Opportunities and challenges for financing women's, children's and adolescents' health in the context of climate change

Women, children and adolescents (WCA), especially in low-income and middle-income countries (LMICs), will bear the worst consequences of climate change during their lifetimes, despite contributing the least to global greenhouse gas emissions. Investing in WCA can address these inequities in climate risk, as well as generating large health, economic, social and environmental gains. However, women's, children's and adolescents' health (WCAH) is currently not mainstreamed in climate policies and financing. There is also a need to consider new and innovative financing arrangements that support WCAH alongside climate goals.We provide an overview of the threats climate change represents for WCA, including the most vulnerable communities, and where health and climate investments should focus. We draw on evidence to explore the opportunities and challenges for health financing, climate finance and co-financing schemes to enhance equity and protect WCAH while supporting climate goals.WCA face threats from the rising burden of ill-health and healthcare demand, coupled with constraints to healthcare provision, impacting access to essential WCAH services and rising out-of-pocket payments for healthcare. Climate change also impacts on the economic context and livelihoods of WCA, increasing the risk of displacement and migration. These impacts require additional resources to support WCAH service delivery, to ensure continuity of care and protect households from the costs of care and enhance resilience. We identify a range of financing solutions, including leveraging climate finance for WCAH, adaptive social protection for health and adaptations to purchasing to promote climate action and support WCAH care needs.

Routine antibiotics for infants less than 6 months of age with growth failure/faltering: a systematic review

OBJECTIVE

This systematic review commissioned by WHO aimed to synthesise evidence from current literature on the effects of systematically given, routine use of antibiotics for infants under 6 months of age with growth failure/faltering.

SETTINGS

Low-income and middle-income countries.

PARTICIPANTS

The study population was infants less than 6 months of age with growth failure/faltering.

INTERVENTION

The intervention group was infants who received no antibiotics or antibiotics other than those recommended in 2013 guidelines by WHO to treat childhood severe acute malnutrition. The comparison group was infants who received antibiotics according to the aforementioned guidelines.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was all-cause mortality, and secondary outcomes: clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections and non-response. The Grading of Recommendations Assessment, Development and Evaluation approach was considered to report the overall evidence quality for an outcome.

RESULTS

We screened 5137 titles and abstracts and reviewed the full text of 157 studies. None of the studies from the literature search qualified to answer the question for this systematic review.

CONCLUSIONS

There is a paucity of evidence on the routine use of antibiotics for the treatment of malnutrition in infants less than 6 months of age. Future studies with adequate sample sizes are needed to assess the potential risks and benefits of antibiotics in malnourished infants under 6 months of age.

PROSPERO REGISTRATION NUMBER

CRD42021277073.

Polio eradication: Addressing the hurdles on the last mile

1988, the World Health Assembly committed to eradicate poliomyelitis, a viral disease that can cause permanent paralysis. Today, only type 1 of the three wild poliovirus types remains circulating in limited geographic areas following widespread use of different poliovirus vaccines. While we are close to zero new cases of wild polio, it is a fragile situation, and there are many remaining and new hurdles to overcome. Here, experts discuss how to address them.

Infections and nutrient deficiencies during infancy predict impaired growth at 5 years: Findings from the MAL-ED study in Pakistan

Background

Socio-economic, nutritional, and infectious factors have been associated with impaired infant growth, but how the presence of these factors during infancy affects growth around 5 years is not well understood.

Methods

This secondary analysis of the MAL-ED cohort included 277 children from Pakistan for whom socio-demographic, breastfeeding, complementary foods, illness, nutritional biomarkers, stool pathogens and environmental enteropathy indicators between 0 and 11 months were recorded. We used linear regression models to analyze associations of these indicators with height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height (WLZ) at 54-66 months (~5 years), and Poisson regression with robust standard errors to estimate risk ratios for stunting and underweight ~5 years, controlling for gender, first available weight, and income.

Results

Among the 237 infants followed longitudinally and evaluated at about 5 years of age, exclusive breastfeeding was short (median = 14 days). Complementary feeding started before 6 months with rice, bread, noodles, or sugary foods. Roots, dairy products, fruits/vegetables, and animal-source foods were provided later than recommended (9-12 months). Anemia (70.9%), deficiencies in iron (22.0%), zinc (80.0%), vitamin A (53.4%) and iodine (13.3%) were common. Most infants (>90%) presented with diarrhea and respiratory infections in their first year. At ~5 years, low WAZ (mean-1.91 ± 0.06) and LAZ (-2.11 ± 0.06) resulted in high prevalence of stunting (55.5%) and underweight (44.4%) but a relatively low rate of wasting (5.5%). While 3.4% had concurrent stunting and wasting ~5 years, 37.8% of children had coexisting stunting and underweight. A higher income and receiving formula or dairy products during infancy were associated with a higher LAZ ~5 years, but infant's history of hospitalizations and more respiratory infections were associated with lower LAZ and higher risk of stunting ~5 years. Infants' intake of commercial baby foods and higher serum-transferrin receptors were associated with higher WAZ and lower risk of underweight ~5 years. Presence of Campylobacter and fecal neopterin >6.8 nmol/L in the first year were associated with increased risk of underweight ~5 years.

