New Option in the Lives Saved Tool (LiST) Allows for the Conversion of Prevalence of Small-for-Gestational-Age and Preterm Births to Prevalence of Low Birth Weight

Multiple micronutrient supplementation cost-benefit tool for informing maternal nutrition policy and investment decisions

Antenatal multiple micronutrient supplementation (MMS) is an intervention that can help reach three of the six global nutrition targets, either directly or indirectly: a reduction in low birth weight, stunting, and anaemia in women of reproductive age. To support global guideline development and national decision-making on investments into maternal nutrition, Nutrition International developed a modelling tool called the MMS cost-benefit tool to help users understand whether antenatal MMS is better value for money than iron and folic acid supplementation (IFAS) during pregnancy. The MMS cost-benefit tool can generate estimates on the potential health impact, budget impact, economic value, cost-effectiveness and benefit-cost ratio of investing in MMS compared to IFAS in LMICs. In the 33 countries with data included in the tool, the MMS cost-benefit tool shows that transitioning is expected to generate substantial health benefits in terms of morbidity and mortality averted and can be very cost-effective in multiple scenarios for these countries. The cost per DALY averted averages at US$ 23.61 and benefit-cost ratio ranges from US$ 41-US$ 1304: $1.0, which suggest MMS is good value for money compared with IFAS. With its user-friendly design, open access availability, and online data-driven analytics, the MMS cost-benefit tool can be a powerful resource for governments and nutrition partners seeking timely and evidence-based analyses to inform policy-decision and investments towards the scale-up of MMS for pregnant women globally.

Intrauterine growth restriction, prematurity, and low birth weight: risk phenotypes of neonatal death, Rio de Janeiro State, Brazil

Intrauterine growth restriction and prematurity determine low birth weight. The combination of the three conditions results in different neonatal phenotypes that interfere with child survival. Neonatal prevalence, survival and mortality were estimated according to neonatal phenotypes in the cohort of live births in 2021 in the state of Rio de Janeiro, Brazil. In this study, live births of multiple pregnancies, with congenital anomalies and inconsistencies in the information of weight and gestational age were excluded. The Intergrowth curve was used to classify weight adequacy. Mortality (< 24 hours, 1-6 and 7-27 days) and survival (Kaplan-Meier) were estimated. In total, 6.8%, 5.5%, and 9.5% of the 174,399 live births were low birth weight, small for gestational age (SGA), and premature, respectively. Considering low birth weight live births, 39.7% were SGA and 70% were premature. The neonatal phenotypes were heterogeneous according to maternal, delivery, pregnancy, and newborn characteristics. The mortality rate per 1,000 live births was high for low birth weight premature newborns, both SGA (78.1) and AGA (adequate for gestational age: 61.1), at all specific ages. Reductions in the survival rate were observed when comparing non-low birth weight and AGA term live births. The estimated prevalence values were lower than those of other studies, partly due to the exclusion criteria adopted. The neonatal phenotypes identified children who were more vulnerable and at higher risk of death. Prematurity contributed more to mortality than SGA, and its prevention is necessary to reduce neonatal mortality in the state of Rio de Janeiro.

Effect of sunflower seed oil emollient therapy on newborn infant survival in Uttar Pradesh, India: A community-based, cluster randomized, open-label controlled trial

BACKGROUND

Hospitalized preterm infants with compromised skin barrier function treated topically with sunflower seed oil (SSO) have shown reductions in sepsis and neonatal mortality rate (NMR). Mustard oil and products commonly used in high-mortality settings may possibly harm skin barrier integrity and enhance risk of infection and mortality in newborn infants. We hypothesized that SSO therapy may reduce NMR in such settings.

METHODS AND FINDINGS

This was a population-based, cluster randomized, controlled trial in 276 clusters in rural Uttar Pradesh, India. All newborn infants identified through population-based surveillance in the study clusters within 7 days of delivery were enrolled from November 2014 to October 2016. Exclusive, 3 times daily, gentle applications of 10 ml of SSO to newborn infants by families throughout the neonatal period were recommended in intervention clusters (n = 138 clusters); infants in comparison clusters (n = 138 clusters) received usual care, such as massage practice typically with mustard oil. Primary analysis was by intention-to-treat with NMR and post-24-hour NMR as the primary outcomes. Secondary analysis included per-protocol analysis and subgroup analyses for NMR. Regression analysis was adjusted for caste, first-visit weight, delivery attendant, gravidity, maternal age, maternal education, sex of the infant, and multiple births. We enrolled 13,478 (52.2% male, mean weight: 2,575.0 grams ± standard deviation [SD] 521.0) and 13,109 (52.0% male, mean weight: 2,607.0 grams ± SD 509.0) newborn infants in the intervention and comparison clusters, respectively. We found no overall difference in NMR in the intervention versus the comparison clusters [adjusted odds ratio (aOR) 0.96, 95% confidence interval (CI) 0.84 to 1.11, p = 0.61]. Acceptance of SSO in the intervention arm was high at 89.3%, but adherence to exclusive applications of SSO was 30.4%. Per-protocol analysis showed a significant 58% (95% CI 42% to 69%, p < 0.01) reduction in mortality among infants in the intervention group who were treated exclusively with SSO as intended versus infants in the comparison group who received exclusive applications of mustard oil. A significant 52% (95% CI 12% to 74%, p = 0.02) reduction in NMR was observed in the subgroup of infants weighing ≤1,500 g (n = 589); there were no statistically significant differences in other prespecified subgroup comparisons by low birth weight (LBW), birthplace, and wealth. No severe adverse events (SAEs) were attributable to the intervention. The study was limited by inability to mask allocation to study workers or participants and by measurement of emollient use based on caregiver responses and not actual observation.

