Deaths In India Research Articles

NONCOMMUNICABLE DISEASES AND HEALTH CARE UTILIZATION: A STUDY OF OLDER ADULTS IN INDIA

Abstract Non-communicable diseases (NCDs) have become one of the leading causes of death in India, and it’s more prevalent among aged population. Access to healthcare facilities (HCFs) can reduce this mortality burden considerably. This study addressed the rural-urban disparity in accessing HCFs for the treatment of NCDs among older adults. Using data from LASI wave-1 (2017-18), 10,865 older adults (aged 60+) who accessed HCFs for NCD treatment were analyzed. Bivariate and multivariate analysis was applied to calculate the distance to avail HCFs through public and private transportation for the last outpatient visit. The findings indicated that NCD patients highly preferred to visit private HCFs for their treatment in India. Sixty-eight percent of the rural NCD patients residing up-to 5 kilometres (km) distance from HCFs were utilizing private transport, whereas it was around four-fifths of urban NCD patients. As the distance to HCFs increases from 5km and more, the use of public transportation by NCD patients in rural areas were significantly higher compared to their urban counterparts. However, private transport use for HCFs located between 5-to-50km was not varied much by place of residence. Findings showed that there was no significant variation in health expenditure at public HCFs among rural-urban patients. Nearly one-fourth of urban and one-fifth of rural older adults were utilizing public HCFs free-of-cost. Urban residents who visited private HCFs had to spend eight times more than those who opted for public HCFs. Only nineteen percentage older adults have health insurance coverage in India, indicating considerable burden of out-of-pocket expenditure.

A Study to Assess Effectiveness of Planned Health Education on Knowledge Regarding Prevention of Selected Non-Communicable Diseases among Women Attending Mahila Sangha Meeting At Selected Urban Area Kolar

Non-communicable diseases (NCDs) are a major health problem in the world, more than two out of three deaths are due to NCDs. More than one in two deaths in India (60%) are because of NCDs. A large proportion of NCDs is preventable if correct information is provided by healthcare workers at the right time to practice a healthy lifestyle which in turn reduces their risk for NCDs. Hence, Women form an important pillar and are the primary nurturer of society, the study was carried out to assess the effectiveness of structured health education regarding the prevention of selected non-communicable disease among women. For the present study Quasi-experimental including one group pretest and post test design was used. First ethical clearance obtained and written permission was obtained from Director, (SKDRD) Shree Kshethra Dharmasthala rural development project B.C, Trust, Kolar. Through a convenient sampling technique using inclusion criteria, 30 women were selected, after taking written consent from the women, they were assessed through an interview schedule for knowledge of non-communicable diseases' prevention, followed by structured health education administered. Post-test was conducted after 30 days utilizing the same tool. The study revealed the mean score of knowledge in the pretest was 11.1 accompanied by SD of 1.6 whereas the mean score of knowledge in post-test was 13.6 accompanied by SD of 2.0. The obtained paired‘t’ value — 9.53 denote that planned health education was effective in improve knowledge score among women at 0.05 level of significance. Study divulged women were lacking knowledge but after planned health education their knowledge score was improved to 2.5 and this also was supported by studies. Hence, the study deduced that planned health education was significantly effective in enhancing knowledge scores among women regarding the prevention of selected non-communicable diseases. Keywords: Non­communicable diseases (NCDs), Prevention, knowledge, women, effectiveness of planned health education

Control Strategies for the COVID-19 Infection Wave in India: A Mathematical Model Incorporating Vaccine Effectiveness

The waning effectiveness of the coronavirus disease-2019 (COVID-19) vaccines and the emergence of new variants have given rise to the possibility of future outbreaks of the infection. COVID-19 has caused more than 43 million reported cases and 526,000 deaths in India so far, and the disease spread is active again despite mass vaccinations. In this article, we present a compartmental epidemiological model incorporating vaccinations with dose-dependent effectiveness. We study a possible sudden outbreak of SARS-CoV2 variants in India, bring out the associated predictions for various vaccination rates, and point out optimum control measures. Our model simulation numbers for the total infected are close to the seroprevalance data in August 2021, and our results show that second dose vaccine effectiveness is the most sensitive parameter in the future evolution of the disease. A combination of vaccination and social distancing is the key to tackling the current situation and for the coming few months. Our simulation shows that social distancing measures show better control over disease spread than higher vaccination rates, and disease spread does not appear to rise sharply in the near future unless a new variant emerges.