Conclusion

Growth indicators ~5 years were associated with poverty, inappropriate complementary feeding, and infections during the first year of life, which supports the early start of public health interventions for preventing growth delay ~5 years.

Indirect effects of COVID-19 on child and adolescent mental health: an overview of systematic reviews

INTRODUCTION

To control the spread of COVID-19, mitigation strategies have been implemented globally, which may have unintended harmful effects on child and adolescent mental health. This study aims to synthesise the indirect mental health impacts on children and adolescents globally due to COVID-19 mitigation strategies.

METHODS

We included relevant reviews from MEDLINE, Embase, PsycINFO, LILACS, CINAHL, The Cochrane Library and Web of Science until January 2022 that examined the impact of COVID-19-related lockdown and stay-at-home measures on the mental health of children and adolescents. Data extraction and quality assessments were completed independently and in duplicate by BC and LH. A Measurement Tool to Assess Systematic Reviews-2 was used to assess the methodological quality.

RESULTS

Eighteen systematic reviews, comprising 366 primary studies, found a pooled prevalence of 32% for depression (95% CI: 27 to 38, n=161 673) and 32% for anxiety (95% CI: 27 to 37, n=143 928) in children and adolescents globally following COVID-19 mitigation measures. Subgroup analyses also uncovered important differences for both depression and anxiety by World Health Organization regions with few studies from Africa and relative high burden of anxiety and depression in the Eastern Mediterranean region.

CONCLUSIONS

Our findings reveal a high prevalence of depression and anxiety in children and adolescents during the COVID-19 pandemic, globally, compared with prepandemic estimates. These findings highlight the urgency for governments and policymakers to strengthen mental health systems in the COVID-19 recovery, especially in low-and middle-income countries where compounding psychological stress, access and affordability of care and discrepant reporting of mental health in this population remains a challenge. We also provide insight into how to alter mitigation strategies to reduce the unintended negative consequences for the health and well-being of children and adolescents in future pandemics.

PROSPERO REGISTRATION NUMBER

CRD42022309348.

Perpetuation of gender discrimination in Pakistani society: results from a scoping review and qualitative study conducted in three provinces of Pakistan

BACKGROUND

Gender discrimination is any unequal treatment of a person based on their sex. Women and girls are most likely to experience the negative impact of gender discrimination. The aim of this study is to assess the factors that influence gender discrimination in Pakistan, and its impact on women's life.

METHODS

A mixed method approach was used in the study in which a systematic review was done in phase one to explore the themes on gender discrimination, and qualitative interviews were conducted in phase two to explore the perception of people regarding gender discrimination. The qualitative interviews (in-depth interviews and focus group discussions) were conducted from married men and women, adolescent boys and girls, Healthcare Professionals (HCPs), Lady Health Visitors (LHVs) and Community Midwives (CMWs). The qualitative interviews were analyzed both manually and electronically through QSR NVivo 10. The triangulation of data from the systematic review and qualitative interviews were done to explore the gender discrimination related issues in Pakistan.

RESULTS

The six major themes have emerged from the systematic review and qualitative interviews. It includes (1) Status of a woman in the society (2) Gender inequality in health (3) Gender inequality in education (4) Gender inequality in employment (5) Gender biased social norms and cultural practices and (6) Micro and macro level recommendations. In addition, a woman is often viewed as a sexual object and dependent being who lacks self identity unless being married. Furthermore, women are restricted to household and child rearing responsibilities and are often neglected and forced to suppress self-expression. Likewise, men are viewed as dominant figures in lives of women who usually makes all family decisions. They are considered as financial providers and source of protection. Moreover, women face gender discrimination in many aspects of life including education and access to health care.

CONCLUSION

Gender discrimination is deeply rooted in the Pakistani society. To prevent gender discrimination, the entire society, especially women should be educated and gendered sensitized to improve the status of women in Pakistan.

Opportunities and challenges to non-communicable disease (NCD) research and training in Pakistan: a qualitative study from Pakistan

INTRODUCTION

Most of the global non-communicable disease (NCD)-related death burden is borne by low and middle-income countries (LMICs). In LMICs like Pakistan, however, a major gap in responding to NCDs is a lack of high-quality research leading to policy development and implementation of NCDs. To assess institutional opportunities and constraints to NCD research and training we conducted a situational analysis for NCD research and training at Aga Khan University Pakistan.

METHODS

We conducted a descriptive exploratory study using grounded theory as a qualitative approach: semistructured interviews of 16 NCD stakeholders (three excluded) and two focus group discussions with postgraduate and undergraduate trainees were conducted. A simple thematic analysis was done where themes were identified, and then recurring ideas were critically placed in their specific themes and refined based on the consensus of the investigators.

