Cohort Profile: Hodal and Lowairpoa Demographic Surveillance Systems

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The Hodal and Lowairpoa Demographic Surveillance Systems (DSS) are located in North and North-East India, respectively, and were established in 2020 to ‘develop a longitudinal cohort of mother–infant dyad to evaluate pregnancy risk factors and their association with adverse pregnancy and infant outcomes’. The goal was to identify potential problems early, create, and facilitate appropriate referral pathways, and apply available and new tools to correct underlying and new vulnerabilities in women and children so that the quality of primary and secondary care is optimized, and pregnancy and birth outcomes improve for women and children. The populations served by Hodal and Lowairpoa DSSs were 199 084 and 150 579, respectively, in the baseline survey (2021–22). The survey round captures detailed household information, congenital anomalies and disabilities, births and deaths, women’s health and pregnancy information, anthropometry (under 5 years of age), and immunization details. The system also updates data for the entire population through quarterly, rapid pregnancy surveillance rounds between the complete DSS rounds by the study teams. The data can also be made available to bona fide researchers upon receipt of a proposal; collaboration requests are also welcomed through the corresponding author ([email protected]). The ground-level facts necessitate efforts to understand the barriers and challenges faced in assessing the magnitude of maternal and newborn health (MNH) problems, implementing government initiatives [1], and capturing real-time longitudinal data for further refinement of MNH strategies to develop sustainable and scalable solutions [2–4]. To address these gaps in implementation research and evidence mapping, a group of researchers from Christian Medical College (CMC)—Tamil Nadu, Society for Applied Studies (SAS)—New Delhi, and Makunda Christian Leprosy and General Hospital (Makunda hospital)—Assam formed the Pregnancy Risk Stratification platform. The group envisaged a ‘longitudinal maternal and newborn cohort that seeks to evaluate pregnancy risk factors and their associations with adverse pregnancy outcomes’. The goal of the study was to identify potential problems early, create, and facilitate appropriate referral pathways, and apply available and new tools to correct underlying and emerging vulnerabilities in women and children so that the quality of primary and secondary care is optimized, and pregnancy and birth outcomes improve for women and children. The study was registered as ‘Surveillance and Pregnancy/Perinatal Research Platform’ for two Indian sites, the Hodal Block of Palwal District in Haryana, and the Lowairpoa Block of Karimganj District in Assam. To support the activities of the platform, both sites setup a demographic surveillance system (DSS) in the year 2019–20. The DSS was intended to identify pregnancies early, promote early Antenatal Care registration, estimate the population-level burden of adverse outcomes among pregnant mothers and mother–infant dyads, monitor the demographic dynamics of the catchment area, facilitate the design of contextually adapted interventions and their evaluation, and build evidence for informed health policies. It was expected that this initiative would be adopted by the government beyond the project life span. The two sites were selected for the study after an initial site assessment by the coordinating site. At the outset, it was envisaged that the study sites should have a high maternal mortality ratio (MMR) and under-five mortality rate and have a catchment population of ∼100 000, with ∼2000 pregnant women annually, to capture the population-level estimates. The eligibility criteria for the sites were an MMR of 150 per 100 000 live births, an under-five mortality rate of 50 or above per 1000 live births, and a functional health facility that caters to the catchment population. The Hodal Demographic Surveillance System (Hodal DSS) was established by the SAS, New Delhi [5]. The SAS has been working closely with the state government of Haryana for more than two decades. The DSS site is located ∼100 km from the International Airport, New Delhi, in the Hodal Block of the Palwal District. For ease of implementation, the catchment areas of 37 villages were categorized into nine clusters, with populations ranging from 13 000 to 20 000, except for one large cluster with a population of 69 000. The catchment area has one subdivisional hospital (SDH), one community health center, two primary healthcare centers (PHCs), 15 subcenters, 10 functional Ayushman Arogya Mandir—Health and Wellness Centers (AAM-HWCs), and several private hospitals (Fig. 1). According to the consensus with the Haryana government, the SDH Hodal was selected as the study-implementing hospital. Study sites (a) Hodal block, Palwal district, Haryana; (b) Lowairpoa Block, Karimganj district, Assam. The Lowairpoa Demographic Surveillance System (Lowairpoa DSS) was established by Makunda hospital, located in the Lowairpoa Block of Karimganj district, Assam. It is a 250-bed, National Accreditation Board for Hospitals entry-level accredited, secondary-level charitable hospital that serves as the referral center for high-risk obstetric patients and sick infants under a public–private partnership with the National Health Mission, Assam. The DSS site, the Lowairpoa Community Development Block, is approximately 350 km away from Dispur, the state capital of Assam. The Lowairpoa Block is completely rural, and agriculture is the mainstay of the economy. It has heterogeneous communities living together in 110 villages, owing to its proximity to an international boundary and two interstate boundaries. The public health system in the Lowairpoa Block comprises 22 subcenters, nine AAM-HWCs, one mini-PHC, and one PHC. The Makunda hospital is the only private, secondary care hospital in the block. For ease of implementation, the DSS site area is divided geographically into five clusters with populations ranging from 25 000 to 49 000 (Fig. 1). For both population-based cohorts, the baseline assessment was conducted from July 2021 to May 2022 to capture descriptive information about the population and document mortality rates. The follow-up round was conducted between May 2023 and September 2023 to update the population parameters. During the baseline surveillance round at Hodal DSS a total of 36 822 households were identified. Among these households, 99.3% consented to participate in the survey, and the remaining did not consent due to the nonavailability of decision-maker family members or the nonavailability of households during the survey. We enrolled 199 084 individuals from 36 560 households. The sample comprised 52.6% males and 47.4% females. The average family size was 5.4, with ∼60% of the population younger than 30 years (Fig. 2). The cohort included 55.8% nuclear families, 51.4% general caste, and 96.4% Hindus with a median monthly income of Indian Rupee 15 000 (10 000–12 000). The primary language of 99.9% of the households was Hindi, 74% reported that they were literate (had at least a primary level of schooling), and 75.1% of the head of household were working (Table 1). Population pyramids. Sociodemographic characteristics IQR, interquartile range; PDS, public distribution system; BPL, below poverty level; APL, above poverty level; INR, —Indian Rupees. The baseline round of Lowairpoa DSS captured a total of 33 651 households. Among these households, 96.7% consented to participate in the survey. We enrolled 150 579 individuals from 32 532 households. The sample consisted of 51.3% males and 48.7% females. The average family size was 4.6, with ∼61% of the population younger than 30 years (Fig. 2). The cohort had 72.8% nuclear families, 41.9% Other Backward Classes caste, and 65.3% and 30.8% following the Hindu and Muslim religions, respectively and had a median monthly income of Indian Rupee 6000 (4000–9000). The primary language of 5

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