A Study to Assess the Knowledge regarding Cervical Cancer among women Residing at Rajanagaram

Cervical cancer is a leading cause of death among women worldwide. The incidence and mortality from cervical cancer remain very high and many women seek health facilities in the late stage of the disease. An extensive health education program on cervical cancer is necessary for women. According to National Cancer Control programmed cancer has become one of the ten leading causes of death in India. It is estimated that there are nearly 2-2.5 million cancer cases at any given point in time. Materials and Methods: Community-based cross-sectional descriptive research design was adopted. A non-probability sampling technique was used to select the samples. Their knowledge regarding cervical cancer was assessed by using a checklist. The data was analyzed by descriptive and inferential statistics. The level of significance was set at 0.05level. The results showed that 69.33% of women had inadequate knowledge, 28.67% of women had moderate knowledge and 2% had adequate knowledge. The test mean was 13.61, the standard deviation was 5.27. The study concluded the need for bringing awareness to women regarding the prevention of cervical cancer

The Pattern of Blood Pressure Distribution and Analysis of Influencing Factors of Pre (Hypertension) Among Young Adults: A Cross-Sectional Survey in Western India

Background: Raised blood pressure is one of the significant preventable causes of cardiovascular diseases. The Global Burden of Diseases report 2019 has identified high systolic blood pressure as the leading risk factor for attributable deaths accounting for about 1.4 million deaths in India. The study aimed to determine the prevalence of prehypertension and hypertension, along with their associated risk factors, among young adults. Methods: A cross-sectional study was conducted in urban science colleges in Gujarat. A multicomponent questionnaire comprised of demographic, dietary and lifestyle characteristics was administered to the participants (18-23 years). Data on weight, height and blood pressure were collected by trained field personnel. The categorical variables were tested by a chi-square test, while the t-test was used to compare quantitative variables. Results: Overall, 415 participants (65% female) were included in the study, with a mean age of 19.5 years. The prevalence of prehypertension and hypertension was 23.4% and 4.8%, respectively. The multivariate analysis showed that the male gender, not being underweight, and overweight was found to be associated with elevated blood pressure. Conclusions: There is a pressing need to identify cardiovascular risk factors at younger ages through regular screening, with more focus should be put on the adaptation of healthy lifestyles.

GeogRaphic and socioecoNomic Distribution of real-world Indian data of home blood pressure monitoring (GRAND Study): Study protocol for an observational study in 18 medical centers across India.

One-fourth of death in India is attributed to cardiovascular disease (CVD) and more than 80% is related to ischemic heart disease and stroke. The main risk factor for CVD is hypertension. Every third person in India suffers from hypertension and the prevalence increased drastically in the past 20 years, especially among the youngest age group of 20 and 44 years. Regardless of being under anti-hypertension medication, the blood pressure (BP) control rate in the country is still low ranging between 6% and 28% only. Assessing the "true BP control rate" should be performed using both clinic BP measurement and out-of-office BP measurement as the latter shows better prognosis for patients' hypertension and CVD outcomes. Home blood pressure monitoring (HBPM) shows superiority over ambulatory BP measurement as multiple measurements can be collected at the patient's convenience. Only limited evidence on HBPM in India is available and it's either lacking in hypertension participants or of a small sample size. This study will investigate the real BP control status among 2000 hypertensive patients from 18 centers in 12 states across Pan-India. The outcome of this study will emphasize the value of establishing BP control management practice guidelines suitable for physicians and help policymakers in building proper strategies for hypertension management to reduce the CVD burden on the health situation in India.

Effectiveness of Pacemaker Care Protocol on Knowledge and Skill Regarding Care of Client Undergoing Pacemaker Implantation Among Nurses