CONCLUSIONS

In this trial, we observed that promotion of SSO therapy universally for all newborn infants was not effective in reducing NMR. However, this result may not necessarily establish equivalence between SSO and mustard oil massage in light of our secondary findings. Mortality reduction in the subgroup of infants ≤1,500 g was consistent with previous hospital-based efficacy studies, potentially extending the applicability of emollient therapy in very low-birth-weight (VLBW) infants along the facility-community continuum. Further research is recommended to develop and evaluate therapeutic regimens and continuum of care delivery strategies for emollient therapy for newborn infants at highest risk of compromised skin barrier function.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN38965585 and Clinical Trials Registry-India (CTRI/2014/12/005282) with WHO UTN # U1111-1158-4665.

Relative impact of pre-eclampsia on birth weight in a low resource setting: A prospective cohort study

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Pre-eclampsia is the major determinant of birthweight across all gestations in Uganda.

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Pre-eclampsia accounts for ×10 more birthweight variability than all other factors.

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In pre-eclampsia, gestation predicts birthweight better than disease severity.

Objectives

Low birth-weight is a major risk factor for perinatal death in sub-Saharan Africa, but the relative contribution of determinants of birth-weight are difficult to disentangle in low resource settings. We sought to delineate the relationship between birth-weight and maternal pre-eclampsia across gestation in a low-resource obstetric setting.

Study design

Prospective cohort study in a tertiary referral centre in urban Uganda, including 971 pre-eclampsia cases and 1461 control pregnancies between 28 and 42 weeks gestation.

Main outcome measures

Nonlinear modeling of birth-weight versus maternal pre-eclampsia status across gestation. Models were adjusted for maternal-fetal characteristics including maternal age, parity, HIV status, and socio-economic status. Propensity score matching was used to control for the severity of pre-eclampsia at different gestational ages.

Results

Mean birth-weight for pre-eclampsia cases was 2.48 kg (±0.81SD) compared to 3.06 kg (±0.46SD) for controls (p < 0.001). At 28 weeks, the mean birth-weight difference between pre-eclampsia cases and controls was 0.58 kg (p < 0.05), narrowing to 0.17 kg at 39 weeks (p < 0.01). Controlling for pre-eclampsia severity only partially explained this gestational difference in mean birth-weight between pre-eclampsia cases and controls. Holding gestational age constant, pre-eclampsia status predicted 7.1–10.5% of total variation in birth-weight, compared to 0.05–0.7% for all other maternal-fetal characteristics combined.

Conclusions

Pre-eclampsia is the dominant predictor of birth-weight in low-resource settings and hence likely to heavily influence perinatal survival. The impact of pre-eclampsia on birth-weight is smaller with advancing gestational age, a difference that is not fully explained by controlling for pre-eclampsia severity.

Multiple Micronutrient Supplements Are More Cost-effective Than Iron and Folic Acid: Modeling Results from 3 High-Burden Asian Countries

BACKGROUND

Recent evidence has encouraged low- and middle-income countries to consider transitioning from long-standing iron and folic acid supplementation (IFA) to multiple micronutrient supplementation (MMS) during pregnancy; however, global guidance is limited. To facilitate national decision-making, a cost-effectiveness model to compare supplementation approaches was developed, and applied to Pakistan, India, and Bangladesh.

OBJECTIVE

We evaluated the incremental cost-effectiveness of transitioning from IFA to MMS.

METHODS

The effectiveness of IFA compared with MMS during pregnancy was compared using 8 health outcomes reported in 2 meta-analyses published in 2017 (Cochrane and The Lancet). Impacts on health outcomes were aggregated using disability-adjusted life years (DALYs). Costs included the supplements and their distribution through antenatal care. The incremental cost-effective ratio (ICER) for transitioning from IFA to MMS was calculated for each country under each meta-analysis scenario, and Monte Carlo simulations were applied to generate a measure of certainty around the results.

RESULTS

The effectiveness of transitioning from IFA to MMS under the Cochrane scenario was smaller and less certain compared with The Lancet scenario. However, even under the Cochrane scenario, MMS would avert 4,391, 5,769, and 8,578 more DALYs than IFA per 100,000 pregnancies in Pakistan, India, and Bangladesh, respectively (62.6%, 76.8%, and 82.6% certainty). The ICER of transitioning from IFA to MMS was 41.54, 31.62, and 21.26 US dollars (USD 2016) per DALY averted, respectively.