RESULTS

The major themes derived were priority research areas in NCDs; methods to improve NCD research integration; barriers to NCD research in LMICs like Pakistan; design of NCD research programme and career paths; and NCD prevention at mass level, policy and link to the government. In general, participants opined that while there was an appetite for NCD research and training, but few high-quality research training programmes in NCDs existed, such programmes needed to be established. The ideal NCD research and training programmes would have in-built protected time, career guidance and dedicated mentorship. Most participants identified cardiovascular diseases as a priority thematic area and health information technology and data science as key methodological approaches to be introduced into research training.

CONCLUSION

We conclude from this qualitative study on NCD research and training that high-quality research training programmes for NCDs are rare. Such programmes need to be established with in-built protected time, career guidance and mentorship for the trainees to improve their research capacity in Pakistan.

Increased vs. Standard Dose of Iron in Ready-to-Use Therapeutic Foods for the Treatment of Severe Acute Malnutrition in a Community Setting: A Systematic Review and Meta-Analysis

The optimal dose of iron in ready-to-use therapeutic foods (RUTF) used to treat uncomplicated severe acute malnutrition (SAM) in community settings is not well established. The objective of this systematic review was to assess if an increased iron dose in RUTF, compared with the standard iron dose in the World Health Organization (WHO)-recommended peanut-based RUTF, improved outcomes in children aged six months or older. We searched multiple electronic databases and only included randomized controlled trials. We pooled the data in a meta-analysis to obtain relative risk (RR) and reported it with a 95% confidence interval (CI). Three studies, one each from Zambia, the Democratic Republic of Congo, and Malawi, were included. In all studies, the RUTF used in the intervention group was milk-free soya–maize–sorghum-based RUTF. The pooled results showed that, compared to the control group, a high iron content in RUTF may lead to increase in hemoglobin concentration (mean difference 0.33 g/dL, 95% CI: 0.02, 0.64, two studies, certainty of evidence: low) and a decrease in any anemia (RR 0.66, 95% CI: 0.48, 0.91, two studies, certainty of evidence: low), but also decrease recovery rates (RR 0.91, 95% CI: 0.84, 0.99, three studies, certainty of evidence: low) and increase mortality (RR 1.30, 95% CI: 0.87, 1.95, three studies, certainty of evidence: moderate). However, the CIs were imprecise for the latter outcome. Future studies with large sample sizes are needed to confirm the beneficial versus harmful effects of high iron content in RUTF in treating uncomplicated SAM in children aged 6-59 months in community settings.

Protocol for a systematic review on routine use of antibiotics for infants less than 6 months of age with growth failure/faltering

INTRODUCTION

Antibiotics have been used as an adjunct in treating children with severe acute malnutrition 6-59 months of age; however, the data for infants less than 6 months are scarce. The WHO recently started guideline development for preventing and treating wasting, including growth failure/faltering in infants less than 6 months. This systematic review commissioned by WHO aims to synthesise evidence from current literature on the effectiveness of antibiotics for infants less than 6 months of age with growth failure/faltering.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis for studies that assessed the effect of antibiotics in the treatment of infants with growth faltering. We will search multiple electronic databases. We will include randomised control trials and non-randomised studies with a control arm. The study population is infants less than 6 months of age with growth failure. The intervention group will be infants who received no antibiotics or antibiotics other than recommended in 2013 guidelines by WHO to treat severe acute malnutrition in children. The comparison group will be infants who received antibiotics according to the 2013 guideline by WHO. We will consider the following outcomes: mortality, clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections, non-response. We will use the meta-analysis to pool the studies where applicable. We will use the Grading of Recommendations Assessment, Development, and Evaluation approach to reporting the overall evidence quality for an outcome.

ETHICS AND DISSEMINATION

This is a systematic review and will not involve contact with a human subject. The findings of this review will be published in a peer-review journal and will guide the WHO's recommendation for the use of antibiotics in infants less than 6 months of age with growth failure.

PROSPERO REGISTRATION NUMBER

CRD42021277073.

Optimal iron content in ready-to-use therapeutic foods for the treatment of severe acute malnutrition in the community settings: a protocol for the systematic review and meta-analysis

INTRODUCTION

The current standard of care for children with severe acute malnutrition (SAM) involves using ready-to-use therapeutic food (RUTF) to promote growth; however, the precise formulation to achieve optimal recovery remains unclear. Emerging research suggests that alternative RUTF formulations may be more effective in correcting SAM-related complications such as anaemia and iron deficiency. This systematic review commissioned by the WHO aims to synthesise the most recent research on the iron content in RUTF and related products in the community-based treatment of uncomplicated severe malnutrition in children aged 6 months and older.

METHODS AND ANALYSIS

We will search multiple electronic databases. We will include randomised controlled trials and non-randomised studies with a control arm. The intervention group will be infants who received RUTF treatments other than the current recommended guidelines set forth by the WHO. The comparison group is children receiving RUTF containing iron at the current WHO-recommended level of 1.9 mg/100 kcal (10-14 mg/100 g). The primary outcomes of interest include blood haemoglobin concentration, any anaemia, severe anaemia, iron-deficiency anaemia, recovery from SAM and any adverse outcomes. We will use meta-analysis to pool findings if sufficient homogeneity exists among included studies. The risk of bias in studies will be evaluated using the Cochrane risk of bias-2. We will use the Grading of Recommendations Assessment, Development, and Evaluation(GRADE) approach to examine the overall certainty of evidence.

