Publications by Dr. Sandul Yasobant
Background: In Gujarat, India, a state led public private partnership scheme to promote facility ... more Background: In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat.
Background: Prevalence of polyneuropathy in the general population has been estimated to be 2.1% ... more Background: Prevalence of polyneuropathy in the general population has been estimated to be 2.1% globally, with gigantic morbidities. One of the rare predictor is an organo-phosphate compound called Tricresyl Phosphate (TCP). In India, TCP exposure happens through traditional food preservation practices (i.e. Castro Oil with Wheat). Thus, this study aims to document the incidence of polyneuropathy and it's underneath factors in one of the block of Gujarat, India.
Health promotion is a prevention strategy that allows people to manage and improve their overall ... more Health promotion is a prevention strategy that allows people to manage and improve their overall health status. In the last few decades, there has been a call for reorientation of health services towards health promotion and prevention. As one of the many stakeholders, the physiotherapy profession needs to clearly define its role in the preventive health care system and establish the scope and boundaries of its role in multidisciplinary teamwork. Further linking of health promotion with physiotherapy could be one step in attaining this goal. Physiotherapists should become role models in looking at the big picture and should have confidence in addressing broader health issues in developing nations like India.
Background: Health advocacy is vital for the attainment of better health outcomes. First step in ... more Background: Health advocacy is vital for the attainment of better health outcomes. First step in the process of advocacy is to identify the problems followed by potential interventions. Along with the need of advocacy, one needs to understand and recognize that the sustainability and effectiveness of any program can be enhanced only by the commitment of policymakers. Keeping this background, this study tried to document that, how advocacy works to make a health system responsive to control diabetes burden in one of the western Indian state, Gujarat.
Background: About 60% of institutional births occur in the private sector in Gujarat due to limit... more Background: About 60% of institutional births occur in the private sector in Gujarat due to limited availability of obstetricians in the government. Chiranjeevi Yojana (CY), a voucher-like program initiated in 2007, accredits private obstetricians who are reimbursed by the state government to provide free delivery care to eligible women i.e. below poverty line and tribal. One million women have delivered under the CY program yet there are no large community based studies of the program. Methodology of a prospective community study is described here. Methods/Designs: A prospective cohort study was done in 142 villages across 3 districts in Gujarat between July, 2013 and November, 2014. A detailed survey was done by trained researchers to ascertain maternal healthcare information including antenatal, in-tra-partum and post-partum care, place of delivery, birth outcomes, out of pocket expenses etc. Results: 54,955 households were surveyed. 73% of all households had poverty documentation. 4274 mothers who delivered in the study period were included. Discussion: This paper is description of the methodology of a large community based survey and household and individual level characteristics. The survey was nested in a larger project to evaluate the CY program in the state of Gujarat.
Background: Diabetes mellitus (DM) is recognized as an important cause of premature death and dis... more Background: Diabetes mellitus (DM) is recognized as an important cause of premature death and disability globally. In India, about 50.9 million people suffer from diabetes and this figure is likely to go upto 80 million by 2025, making it the "Diabetic Capital" of the world. Evidences signposts that appropriate health education program could improve the knowledge of diabetic patients and change their attitude. Therefore, this study aims to document the baseline knowledge about diabetes; followed which an intervention and change in knowledge level among Type-2 diabetes patients in Gujarat, India.
Background: Worldwide there are more than 1.2 billion adolescent ; more than half of all adolesce... more Background: Worldwide there are more than 1.2 billion adolescent ; more than half of all adolescents live in Asia and India has the highest adolescent population than any other country. Adolescents face a range of health challenges; contributing to increased morbidity and mortality. However, the comprehensive data on status of morbidity are scarce. Present study assesses nutritional status of adolescents attended Adolescent Health Day (AHD) in one of the taluka of Gujarat.