CONCLUSIONS

Despite discrepancies in the overall effect of MMS depending on the meta-analysis used, MMS is cost-effective and generates positive health outcomes for both infants and pregnant women. Whilst the effectiveness of MMS is sensitive to the prevalence of certain health outcomes under the conservative scenario (Cochrane), MMS nevertheless averts more DALYs than IFA with high certainty and should re-enter public health discussion in Pakistan, India, and Bangladesh.

Projecting stunting and wasting under alternative scenarios in Odisha, India, 2015-2030: a Lives Saved Tool (LiST)-based approach

OBJECTIVE

Although nutrition-specific interventions are designed based on maternal, household and community-level correlates, no attempt has been made to project stunting and wasting and identify intervention priorities in India. The objective of this paper is to model the stunting and wasting in the state of Odisha, India by scaling up maternal and child health interventions under alternative scenarios.

DESIGN

This study primarily used data from National Family Health Survey 4, 2015-2016.

MEASURES

The LiST (Lives Saved Tool) software is used to model the nutritional outcomes and prioritise interventions. The projections were carried out under four alternative scenarios: scenario 1-if the coverage indicators continued based on past trends; scenario 2-scaled up to the level of the richest quintile; scenario 3-scaled up to that of Tamil Nadu; and scenario 4-scaled up to an aspirational coverage level.

RESULTS

In 2015, out of 3.52 million under-5 children in Odisha, around 1.20 million were stunted. By 2030, the numbers of stunted children will be 1.11 million under scenario 1, 1.07 million under scenario 2, 1.09 million under scenario 3 and 0.89 million under scenario 4. The projected stunting level will be 25% under scenario 4 and around 31% under all other scenarios. By 2030, the level of wasting will remain unchanged at 20% under the first three scenarios and 4.3% under scenario 4. Appropriate complementary feeding would avert about half of the total stunting cases under all four scenarios, followed by zinc supplementation. Water connection at home, washing hands with soap and improved sanitation are other effective interventions.

CONCLUSION

Sustaining the maternal and child health interventions, promoting evidence-based stunting and wasting reduction interventions, and a multisectoral approach can achieve the World Health Assembly targets and Sustainable Development Goals of undernutrition in Odisha.

Modeling the Impact of Nutrition Interventions on Birth Outcomes in the Lives Saved Tool (LiST)

Background: Negative birth outcomes [small-for-gestational age (SGA) and preterm birth (PTB)] are common in low- and middle-income countries and have important subsequent health and developmental impacts on children. There are numerous nutritional and non-nutritional interventions that can decrease the risk of negative birth outcomes and reduce subsequent risk of mortality and growth faltering.Objective: The objective of this article was to review the current evidence for the impact of nutritional interventions in pregnancy [calcium supplementation, iron and folic acid supplementation, multiple micronutrient (MMN) supplementation, and balanced energy supplementation (BES)] and risk factors (maternal anemia) on birth outcomes, with the specific goal of determining which intervention-outcome linkages should be included in the Lives Saved Tool (LiST) software.Methods: A literature search was conducted by using the WHO e-Library of Evidence for Nutrition Actions as the starting point. Recent studies, meta-analyses, and systematic reviews were reviewed for inclusion on the basis of their relevance to LiST.Results: On the basis of the available scientific evidence, the following linkages were found to be supported for inclusion in LiST: calcium supplementation on PTB (12% reduction), MMN supplementation on SGA (9% reduction), and BES on SGA (21% reduction among food-insecure women).Conclusions: The inclusion of these linkages in LiST will improve the utility of the model for users who seek to estimate the impact of antenatal nutrition interventions on birth outcomes. Scaling up these interventions should lead to downstream impacts in reducing stunting and child mortality.

Nutrition Interventions in the Lives Saved Tool (LiST)

The Lives Saved Tool (LiST) was initially developed in 2003 to estimate the impact of increasing coverage of efficacious interventions on under-5 mortality. Over time, the model has been expanded to include more outcomes (neonatal mortality, maternal mortality, stillbirths) and interventions. The model has also added risk factors, such as stunting and wasting, and over time has attempted to capture a full range of nutrition and nutrition-related interventions (e.g., antenatal supplementation, breastfeeding promotion, child supplemental feeding, acute malnutrition treatment), practices (e.g., age-appropriate breastfeeding), and outcomes (e.g., stunting, wasting, birth outcomes, maternal anemia). This article reviews the overall nutrition-related structure, assumptions, and outputs that are currently available in LiST. This review focuses on the new assumptions and structure that have been added to the model as part of the current effort to expand and improve the nutrition modeling capability of LiST. It presents the full set of linkages in the model that relate to nutrition outcomes, as well as the research literature used to support those linkages.