ETHICS AND DISSEMINATION

This is a systematic review and will not involve direct contact with human subjects. The findings of this review will be published in a peer-reviewed journal and will guide the WHO's recommendation on the optimal iron content in RUTFs for the treatment of SAM in children aged 6-59 months.

Characteristics and birth outcomes of pregnant adolescents compared to older women: An analysis of individual level data from 140,000 mothers from 20 RCTs

BACKGROUND

Adolescence is a critical period of maturation when nutrient needs are high, especially among adolescents entering pregnancy. Using individual-level data from 140,000 participants, we examined socioeconomic, nutrition, and pregnancy and birth outcomes for adolescent mothers (10-19 years) compared to older mothers in low and middle-income countries.

METHODS

This study was conducted between March 16, 2018 and May 25, 2021. Data were obtained from 20 randomised controlled trials of micronutrient supplementation in pregnancy. Stratified analyses were conducted by age (10-14 years, 15-17 years, 18-19 years, 20-29 years, 30-39 years, 40+ years) and geographical region (Africa, Asia). Crude and confounder-adjusted means, prevalence and relative risks of pregnancy, nutrition and birth outcomes were estimated using multivariable linear and log-binomial regression models with 95% confidence intervals.

FINDINGS

Adolescent mothers comprised 31.6% of our data. Preterm birth, small-for-gestational age (SGA), low birthweight (LBW) and newborn mortality followed a U-shaped trend in which prevalence was highest among the youngest mothers (10-14 years) and then reduced gradually, but increased again for older mothers (40+ years). When compared to mothers aged 20-29 years, there was a 23% increased risk of preterm birth, a 60% increased risk of perinatal mortality, a 63% increased risk of neonatal mortality, a 28% increased risk of LBW, and a 22% increased risk of SGA among mothers 10-14 years. Mothers 40+ years experienced a 22% increased risk of preterm birth and a 103% increased risk of stillbirth when compared to the 20-29 year group.

INTERPRETATION

The youngest and oldest mothers suffer most from adverse pregnancy and birth outcomes. Policy and programming agendas should consider both biological and socioeconomic/environmental factors when targeting these populations.

FUNDING

Bill and Melinda Gates Foundation (Grant No: OP1137750).

The Effect of Consumption of Animal Milk Compared to Infant Formula for Non-Breastfed/Mixed-Fed Infants 6–11 Months of Age: A Systematic Review and Meta-Analysis

Many infants do not receive breastmilk for the recommended 2-year duration. Instead, alternative milk beverages are often used, including infant formula and raw animal milk products. The purpose of this systematic review was to summarize the effect of animal milk consumption, compared to infant formula, on health outcomes in non-breastfed or mixed-fed infants aged 6–11 months. We searched multiple databases and followed Cochrane guidelines for conducting the review. The primary outcomes were anemia, gastrointestinal blood loss, weight-for-age, length-for-age, and weight-for-length. Nine studies were included: four randomized controlled trials (RCT) and five cohort studies. All studies, except one, were conducted in high income countries. There was a low certainty of evidence that cow’s milk increased the risk of anemia compared to formula milk (Cohort studies RR: 2.26, 95% CI: 1.15, 4.43, RCTs: RR: 4.03, 95% CI: 1.68, 9.65) and gastrointestinal blood loss (Cohort study RR: 1.52, 95% CI: 0.73, 3.16, RCTs: RR: 3.14, 95% CI: 0.98, 10.04). Additionally, there was low certainty evidence that animal milk consumption may not have a differential effect on weight and length-for-age compared to formula milk. Overall, the evidence was of low certainty and no solid conclusions can be drawn from this data. Further studies are needed from low- and middle-income countries to assess optimal milk type in non-breastfed infants aged 6–11 months.

Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial

BACKGROUND

Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh.

METHODS AND ANALYSIS

A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03588377.

Implementation of health and health-related sustainable development goals: progress, challenges and opportunities - a systematic literature review

Introduction

While health is one of the Sustainable Development Goals (SDGs), many other ‘health-related’ goals comprise determinants of health. Integrated implementation across SDGs is needed for the achievement of Agenda 2030. While existing literature is rich in normative recommendations about potentially useful approaches, evidence of implementation strategies being adopted by countries is limited.

Methods

We conducted a systematic review with qualitative synthesis of findings using peer reviewed and grey literature from key databases. We included publications examining implementation of health and health-related SDGs (HHSDGs) at national or subnational level published between June 2013 and July 2019.