Non Communicable Diseases (NCDs) also known as chronic diseases, which includes cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes. NCDs result in rapid deaths as seen in certain diseases like autoimmune diseases, heart diseases, stroke, cancers, diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and others. Cardiovascular diseases are one of the major incidence of non-communicable diseases and leading causes of deaths in India. The heart is endowed with a specialized system for generating rhythmic electrical impulses and for conducting these impulses rapidly throughout the heart to cause contraction of the heart muscle. When this system functions normally, the atria contract about one-sixth of a second ahead of the ventricles. This orderly electrical activity must precede contraction to provide adequate cardiac output for perfusion of all body organs and tissues. Aim and objective: To assess the effectiveness of pacemaker care protocol on knowledge and skill regarding care of client undergoing pacemaker implantation among nurses at selected hospital. Methodology: A quasi-experimental non equivalent control group design was chosen to conduct the study among 60 Nurses, who were selected using purposive sampling technique. Immediately after pretest assessment, intervention was given in experimental group and hospital routine was carried out in control group. After seven days post test was collected in both the groups. The comparison of post test level of knowledge between experimental and control group revealed that t of 12.002, was statistically significant at p<0.001level.The comparison of the post test level of skill, revealed t value of 9.577, which was highly statistically significant at p< 0.001level.

Immunological Responses of Arsenicum album 30CH to Combat COVID-19: Protocol for a Double-Blind, Randomized, Placebo-Controlled Clinical Trial in the Pathanamthitta District of Kerala.

COVID-19 is a recent major public health concern caused by the SARS-CoV-2 virus, with approximately 44.6 million COVID-19-positive cases and 530,000 deaths in India (as of February 1, 2023). The COVID-19 vaccination drive in India was initiated in January 2021; however, an effective preventive strategy with high efficacy and immunological safety remains elusive. The aim of this study is to assess the immunogenic responses of Arsenicum album 30CH (AA30CH) as COVID-19 prophylaxis, including assessment of immunological markers, innate and acquired immune responses, COVID-19 symptoms, and its associated antibody responses. This randomized controlled clinical trial (RCT) will include two parallel comparator groups of AA30CH and placebo with an allocation ratio of 1:1 conducted in the Pathanamthitta district of Kerala, India. The placebo or AA30CH will be administered in three intervention schedules and blood samples will be collected before and after each of the intervention schedules. Based on the inclusion and exclusion criteria, 112 participants per arm (with an expected dropout of 20%) will be screened. Immunogenic responses will be evaluated by determining the antigen density and modulation in immunological markers and lymphocyte subsets CD3, CD4, CD8, CD24, CD27, CD38, CD4 interferon-γ, CD4 CD17, CD4 CD25 (activated T lymphocytes), T cells, B cells, dendritic cells (mature and immature), and natural killer cells on days 1, 5, 23,27, 45, 49, and 66. The innate and acquired immune responses will also be evaluated by a real-time reverse-transcriptase polymerase chain reaction (RT-PCR) array profiler (84-gene set) before and after the study interventions. The toxicity status of AA30CH in study participants will be evaluated through hepatic, renal, and hematological parameters and peripheral smears on days 1, 5, 23, 27, 45, 49, and 66. The number of participants developing COVID-19-like symptoms per National Centre for Disease Control guidelines and the number of participants testing positive for COVID-19 in RT-PCR during follow-ups in any of the three intervention schedules will be identified. Moreover, a subgroup analysis will be used to assess the COVID-19 antibody responses between vaccinated and unvaccinated participants. This RCT protocol has been approved by various committees and funded by the Central Council for Research in Homoeopathy, Ministry of Ayush, Government of India. The project has been implemented in collaboration with the Department of Homoeopathy, Government of Kerala. The RCT was rolled out on January 25, 2023, and enrollment was completed April 3, 2023. The immunological assays will be conducted at the Department of Biotechnology-Translational Health Science and Technology Institute, Faridabad, India. This study will represent the first evaluation of the immunological efficacy and safety of AA30CH in an RCT, which may significantly impact the use of homeopathy as an evidence-based medicine approach. Clinical Trials Registry-India CTRI/2022/08/045089; https://tinyurl.com/mryrpkvk. DERR1-10.2196/48479.

Can you die twice? In India you can! Paradox and ambiguities in the legal determination of brainstem death in India

Can you die twice? In India you can! Paradox and ambiguities in the legal determination of brainstem death in India

Real Time Patient Vital Monitoring and Alarm System with Prediction of Anomalies and Future Clinical Episodes using Machine Learning Models

Heart disease is a leading cause of death in India. Many times, heart diseases do not show symptoms until they become a matter of concern. This silent nature calls for real time monitoring of vitals. In this paper, we propose a healthcare monitoring system which makes use of existing wearable devices to measure vitals of the user’s body. The data gathered is used to perform real time analysis to detect any irregularities and simultaneously to predict if there are any underlying problems that might be of future concern.