Background: Work-related musculoskeletal disorders (WMSDs) are responsible for morbidity in many ... more Background: Work-related musculoskeletal disorders (WMSDs) are responsible for morbidity in many working populations, which are of multifactorial in origin and of global concern due to industrialization. Dentists as one of the health-care professionals are prone to develop these WMSDs. The study aims to determine the prevalence of WMSDs among dentists in Bhopal region and explores the various risk factors for the development of MSDs and WMSDs. Materials and Methods: This proposed study is a cross-sectional study conducted among dentists of two randomly selected dental colleges of Bhopal, India. A structured questionnaire was used to collect the demographic information, occupational history, risk factors, and ergonomic awareness with job task details. Prevalidated standardized tools such as quick exposure check list, rapid entire body assessment score sheet, and Nordic Musculoskeletal Questionnaire were also used. Data were entered in MS-Excel and analyzed through SPSS version 18. Results: More than 92% of the participants reported pain and discomfort in at least one part of their body. The major affected body part is neck, followed by the lower back and wrist. More than half of the orthodontists and oral surgeons reported that their MSDs are work-related origin. Pearson's correlation test indicated that there is a positive correlation between the current exposure and risk (r = 0.613). Multivariate regression analysis found that younger participants, male (OR = 4.1), involved physical activity (OR = 1.04), dentists not taught about ergonomics in their dental school (OR = 1.69) or never attended any workshops (OR = 1.38), who reported task involving sustained muscle contraction (OR = 1.12) or task with repetitive movements (OR = 1.11) are the major risk factors for the development of MSDs among the dentists. Conclusion: This risk assessment study found that there is a high prevalence of MSDs and WMSDs among dentists. Ergonomic awareness and health promotion need to be integrated with the professional practice for dentists.
Background: Waste management is a necessary activity around the world, but involves a variety of ... more Background: Waste management is a necessary activity around the world, but involves a variety of health hazards. In a developing country like India, municipal solid waste is collected manually requiring heavy physical activity. Among all occupational health issues, musculoskeletal problems are common among waste collectors in the form of nonfatal injuries because of the presence of such risk factors (lifting, carrying, pulling, and pushing). We have thus conducted this study to evaluate musculoskeletal disorders (MSDs) among municipal solid waste (MSW) workers. Methodology: A cross-sectional study using probability proportionate to size sampling, recruited 220 MSW workers from the Chennai Municipal Corporation, India for this study. A pretested validated questionnaire has been used to collect data on demographic and occupational history and information on musculoskeletal pain. Data analysis was performed using R software (3.0.1 version). Results: 70% of the participants reported that they had been troubled with musculoskeletal pain in one or more of the 9 defined body regions during the last 12 months, whereas 91.8% had pain during the last 7 days. Higher prevalence of symptoms in knees, shoulders, and lower back was found to be 84.5%, 74.5%, and 50.9% respectively. Female illiterate workers with lower socioeconomic status were found to have higher odds for MSDs. Similarly, higher body mass index having no physical activity increases the chance of odds having MSDs. Conclusion: The higher percentage of musculoskeletal symptoms among MSW workers could be attributed to the long duration of employment, the low job control, and the nature of their job, which is physically demanding. A workplace of health promotion model integration can minimize the reported high prevalence, and a prospective cohort study could be recommended further.
Background: Dengue is an infectious disease associated with high mortality and morbidity. Being a... more Background: Dengue is an infectious disease associated with high mortality and morbidity. Being a viral disease, there is no specific drug available for treatment. There are some reports that Carica papaya leaf extract may improve the clinical condition of dengue patients; however, to support this, at present, there is no systematically searched and synthesized evidence available. Objectives: This systematic review and meta‑analysis was designed to search the available evidence related to the efficacy and safety of C. papaya leaf extract in dengue and to synthesize the evidence in meaningful form through meta‑analysis so that inference can be drawn. Materials and Methods: Randomized controlled trials related to the efficacy and safety of C. papaya leaf extract in dengue were searched from PubMed, Cochrane Clinical Trial Registry and Google Scholar. The primary endpoint was mortality, and secondary endpoints were increase in platelet count, hospitalization days, and Grade 3 and 4 adverse events. Data related to primary and secondary endpoints were pooled together and analyzed by review manager (Review Manager (RevMan) Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, Denmark) software. The random effect model was used. The bias was analyzed by the Cochrane risk of bias tool. Results: Total four trials enrolling 439 subjects were included in the analysis. Of 439 subjects, data of 377 subjects were available for analysis. C. papaya leaf extract was found to be associated with increase in platelet count in the overall analysis (mean difference [MD] =20.27 [95% confidence interval (CI) 6.21–34.73; P = 0.005]) and analysis after 4 th day (MD = 28.25 [95% CI 14.14–42.37; P < 0.0001]). After 48 h, there was no significant difference between C. papaya and control group (MD = 13.38 [95% CI − 7.71–34.51; P = 0.21]). There was significant decrease in hospitalization days in the C. papaya group (MD = 1.90 [95% CI 1.62–2.18; P < 0.00001]). Because of nonavailability of data in published clinical trials, mortality, and adverse events cannot be pooled. Conclusion: C. papaya leaf extract can be considered as a potential candidate for increase in platelet count in patients of dengue, however; there is need of high‑quality evidence in the form of large clinical trials before a decision related to the use of such extract is made.