Results

Of the 32 included publications, 24 provided information at the national level while eight provided information for multiple countries or regions. Our findings indicate that high-level political commitment is evident in most countries and HHSDGs are being aligned with existing national development strategies and plans. A multisectoral, integrated approach is being adopted in institutional setups but evidence on effectiveness of these approaches is limited. Funding constraints are a major challenge for many countries. HHSDGs are generally being financed from within existing funded plans and, in some instances, through SDG-specific budgeting and tracking; additional funding is being mobilised by increasing domestic taxation and subsidisation, and by collaborating with development partners and private sector. Equity is being promoted by improving health service access through universal health coverage and social insurance schemes, especially for disadvantaged populations. Governments are collaborating with development partners and UN agencies for support in planning, institutional development and capacity building. However, evidence on equity promotion, capacity building initiatives and implementation approaches at subnational level is limited. Lack of coordination among various levels of government emerges as a key challenge.

Conclusion

strengthening implementation of multisectoral work, capacity building, financial sustainability and data availability are key considerations to accelerate implementation of HHSDGs.

A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems

This paper introduces a framework for conducting and disseminating mixed methods research on positive outlier countries that successfully improved their health outcomes and systems. We provide guidance on identifying exemplar countries, assembling multidisciplinary teams, collecting and synthesising pre-existing evidence, undertaking qualitative and quantitative analyses, and preparing dissemination products for various target audiences. Through a range of ongoing research studies, we illustrate application of each step of the framework while highlighting key considerations and lessons learnt. We hope uptake of this comprehensive framework by diverse stakeholders will increase the availability and utilisation of rigorous and comparable insights from global health success stories.

Fetal cerebellar growth and Sylvian fissure maturation: international standards from Fetal Growth Longitudinal Study of INTERGROWTH-21st Project

OBJECTIVE

To construct international ultrasound-based standards for fetal cerebellar growth and Sylvian fissure maturation.

METHODS

Healthy, well nourished pregnant women, enrolled at < 14 weeks' gestation in the Fetal Growth Longitudinal Study (FGLS) of INTERGROWTH-21^st , an international multicenter, population-based project, underwent serial three-dimensional (3D) fetal ultrasound scans every 5 ± 1 weeks until delivery in study sites located in Brazil, India, Italy, Kenya and the UK. In the present analysis, only those fetuses that underwent developmental assessment at 2 years of age were included. We measured the transcerebellar diameter and assessed Sylvian fissure maturation using two-dimensional ultrasound images extracted from available 3D fetal head volumes. The appropriateness of pooling data from the five sites was assessed using variance component analysis and standardized site differences. For each Sylvian fissure maturation score (left or right side), mean gestational age and 95% CI were calculated. Transcerebellar diameter was modeled using fractional polynomial regression, and goodness of fit was assessed.

RESULTS

Of those children in the original FGLS cohort who had developmental assessment at 2 years of age, 1130 also had an available 3D ultrasound fetal head volume. The sociodemographic characteristics and pregnancy/perinatal outcomes of the study sample confirmed the health and low-risk status of the population studied. In addition, the fetuses had low morbidity and adequate growth and development at 2 years of age. In total, 3016 and 2359 individual volumes were available for transcerebellar-diameter and Sylvian-fissure analysis, respectively. Variance component analysis and standardized site differences showed that the five study populations were sufficiently similar on the basis of predefined criteria for the data to be pooled to produce international standards. A second-degree fractional polynomial provided the best fit for modeling transcerebellar diameter; we then estimated gestational-age-specific 3^rd , 50^th and 97^th smoothed centiles. Goodness-of-fit analysis comparing empirical centiles with smoothed centile curves showed good agreement. The Sylvian fissure increased in maturation with advancing gestation, with complete overlap of the mean gestational age and 95% CIs between the sexes for each development score. No differences in Sylvian fissure maturation between the right and left hemispheres were observed.

CONCLUSION

We present, for the first time, international standards for fetal cerebellar growth and Sylvian fissure maturation throughout pregnancy based on a healthy fetal population that exhibited adequate growth and development at 2 years of age. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Effect of consumption of animal milk compared to infant formula for non-breastfed/mixed-fed infants 6-11 months of age: a systematic review (protocol)

INTRODUCTION

Prevalence rates of breastfeeding remain low even though the World Health Organization (WHO) and the American Academy of Pediatrics recommend exclusive breast feeding for the first 6 months of life in combination with appropriate complementary feeding beyond six 6 months of age. There have been several studies that address the implication of drinking animal milk and/or infant formula on children's health and development when breast feeding is not offered during the first year of life. Vast improvements have been made in infant formula design, which may increase its benefits compared with animal's milk. The objective of this review is therefore to synthesise the most recent evidence on the effects of the consumption of animal milk compared with infant formula in non-breastfed or mixed breastfed infants aged 6-11 months.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis of studies that assessed the effect of animal milk compared with formula or mixed-fed (breastmilk and formula) on infants aged 6-11 months. The primary outcomes of interest include anaemia, gastrointestinal blood loss, weight for age, height for age and weight for height. We will include randomised and non-randomised studies with a control group. We will use the Cochrane risk of bias tools to assess the risk of bias. We will use meta-analysis to pool findings if the identified studies are conceptually homogenous and data are available from more than one study. We will assess the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

ETHICS AND DISSEMINATION

This is a systematic review, so no patients will be directly involved in the design or development of this study. The findings from this systematic review will be disseminated to relevant patient populations and caregivers and will guide the WHO's recommendations on formula consumption versus animal milk in infants aged 6-11 months.

