS, Gandhi N, Tandon BN, Krishnamurthy KS. Integrated Child Development Services Scheme and nutritional status of Indian children. J Trop Pediatr 1995; 41: 123-8 pmid: 7776397.
• Nanda P. Female health workers – responsibilities and constraints. Health Millions 1993; 1: 25-6 pmid: 12286354.
• Tandon BN, Ramachandran K, Bhatnagar S. Integrated child development service in India: evaluation of the delivery of nutrition and health services and the effect on the nutritional status of the children. Indian J Med Res 1981; 73: 385-94 pmid: 7275234.
• National Family Health Survey-II (NFHS-II) 1989-1999. Mumbai: International Institute for Populations Sciences and ORC-Macro; 2001.
• Ganzach Y, Saporta I, Weber Y. Interaction in linear versus logistic models: a substantive illustration using the relationship between motivation, ability, and performance. Organ Res Methods 2000; 3: 237-52 doi: 10.1177/109442810033002.
• Ai C, Norton EC. Interaction terms in logit and probit models. Econ Lett 2003; 80: 123-9 doi: 10.1016/S0165-1765(03)00032-6.
• Rothman K. Epidemiology: an introduction. New York: Oxford University Press; 2002.
• Stata Statistical Software. Release 8. College Station, TX: StataCorp. LP; 2003.
• Baqui AH, Darmstadt GL, Williams E, Kumar V, Kiran T, Panwar D, et al., et al. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bull World Health Organ 2006; 84: 706-13 doi: 10.2471/BLT.05.026443 pmid: 17128340.
• Kielmann AA, Taylor CE, Parker RL. The Narangwal Nutrition Study: a summary review. Am J Clin Nutr 1978; 31: 2040-57 pmid: 102180.
• Ali M, Asefaw T, Byass P, Beyene H, Pedersen FK. Helping northern Ethiopian communities reduce childhood mortality: population-based intervention trial. Bull World Health Organ 2005; 83: 27-33 pmid: 15682246.
• El Arifeen S, Blum LS, Hoque DM, Chowdhury EK, Khan R, Black RE, et al., et al. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study. Lancet 2004; 364: 1595-602 doi: 10.1016/S0140-6736(04)17312-1 pmid: 15519629.
• Huicho L, Davila M, Campos M, Drasbek C, Bryce J, Victora CG. Scaling up integrated management of childhood illness to the national level: achievements and challenges in Peru. Health Policy Plan 2005; 20: 14-24 doi: 10.1093/heapol/czi002 pmid: 15689426.
• Huicho L, Davila M, Gonzales F, Drasbek C, Bryce J, Victora CG. Implementation of the Integrated Management of Childhood Illness strategy in Peru and its association with health indicators: an ecological analysis. Health Policy Plan 2005; 20: i32-41 doi: 10.1093/heapol/czi052 pmid: 16306067.
• Bryce J, Victora CG, Habicht JP, Black RE, Scherpbier RW. Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness. Health Policy Plan 2005; 20: i5-17 doi: 10.1093/heapol/czi055 pmid: 16306070.
• Victora CG, Schellenberg JA, Huicho L, Amaral J, El Arifeen S, Pariyo G, et al., et al. Context matters: interpreting impact findings in child survival evaluations. Health Policy Plan 2005; 20: i18-31 doi: 10.1093/heapol/czi050 pmid: 16306066.
• Armstrong Schellenberg J, Bryce J, de Savigny D, Lambrechts T, Mbuya C, Mgalula L, et al., et al. The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania. Health Policy Plan 2004; 19: 1-10 doi: 10.1093/heapol/czh001 pmid: 14679280.
• Tandon BN, Gandhi N. Immunization coverage in India for areas served by the Integrated Child Development Services programme. The Integrated Child Development Services Consultants. Bull World Health Organ 1992; 70: 461-5 pmid: 1394779.
• Rachna program 2001-2006: summary of approaches and results. New Delhi: Care; 2007. pp. 1-46.

Affiliations

• Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, United States of America (USA).
• Department of Population and Family Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
• CARE-India, New Delhi, India.
• King George Medical University, Lucknow, India.