A Community-based Epidemiological Study on non-fatal Road Traffic Accidents in Puducherry, South India

Introduction: Road traffic accidents are the sixth leading cause of death in India with a greater share of hospitalization, disabilities, deaths and socio-economic losses. Objective: To identify the pattern of non-fatal road traffic accidents, socio-demographic profile of accident victims and antecedent factors influencing these road traffic injuries. Method: A cross-sectional study was conducted for six months in Puducherry. From existing 27 wards of Lawspet, six wards were selected by simple random sampling technique and all the households in selected wards were included. The minimum required sample size was estimated to be 165 by considering prevalence of non-fatal road traffic accidents in Puducherry as 5.6%. Face-to-face interview with a semi-structured questionnaire was used for data collection. Data entry and analysis were performed using Epi-data manager 4.2.0. Results: Total 169 accident victims were included in the study from the households of selected wards. Mean age of the accident victims was found to be 36.2 (11.4) years. Two‑wheeler accidents accounted for 144 (85.2%) and 123 (72.7%) accident victims were drivers at the time of accident. Majority (95.1 %) of the victims did not wear helmet while driving two-wheelers and none of the four-wheel drivers/pillions wore seat belts. Majority of the accidents occurred on usual tar roads 116 (68.6%) and 42 (24.9%) on highways. 102 (60.4%) accidents occurred in bi-directional roads.Conclusion: Simple or minor injuries were high compared to serious injuries requiring hospitalization. Majority of the accidents occurred during Fridays, Saturdays and Sundays. The accidents exhibited a bimodal distribution with day and night time.

Brief overview of Jaundice and its Current treatment options

The sickness of jaundice is intricate. The cause of jaundice is a high bilirubin level in the body. Jaundice commonly manifests as skin, mucous membranes, and skin that are yellow. Pre-hepatic jaundice is caused by hemolysis of red blood cells, hepatic jaundice is caused by a problem with the liver's ability to collect, conjugate, and excrete bilirubin, and post-hepatic jaundice is caused by the obstruction of the extra hepatobiliary system.When bilirubin is metabolised, red blood cells (RBCs) go through hemolysis and release haemoglobin as a result. Heme is broken down by the heme oxygenase in the reticuloendothelial system into biliverdin and carbon monoxide. Then, biliverdin is converted into unconjugated bilirubin by the enzyme biliverdin reductase. Jaundice typically manifests as extreme weakness, fever and a headache, decrease in appetite, extremely constipated, Nausea, urine, tongue, skin, and eyes that are all yellow, dull discomfort near the liver.In the entire world, liver disease is one of the leading causes of illness and mortality. The total number of liver disease-related deaths in India reached 2.95%, per W.H.O. data released in 2017. One in five Indians may have a liver disorder.The aetiology, causes, symptoms, and combination therapy of jaundice are covered in this review study.

Caution While Sailing Uncharted Seas-response to Organ Donation after Circulatory Determination of Death in India

Caution While Sailing Uncharted Seas-response to Organ Donation after Circulatory Determination of Death in India

Changing pattern of suicide deaths in India

Changing pattern of suicide deaths in India

A cross-sectional study of road traffic accident victims at a tertiary care teaching hospital at Gwalior city in Madhya Pradesh of Central India

Background: Road crash deaths in India, which were the highest in the world, are a burden on its demographic dividend and have a tangible impact on poverty. Aims and Objectives: The present study was conducted to investigate the sociodemographic characteristics, type of vehicle, types of road, primary treatment, and safety measures adopted by the victims of road traffic accidents (RTA). Materials and Methods: The present cross-sectional study was conducted at Trauma Center, Madhav Dispensary, J.A. Group of Hospitals Gwalior, M.P. on 528 Victims of RTA between the period of January 01, 2020, and June 30, 2021. The descriptive statistical measures such as mean, standard deviation, frequency, and percentage were used. The data analysis was done in Microsoft Excel Software. Results: In the present study, a total of 528 RTA victims were enquired. Their average age was 33.02±13.31 years, with 81.8% were male and 18.2% were female. Most of the victims (67.80%) were on two-wheeler vehicles. About half of the victims were found to have Head on Collision during accidents. The accidents mostly occurred in the time period from 9.00 am to 9.00 pm. It was observed that 65.90% RTA victims had soft-tissue injury and bony injury. Conclusion: It was vital to obtain valid information of the real importance of RTA along with the preventive action concerning RTAs. It was recommended to provide the basic treatment to victims related with RTA at Primary Care Center of the nearest accident place.