TRIAL REGISTRATION NUMBER

CRD42020210925.

Factors associated with head circumference and indices of cognitive development in early childhood

BACKGROUND

While head circumference (HC) has been related to intracranial volume and brain size, its association with cognitive function remains unclear. We sought to understand the relationship among various biological and socioeconomic risk factors, HC and cognitive development.

METHODS

We analysed data across resource-poor settings in Bangladesh, India, Nepal, Peru, South Africa and Tanzania from the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development longitudinal birth cohort study. Participating children were enrolled and followed up between 2009 and 2014. A final sample of 1210 children aged 0-24 months were included in the analyses. The main outcomes were HC for age Z-score and cognitive, gross motor and language scores from Bayley Scales of Infant Development-III tests. Length, weight and HC were measured monthly, and cognitive tests were administered at 6, 15 and 24 months of age. To disentangle the associations between risk factors and HC from linear growth and to distinguish the direct and indirect effects of these risk factors on cognitive function, we conducted mediation analysis using longitudinal models to account for all data measured during follow-up.

RESULTS

Average HC-for-age Z-score (HCAZ) was -0.54 (95% CI -0.47 to -0.62) near birth and -1.01 (95% CI -0.94 to -1.08) at 24 months. Children with higher enrolment weight (p<0.0001), higher socioeconomic score (p=0.00037) and taller mothers (p=0.00084) had higher HCAZ at all ages, while enteropathogen infection (p=0.013) and more febrile episodes (p=0.013) were associated with lower HCAZ. The associations between HCAZ and enrolment weight-for-age, maternal height, socioeconomic status or pathogen burden were partly mediated through their associations with length-for-age. HCAZ showed no association with cognitive, gross motor or language skills at 6, 15 and 24 months of age.

CONCLUSIONS

The main risk factors associated with HC are similar to those associated with body length, and HC is not related to cognitive function.

International standards for fetal brain structures based on serial ultrasound measurements from Fetal Growth Longitudinal Study of INTERGROWTH-21st Project

OBJECTIVE

To create prescriptive growth standards for five fetal brain structures, measured using ultrasound, in healthy, well-nourished women at low risk of impaired fetal growth and poor perinatal outcome, taking part in the Fetal Growth Longitudinal Study (FGLS) of the INTERGROWTH-21^st Project.

METHODS

This was a complementary analysis of a large, population-based, multicenter, longitudinal study. The sample analyzed was selected randomly from the overall FGLS population, ensuring an equal distribution among the eight diverse participating sites and of three-dimensional (3D) ultrasound volumes across pregnancy (range: 15-36 weeks' gestation). We measured, in planes reconstructed from 3D ultrasound volumes of the fetal head at different timepoints in pregnancy, the size of the parieto-occipital fissure (POF), Sylvian fissure (SF), anterior horn of the lateral ventricle, atrium of the posterior horn of the lateral ventricle (PV) and cisterna magna (CM). Fractional polynomials were used to construct the standards. Growth and development of the infants were assessed at 1 and 2 years of age to confirm their adequacy for constructing international standards.

RESULTS

From the entire FGLS cohort of 4321 women, 451 (10.4%) were selected at random. After exclusions, 3D ultrasound volumes from 442 fetuses born without a congenital malformation were used to create the charts. The fetal brain structures of interest were identified in 90% of cases. All structures, except the PV, showed increasing size with gestational age, and the size of the POF, SF, PV and CM showed increasing variability. The 3^rd , 5^th , 50^th , 95^th and 97^th smoothed centiles are presented. The 5^th centiles for the POF and SF were 3.1 mm and 4.7 mm at 22 weeks' gestation and 4.6 mm and 9.9 mm at 32 weeks, respectively. The 95^th centiles for the PV and CM were 8.5 mm and 7.5 mm at 22 weeks and 8.6 mm and 9.5 mm at 32 weeks, respectively.

CONCLUSIONS

We have produced prescriptive size standards for fetal brain structures based on prospectively enrolled pregnancies at low risk of abnormal outcome. We recommend these as international standards for the assessment of measurements obtained using ultrasound from fetal brain structures. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Global strategies and local implementation of health and health-related SDGs: lessons from consultation in countries across five regions

Evidence on early achievements, challenges and opportunities would help low-income and middle-income countries (LMICs) accelerate implementation of health and health-related sustainable development goals (HHSDGs). A series of country-specific and multicountry consultative meetings were conducted during 2018-2019 that involved 15 countries across five regions to determine the status of implementation of HHSDGs. Almost 120 representatives from health and non-health sectors participated. The assessment relied on a multidomain analytical framework drawing on existing public health policy frameworks. During the first 5 years of the sustainable development goals (SDGs) era, participating LMICs from South and Central Asia, East Africa and Latin America demonstrated growing political commitment to HHSDGs, with augmentation of multisectoral institutional arrangements, strengthening of monitoring systems and engagement of development partners. On the other hand, there has been limited involvement of civic society representatives and academia, relatively few capacity development initiatives were in place, a well-crafted communication strategy was missing, and there is limited evidence of additional domestic financing for implementing HHSDGs. While the momentum towards universal health coverage is notable, explicit linkages with non-health SDGs and integrated multisectoral implementation strategies are lacking. The study offers messages to LMICs that would allow for a full decade of accelerated implementation of HHSDGs, and points to the need for more implementation research in each domain and for testing interventions that are likely to work before scale-up.