Background: “Chiranjeevi Yojana (CY)”, a state-led large-scale demand-side financing scheme (DSF)... more Background: “Chiranjeevi Yojana (CY)”, a state-led large-scale demand-side financing scheme (DSF) under publicprivate
partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005.
The scheme aims to provide free institutional childbirth services in accredited private health facilities to women
from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility
with the intention of service being free to the user. This community-based study estimates CY uptake among
eligible women and explores factors associated with non-utilization of the CY program.
Methods: This was a community-based cross sectional survey of eligible women who gave birth between January
and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by
trained research assistant to collect information on socio-demographic details, pregnancy details, details of
childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the
factors associated with non-utilization of the CY program.
Results: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered
at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who
belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6,
95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY
program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of
required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY
program overall paid more than women who delivered in the free public facilities.
Conclusion: Uptake of the CY among eligible women was low after almost a decade of implementation.
Community level awareness programs are needed to increase participation among eligible women. OOP expense
was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy
which needs to be studied. There is also a need to ensure financial protection of women who have C-section.
Background Work-related musculoskeletal disorders (WMSDs), especially low back pain and neck pain... more Background Work-related musculoskeletal disorders (WMSDs), especially low back pain and neck pain cause substantial socio-economic losses. Professional drivers are particularly at high risk for developing back pain, neck pain due to sitting for long duration and vehicle vibration. This present study focuses on assessing the personal as well as ergonomics exposure over the developmental risk of work-related musculoskeletal disorders among bus drivers. Method For this pilot study, 28 (Age=34.5 ±9.5) male drivers were selected and data regarding general information, driver seat ergonomics were collected. Standard tools of Quick Exposure Check (QEC), Rapid Entire Body Assessment (REBA), Rapid Upper Limb Assessment (RULA), Nordic Musculoskeletal Questionnaire (NMQ) were used to analyse the risk of WMSDs. Results The current personal exposure of bus drivers assessed using QEC methodology found that back and shoulder region exposure is very high as compared to the neck and wrist region. Th...
About 56,000 maternal deaths occur every year in India; which is about 20% of the global burden h... more About 56,000 maternal deaths occur every year in India; which is about 20% of the global burden hence India's progress in reducing maternal deaths is crucial to the global achievement of Millennium Development Goal 5. In spite of rapid economic growth of the country; maternal mortality remains high as a result of geographic, cultural, political and management issues rather than a lack of technical knowledge. Vulnerable groups such as tribal mothers have the higher maternal mortality due to weak health systems and this study follows the path to death for such mothers in a tribal district of Gujarat. The study will improve understanding of determinants of mortality among this high risk group. Methodology
Background Providing quality maternal and newborn care in facilities is crucial to reduce materna... more Background Providing quality maternal and newborn care in facilities is crucial to reduce maternal mortality as institutional deliveries increased tremendously in last decade. With implementation of Chiranjeevi Yojana, a scheme to provide free delivery care to poor mothers by private providers, it is even more important to examine and compare the quality of care between public and private sector. Present study uses Hulton framework for the evaluation of quality of maternity care of the public and private facilities in Gujarat (three districts- Sabarkantha, Surendranagar, Dahod). Methodology A community based cross-sectional study with analytical sample of 2799 mothers of which 73% delivered in private sector and rest 27% at public sector. Study assessed experience of mothers regarding quality of care (Human resources, Cognition, Respect, dignity and equity of care, Emotional support), using a structured questionnaire, administered within seven days of delivery at home by trained dat...
Introduction: The tremendous potential of Geo Information System (GIS) to improve planning, imple... more Introduction: The tremendous potential of Geo Information System (GIS) to improve planning, implementation and monitoring of programs and enhance policymaking processes for universal access to healthcare is underutilized. Currently, the limited use of GIS is for tracking immunizations, surveillance, and establishing service areas. The challenge is limited use of visualization of spatial data as an essential tool by public health experts. Major reasons are restricted access and inability to interpret by non-GIS professionals. WebGIS technologies present a possible solution to this challenge. To demonstrate the potential of this technology to visualize a large scale data and compare it with the traditional GIS methods, this study describes experience and lessons learnt for the MATIND project in Gujarat state of India. Methodology: An impact evaluation maternal health project in three districts of Gujarat collected information on different aspects of facilities and maternal healthcare ...