Effectiveness of Self-Instructional Module (SIM) on Knowledge Regarding Breast Cancer among Women

Women are blessed with a kind heart, a sea of love, and a bundle of affection. They are, undoubtedly, a symbol of love and a pillar of strength. They are always there, like a beacon in the night. A woman is not only beautiful, but, a woman is a companion to a man, family and society given by God Almighty. Yes, women are indeed God’s most beautiful creation. Every woman should know this, and should live up to it. Women should respect themselves. Today, sadly, things have changed. Many women have no sense of their health and their wellness. Cancer has become one of the ten leading causes of death in India. According to Indian Council of Medical Research there are nearly 1.5-2 million cancer cases at any given point of time. Over 7 lakh new cases of cancer and 3 lakh deaths occur annually due to cancer. Nearly 15 lakh patients require facilities for diagnosis, treatment and follow up at a given time.3 The incidence of breast cancer is rising in every country of the world especially in developing countries such as India. This is because more and more women in India are beginning to work outside their homes which allow the various risk factors of breast cancer to come into play. These include late age at first childbirth, fewer children and shorter duration of breast-feeding.4 Breast cancer has increased incidence of among women residing in metropolitan cities. Statistically, breast cancer is supposed to be more common among unmarried women; those who are married, but have not had children; and those who have had children, but did not breast feed their babies. It is also related with smoking, alcohol drinking and high fat intake to the causation of breast cancer and this probably explains its etiological relationship to a modern lifestyle and environment.5 Materials and Methods: Descriptive survey design is selected using convenient sampling and 60 working women were selected as sample. A structured questionnaire is used to assess the knowledge of the working women regarding breast cancer. The questionnaire consisted of two parts: Part –A to collect the demographic data, Part-B consisting of questions regarding the various aspects of knowledge about breast cancer. Results: Major findings of the study revealed that the majority of 50%women belonged to the age group of 41-50 yrs, 75% women are married 50% are graduate, majority (40%) of women had two children and 40 never breast fed majority of women (40%) had a family monthly income of Rs. 20001-30000, and had no history of breast cancer running in the family. The mean knowledge score was 5.7 (SD  2.47) and 22% of the study population had poor knowledge regarding breast cancer. Demographic variables like age, marital status educational status, duration of breast feeding and family history were associated with the level of knowledge. A self-instructional module was prepared for use as a teaching aid and found effective with‘t’ value 17.77 at p<0.01 level. Conclusion: After the detailed analysis of the study findings showed that the earlier studies done on the knowledge of women regarding breast cancer. There is lack of knowledge even in the educated women regarding breast cancer. It is the responsibility of all the nursing educators, administrators and policy makers to find out the barriers in the gain of knowledge and should try to remove them and to develop strategies which can make emphasis on prevention and early detection of diseases

The PURPOSe cause of death study in stillbirths and neonatal deaths in India and Pakistan: A review.

The PURPOSe study was a prospective, observational study conducted in India and Pakistan to determine the cause of death for stillbirths and preterm neonatal deaths, using clinical data together with minimally invasive tissue sampling (MITS) and the histologic and polymerase chain reaction (PCR) evaluation of fetal/neonatal tissues and the placenta. After evaluating all available data, an independent panel chose a maternal, a placental and a fetal/neonatal cause of death. Here, we summarise the major results. Among the most important findings were that most stillbirths were caused by fetal asphyxia, often preceded by placental malperfusion, and clinically associated with pre-eclampsia, placental abruption and a small-for-gestational-age fetus. The preterm neonatal deaths were primarily caused by birth asphyxia, followed by various infections. An important finding was that many of the preterm neonatal deaths were caused by a nosocomial infection acquired after neonatal intensive care (NICU) admission; the most common organisms were Acinetobacter baumannii, followed by Klebsiella pneumoniae, Escherichia coli/Shigella and Haemophilus influenzae. Group B streptococcus was less commonly present in the placentas or internal organs of the neonatal deaths.