Characterizing Agreement in the Level of Interarm Blood Pressure Readings of Adults in the Emergency Department (CALIBRATE Study)

Background: Increased interarm systolic blood pressure difference (IASBPD) is one of the major predictors of cardiovascular disease. An IASBPD of >10 mmHg is of clinical significance. However, studies have reported a high number of patients visiting the emergency department (ED) with high IASBPD and varying correlation of IASBPD to age, ethnic background, and comorbidities such as hypertension and diabetes. Objective: The CALIBRATE study aimed to measure the IABPDs in the multiethnic patient population presenting to the ED in Qatar and to assess the distribution of IASBPD in this population. Methods: In a sitting position, two consecutive blood pressure (BP) measurements were recorded from the right and left arms for each participant using a calibrated automated machine and appropriate cuff sizes. The data were recorded using predefined data fields, including patient demographics, past medical, and social and family history. The continuous variables were reported as mean or median based on the distribution of data. The data were analyzed using Stata MP 14.0. Results: A total of 1800 patients, with a mean age of 34 (10) years, were prospectively recruited from the ED. The median absolute systolic BP difference (ΔSBP) between the right and left arms was 6 (3-10) mmHg, and it was the same for the first (ΔSBP1) and the second readings (ΔSBP2). The absolute average of ΔSBP1 and ΔSBP2 was 7 (4-10) mmHg. The difference in systolic BP difference (SBP) of < 20 mmHg for interarm blood pressure was seen in the 95th percentile of the population. No meaningful association could be detected between the IABPD and the study variables such as age, demographics, regions of interest, and risk factors. Conclusion: In population presenting to the ED, the IASBPD of at least 20 mmHg reached at the 95th percentile, validating the known significant difference. The utility of SBP difference can be improved further by taking the average of two individual readings.

Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival

Introduction

Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs).

Methods

We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8 million surveyed mothers (15-49 years) and 1.1 million children under 5 years including newborns (<1 month), young children (1-59 months) and school-aged children and adolescents (5-14 years). Outcomes include annual maternal and child mortality rates and coverage (%) of family planning services, 1+antenatal care visit, skilled attendant at birth (SBA), exclusive breast feeding (0-5 months), early initiation of breast feeding (within 1 hour), neonatal protection against tetanus, newborn postnatal care within 2 days, 3 doses of diphtheria, pertussis and tetanus vaccine, measles vaccination, and careseeking for pneumonia and diarrhoea.

Results

Conflict countries had consistently higher maternal and child mortality rates than non-conflict countries since 1990 and these gaps persist despite rates continually declining for both groups. Access to essential reproductive and maternal health services for poorer, less educated and rural-based families was several folds worse in conflict versus non-conflict countries.

Conclusions

Inequalities in coverage of reproductive/maternal health and child vaccine interventions are significantly worse in conflict-affected countries. Efforts to protect maternal and child health interventions in conflict settings should target the most disadvantaged families including the poorest, least educated and those living in rural areas.

Prevalence and determinants of iron deficiency anemia among non-pregnant women of reproductive age in Pakistan

BACKGROUND AND OBJECTIVES

Iron deficiency Anemia (IDA) in women of reproductive age is a recognized public health concern that impairs health and well-being in women and is associated with adverse reproductive outcomes. In Pakistan there is a dearth of up-to-date information on the prevalence and predictors of IDA. This study sought to investigate IDA in Pakistani women.

METHODS AND STUDY DESIGN

Secondary analysis was performed using the National Nutrition Survey in Pakistan 2011- 2012. We used a pre-structured instrument to collect socio demographic, reproductive and nutritional data on women. We also collected anthropometric measurements and blood samples for micronutrient deficiencies. Univariate and multivariate logistic regression were used to analyse the data.

RESULTS

A total of 7491 non-pregnant women aged between 15-49 years were included in the analysis. The prevalence of IDA was 18.1%. In the multivariate regression analysis; not using iron folic acid supplementation during the last pregnancy adjusted odds ratio (AOR) (95% CI) 1.31 (1.05, 1.64), a history of four or more pregnancies AOR (95% CI) 1.30 (1.04, 1.60), birth interval of <24 months AOR (95% CI) 1.27 (1.06, 1.71), household food insecurity AOR (95% CI) 1.42 (1.23, 1.63) and presence of clinical anemia AOR (95% CI) 5.82 (4.82, 7.02) were significantly associated with increased odds of IDA while with obesity AOR (95% CI) 0.60 (0.4, 0.88) showed a protective effect on IDA.