Background: Work-related musculoskeletal disorders (WMSDs), especially low back pain and neck pai... more Background: Work-related musculoskeletal disorders (WMSDs), especially low back pain and neck pain cause
substantial socio-economic losses. Professional drivers are particularly at high risk for developing back pain and
neck pain from prolonged sitting and vehicular vibration. This study assesses ergonomic exposure on the
developmental risk of WMSDs among bus drivers.
Methodology: A total of 280 male drivers with acute body pain in any region were randomly selected for the study,
and ergonomic information on driver’s seat was collected using a validated questionnaire. Then the exposure and
risks of developing WMSDS were assessed using Quick Exposure Check (QEC), Rapid Entire Body Assessment
(REBA), Rapid Upper Limb Assessment (RULA) and Nordic Musculoskeletal Questionnaire (NMQ).
Results: The results of QEC showed that back and shoulder had very high exposure followed by neck and wrist.
REBA revealed that nearly half (46%) of the drivers were at high risk of developing WMSDs, whereas14% were at
very high risk and 29% were at medium risk. As per RULA, 46% of bus drivers needed further ergonomic
investigation and modification of workstation/work style, indicating that the risk for WMSDs is potentially high.
Among others, 29% were at moderate risk and 14% were at low risk, whereas 11% were at very high risk, requiring
immediate change. From NMQ, it was found that 26% of drivers had musculoskeletal problems in the neck, 24% in
the back, 20% in the upper limbs (shoulder and wrists were equally affected), 6% in the knees and 4% in the ankles.
Conclusion: The current study evaluated the risks of developing WMSDs among bus drivers. Exposure to unsafe
ergonomic practices/conditions and health risks were evident from the findings of the study. Prospective studies are
necessary to confirm the cause and effect in this association. Ergonomic intervention measures with workplace
health promotion activities need to be implemented in order to reduce the risk of WMSDs among bus drivers.
Background: The high rate of maternal mortality in India is of grave concern. Poor rural Indian w... more Background: The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are
most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable
emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the
public sector combined with financial barriers to accessing private sector obstetrician services preclude this
underserved population from availing lifesaving functions of comprehensive EmOC such as C-section.
In order to overcome this limitation, Government of Gujarat initiated a unique publicprivate partnership
program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers
to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY,
private sector providers render obstetric care services to poor women at no cost to patients. This paper
examines the CY’s effectiveness in improving availability of CEmOC services between 2006 and 2012 in three
districts of Gujarat, India.
Methods: Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected
in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used
along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10
was used to analyze the availability of services using two-step floating catchment area (2SFCA) method.
Results: Our analysis suggests that the availability of CEmOC services within reasonable travel distance has
greatly improved in all three study districts as a result of CY. We also show that the declining participation
of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability
of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a
comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance.
Conclusions: This paper demonstrates how GIS could be useful for evaluating programs especially those
focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for
programmatic planning, particularly for optimizing resource allocation.
Health promotion and the maintenance of the quality of life are realized recently. Advancement in... more Health promotion and the maintenance of the quality of life are realized recently. Advancement in technologies offers new possibilities for both the promotion of positive health behaviors that were unimaginable even a decade ago. Though promoting physical activity has been proven an important component of health promotion by many researchers, still a lot of efforts on how to improve physical activity being provided by group of researchers. Technologies such as pedometers, accelerometers, and heart rate monitors have been used to promote physical activity for years. Newer technologies such as global positioning system (GPS), geographic information systems (GIS), interactive video games, and persuasive technology, Internet-based physical activity interventions have been used recently to promote and change exercise behavior. This chapter seeks to provide a complete insight of technologies used to changing health behaviors especially physical health promotion and will take a forward to analyses all the issues while using these technologies and future research directions.
India is the second most populous country and the highest contributor of maternal deaths globally... more India is the second most populous country and the highest contributor of maternal deaths globally. The maternal mortality ratio of India has been reduced from 400 in 1999 to 178 in 2012, a drop of more than 50% as per Sample Registration System (SRS), India report. Despite this decrease, India will not be able to achieve the fifth Millenium Development Goal (MDG 5) by 2015, and the magnitudeof decrease in maternal mortality has remained same for the past decade. India has implemented national level programs to improve maternal health starting with Child Survival Safe Motherhood (CSSM) in the 1990s, to the recent National Rural Health Mission (NRHM) implemented in 2005 which has led to some improvement in maternal healthcare utilization despite as documented in demographic surveys. The coverage of antenatal care has improved, with about 75% of all mothers receiving some antenatal care in 2007-08 compared to 65% in 1998-99. Similarly, institutional deliveries rose to 50% in 2008 from 34% in 1999.