Ayurvedic Principles to Prevent Lifestyle Disorders

In India, almost 61 percent of all death in India is due to lifestyle disorders and non-communicable diseases WHO identifies prime risk factors for LSD. These are alcohol and tobacco intake, poor diet intake, lack of physical activities, mental stress, etc. According to sustainable development goal l3.4, which mandates a 1/3rd reduction in premature death due to lifestyle disorder by 2030.
 An individual or group of people who have a lifestyle disorder (LSD) are essentially inviting themselves to develop any number of ailments that are mostly based on how they live. These include conditions including chronic bronchitis, hypertension, heart disease, stroke, obesity, diabetes, and malignancies brought on by diet and cigarette use. Ayurveda describes several principles to prevent LSD like Dincharya (daily routine), Ritucharya (seasonal routine), Sadvratta (code of conduct), etc but seven principles are essential to follow to lead a healthy life. These are 1. Tri-upstairs (Ahara, Vihara, Brahmacharya) which is the main pillar of health, 2. Dincharya, 3. Ritucharya, 4. Avoidance of Vegadharana (suppression of natural urges), 5. Avoidance of Prajnapradha (renunciation) 6. Sadvratta (good code of conduct), 7. Yoga (to avoid mental stress). This article mainly emphasizes the preventive aspect of Lifestyle disorder by using the Ayurveda principle.

Theorizing necroptics: Invisibilization of violence and death-worlds

This paper examines the invisibilization of violence and deaths in India’s leading daily during the 1918 influenza pandemic, the Times of India. The pandemic killed more than 14 million Indians in a short span of time. Studying this historical event and the way it was reported in an influential newspaper, this research shows how media representations not only invisibilized the alarming levels of mortality, but also elided the efforts of colonial capitalism to profit from the loss of human life. Building on the work of Achille Mbembe, and through the concept of necroptics, this study examines the invisibility of violence as malign neglect that contributes to death-worlds. It shows how colonial violence was erased or mystified through media necroptics, which created untraceable deaths, that is, framed deaths as natural or systemic outcomes.

Adverse birth outcomes among women with 'low-risk' pregnancies in India: findings from the Fifth National Family Health Survey, 2019-21.

Despite substantial progress in improving maternal and newborn health, India continues to experience high rates of newborn mortality and stillbirths. One reason may be that many births happen in health facilities that lack advanced services-such as Caesarean section, blood transfusion, or newborn intensive care. Stratification based on pregnancy risk factors is used to guide 'high-risk' women to advanced facilities. To assess the utility of risk stratification for guiding the choice of facility, we estimated the frequency of adverse newborn outcomes among women classified as 'low risk' in India. We used the 2019-21 Fifth National Family Health Survey (NFHS-5)-India's Demographic and Health Survey-which includes modules administered to women aged 15-49 years. In addition to pregnancy history and outcomes, the survey collected a range of risk factors, including biomarkers. We used national obstetric risk guidelines to classify women as 'high risk' versus 'low risk' and assessed the frequency of stillbirths, newborn deaths, and unplanned Caesarean sections for the respondent's last pregnancy lasting 7 or more months in the past five years. We calculated the proportion of deliveries occurring at non-hospital facilities in all the Indian states. Using data from nearly 176,699 recent pregnancies, we found that 46.6% of India's newborn deaths and 56.3% of stillbirths were among women who were 'low risk' according to national guidelines. Women classified as 'low risk' had a Caesarean section rate of 8.4% (95% CI 8.1-8.7%), marginally lower than the national average of 10.0% (95% CI 9.8-10.3%). In India as a whole, 32.0% (95% CI 31.5-32.5%) of deliveries occurred in facilities that were likely to lack advanced services. There was substantial variation across the country, with less than 5% non-hospital public facility deliveries in Punjab, Kerala, and Delhi compared to more than 40% in Odisha, Madhya Pradesh, and Rajasthan. Newborn mortality tended to be lower in states with highest hospital delivery rates. Individual risk stratification based on factors identified in pregnancy fails to accurately predict which women will have delivery complications and experience stillbirth and newborn death in India. Thus a determination of 'low risk' should not be used to guide women to health facilities lacking key life saving services, including Caesarean section, blood transfusion, and advanced newborn resuscitation and care. Bill and Melinda Gates Foundation and the World Bank. The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the Gates Foundation or of the World Bank, its Executive Directors, or the countries they represent.