This chapter analyses the trends in maternal mortality in India, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health indicators and suggests future actions to improve the situation. Geographical vastness and enormous sociocultural diversity mean that maternal mortality and maternal health care utilization varies across India, and uniform implementation of health-sector reforms is not possible. Improved documentation of maternal healthcare utilization and maternal health indicators including maternal deaths is recommended. Implementation of evidence-based, focused strategies along with effective monitoring is important for making meaningful difference in improving maternal health care utilization along with building a strong health system to make sustainable progress in maternal mortality reduction.
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Publications by Dr. Sandul Yasobant
partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005.
The scheme aims to provide free institutional childbirth services in accredited private health facilities to women
from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility
with the intention of service being free to the user. This community-based study estimates CY uptake among
eligible women and explores factors associated with non-utilization of the CY program.
Methods: This was a community-based cross sectional survey of eligible women who gave birth between January
and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by
trained research assistant to collect information on socio-demographic details, pregnancy details, details of
childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the
factors associated with non-utilization of the CY program.
Results: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered
at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who
belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6,
95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY
program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of
required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY
program overall paid more than women who delivered in the free public facilities.
Conclusion: Uptake of the CY among eligible women was low after almost a decade of implementation.
Community level awareness programs are needed to increase participation among eligible women. OOP expense
was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy
which needs to be studied. There is also a need to ensure financial protection of women who have C-section.
substantial socio-economic losses. Professional drivers are particularly at high risk for developing back pain and
neck pain from prolonged sitting and vehicular vibration. This study assesses ergonomic exposure on the
developmental risk of WMSDs among bus drivers.
Methodology: A total of 280 male drivers with acute body pain in any region were randomly selected for the study,
and ergonomic information on driver’s seat was collected using a validated questionnaire. Then the exposure and
risks of developing WMSDS were assessed using Quick Exposure Check (QEC), Rapid Entire Body Assessment
(REBA), Rapid Upper Limb Assessment (RULA) and Nordic Musculoskeletal Questionnaire (NMQ).
Results: The results of QEC showed that back and shoulder had very high exposure followed by neck and wrist.
REBA revealed that nearly half (46%) of the drivers were at high risk of developing WMSDs, whereas14% were at
very high risk and 29% were at medium risk. As per RULA, 46% of bus drivers needed further ergonomic
investigation and modification of workstation/work style, indicating that the risk for WMSDs is potentially high.
Among others, 29% were at moderate risk and 14% were at low risk, whereas 11% were at very high risk, requiring
immediate change. From NMQ, it was found that 26% of drivers had musculoskeletal problems in the neck, 24% in
the back, 20% in the upper limbs (shoulder and wrists were equally affected), 6% in the knees and 4% in the ankles.
Conclusion: The current study evaluated the risks of developing WMSDs among bus drivers. Exposure to unsafe
ergonomic practices/conditions and health risks were evident from the findings of the study. Prospective studies are
necessary to confirm the cause and effect in this association. Ergonomic intervention measures with workplace
health promotion activities need to be implemented in order to reduce the risk of WMSDs among bus drivers.
most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable
emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the
public sector combined with financial barriers to accessing private sector obstetrician services preclude this
underserved population from availing lifesaving functions of comprehensive EmOC such as C-section.
In order to overcome this limitation, Government of Gujarat initiated a unique publicprivate partnership
program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers
to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY,
private sector providers render obstetric care services to poor women at no cost to patients. This paper
examines the CY’s effectiveness in improving availability of CEmOC services between 2006 and 2012 in three
districts of Gujarat, India.
Methods: Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected
in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used
along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10
was used to analyze the availability of services using two-step floating catchment area (2SFCA) method.
Results: Our analysis suggests that the availability of CEmOC services within reasonable travel distance has
greatly improved in all three study districts as a result of CY. We also show that the declining participation
of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability
of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a
comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance.
Conclusions: This paper demonstrates how GIS could be useful for evaluating programs especially those
focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for
programmatic planning, particularly for optimizing resource allocation.
This chapter analyses the trends in maternal mortality in India, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health indicators and suggests future actions to improve the situation. Geographical vastness and enormous sociocultural diversity mean that maternal mortality and maternal health care utilization varies across India, and uniform implementation of health-sector reforms is not possible. Improved documentation of maternal healthcare utilization and maternal health indicators including maternal deaths is recommended. Implementation of evidence-based, focused strategies along with effective monitoring is important for making meaningful difference in improving maternal health care utilization along with building a strong health system to make sustainable progress in maternal mortality reduction.
partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005.
The scheme aims to provide free institutional childbirth services in accredited private health facilities to women
from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility
with the intention of service being free to the user. This community-based study estimates CY uptake among
eligible women and explores factors associated with non-utilization of the CY program.
Methods: This was a community-based cross sectional survey of eligible women who gave birth between January
and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by
trained research assistant to collect information on socio-demographic details, pregnancy details, details of
childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the
factors associated with non-utilization of the CY program.
Results: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered
at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who
belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6,
95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY
program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of
required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY
program overall paid more than women who delivered in the free public facilities.
Conclusion: Uptake of the CY among eligible women was low after almost a decade of implementation.
Community level awareness programs are needed to increase participation among eligible women. OOP expense
was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy
which needs to be studied. There is also a need to ensure financial protection of women who have C-section.
substantial socio-economic losses. Professional drivers are particularly at high risk for developing back pain and
neck pain from prolonged sitting and vehicular vibration. This study assesses ergonomic exposure on the
developmental risk of WMSDs among bus drivers.
Methodology: A total of 280 male drivers with acute body pain in any region were randomly selected for the study,
and ergonomic information on driver’s seat was collected using a validated questionnaire. Then the exposure and
risks of developing WMSDS were assessed using Quick Exposure Check (QEC), Rapid Entire Body Assessment
(REBA), Rapid Upper Limb Assessment (RULA) and Nordic Musculoskeletal Questionnaire (NMQ).
Results: The results of QEC showed that back and shoulder had very high exposure followed by neck and wrist.
REBA revealed that nearly half (46%) of the drivers were at high risk of developing WMSDs, whereas14% were at
very high risk and 29% were at medium risk. As per RULA, 46% of bus drivers needed further ergonomic
investigation and modification of workstation/work style, indicating that the risk for WMSDs is potentially high.
Among others, 29% were at moderate risk and 14% were at low risk, whereas 11% were at very high risk, requiring
immediate change. From NMQ, it was found that 26% of drivers had musculoskeletal problems in the neck, 24% in
the back, 20% in the upper limbs (shoulder and wrists were equally affected), 6% in the knees and 4% in the ankles.
Conclusion: The current study evaluated the risks of developing WMSDs among bus drivers. Exposure to unsafe
ergonomic practices/conditions and health risks were evident from the findings of the study. Prospective studies are
necessary to confirm the cause and effect in this association. Ergonomic intervention measures with workplace
health promotion activities need to be implemented in order to reduce the risk of WMSDs among bus drivers.
most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable
emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the
public sector combined with financial barriers to accessing private sector obstetrician services preclude this
underserved population from availing lifesaving functions of comprehensive EmOC such as C-section.
In order to overcome this limitation, Government of Gujarat initiated a unique publicprivate partnership
program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers
to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY,
private sector providers render obstetric care services to poor women at no cost to patients. This paper
examines the CY’s effectiveness in improving availability of CEmOC services between 2006 and 2012 in three
districts of Gujarat, India.
Methods: Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected
in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used
along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10
was used to analyze the availability of services using two-step floating catchment area (2SFCA) method.
Results: Our analysis suggests that the availability of CEmOC services within reasonable travel distance has
greatly improved in all three study districts as a result of CY. We also show that the declining participation
of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability
of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a
comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance.
Conclusions: This paper demonstrates how GIS could be useful for evaluating programs especially those
focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for
programmatic planning, particularly for optimizing resource allocation.
This chapter analyses the trends in maternal mortality in India, the maternal healthcare-delivery system at different levels, and the implementation of national maternal health programmes, including recent innovative strategies. It identifies the causes for limited success in improving maternal health indicators and suggests future actions to improve the situation. Geographical vastness and enormous sociocultural diversity mean that maternal mortality and maternal health care utilization varies across India, and uniform implementation of health-sector reforms is not possible. Improved documentation of maternal healthcare utilization and maternal health indicators including maternal deaths is recommended. Implementation of evidence-based, focused strategies along with effective monitoring is important for making meaningful difference in improving maternal health care utilization along with building a strong health system to make sustainable progress in maternal mortality reduction.