CONCLUSION

To reduce IDA in Pakistani women, the country needs a multifaceted approach that incorporates iron supplementation, food fortification, improved family planning services and efforts to reduce food insecurity.

Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya

IMPORTANCE

Previous work has underscored subnational inequalities that could impede additional health gains in Kenya.

OBJECTIVE

To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018.

EXPOSURES

Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered.

MAIN OUTCOMES AND MEASURES

Absolute and relative measures of inequality in coverage of RMNCAH interventions.

RESULTS

For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of -7.9% (95% CI, -11.1% to -4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations.

CONCLUSIONS AND RELEVANCE

Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.

Effect of Vitamin D Supplementation on the Salivary Cytokines of Pregnant Women: A Randomized Placebo-Controlled Trial

OBJECTIVE

We aimed to determine the salivary cytokine profiles of IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ and IL-17 among pregnant women and determine if the cytokine profiles change upon administration of vitamin D to these women.

METHODS

It was a community-based, blinded, placebo-controlled, randomized trial. The intervention group comprised pregnant females (n = 36) who received oral vitamin D 4000 IU/day for 6 months (starting from 12 - 16 weeks until the end of pregnancy). Controls comprised pregnant females who received placebo (n = 49) for the same duration. Probing depth (PD), attachment loss (AL) and bleeding on probing (BOP) were recorded. Saliva samples were subjected to multiplex ELISA analysis of cytokines. Serum vitamin D levels were determined. Outcome was assessed within 14 days post-partum. Periodontal examinations were done; blood and saliva samples were subjected to the set of tests described at baseline. SPSS 19.0 and Graph Pad 6.0 were used for analysis. The study was registered at www.clinicaltrials.gov with identifier number NCT01422122.

RESULTS

The two study groups were comparable at the baseline. Although IL-6 showed wide variation, none of the pro-inflammatory cytokine levels was affected by six months of oral vitamin D supplementation. Similarly, the mean salivary levels of the anti-inflammatory cytokines IL-4 and IL-10 also remained unaffected in the two groups.

CONCLUSION

There was no association between hypovitaminosis D and periodontal disease among the studied sample of pregnant women. None of the salivary cytokines showed any significant change after six months of oral vitamin D supplementation to the pregnant women.

The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21st Project

OBJECTIVES

To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well-dated pregnancies and access to antenatal care.

DESIGN

Population-based, prospective, observational study.

SETTING

Eight international urban populations.

POPULATION

Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21^st Project.

METHODS

Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies.

MAIN OUTCOME MEASURES

Antepartum stillbirth was defined as any fetal death after 16 weeks' gestation before the onset of labour.

RESULTS

Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, hazard ratio (HR): 1.6 (95% CI, 1.2-2.1); single marital status, HR 2.0 (95% CI, 1.4-2.8); age ≥40 years, HR 2.2 (95% CI, 1.4-3.7); essential hypertension, HR 4.0 (95% CI, 2.7-5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0-9.1); pre-eclampsia, HR 1.6 (95% CI, 1.1-3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0-5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5-4.5). Birth weight <3rd centile was associated with antepartum stillbirth [HR, 4.6 (95% CI, 3.4-6.2)]. The greatest risk was seen in babies not suspected to have been growth restricted antenatally, with an HR of 5.0 (95% CI, 3.6-7.0). The population-attributable risk of antepartum death associated with small-for-gestational-age neonates diagnosed at birth was 11%.

CONCLUSIONS

Antepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth.

TWEETABLE ABSTRACT

International stillbirth study finds individual risks poor predictors of death but combinations promising.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan

BACKGROUND

Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk.

METHODS/DESIGN

The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics.

DISCUSSION

This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

Urban and rural comparison of vitamin D status in Pakistani pregnant women and neonates

We undertook a cross-sectional study in rural Jehlum and urban Karachi to evaluate the prevalence of vitamin D deficiency in Pakistani pregnant women and neonates and to assess any association of serum 25(OH) vitamin D [25(OH)D] concentration with vitamin D binding protein (Gc) genotypes. Altogether, 390 women and 266 neonates were recruited from urban and rural sites, respectively. Serum 25(OH)D was measured by an immunoassay, while Gc genotypes were identified using polymerase chain reaction followed by restriction fragment length polymorphism or PCR-RFLP. One-way analysis of variance or ANOVA and linear regression were used for statistical analysis. In urban Karachi, 99.5% of women and 97.3% of neonates were vitamin D deficient (< 50 nmol/L), while 89% of women and 82% of neonates were deficient in rural Jehlum. Gc genotypes were not associated with serum 25(OH)D concentrations in both women and their neonates. We conclude that vitamin D deficiency is highly prevalent in Pakistani women and their neonates, and Gc genotypes are not associated with serum 25(OH)D concentrations.

Diagnostic accuracy of WHO verbal autopsy tool for ascertaining causes of neonatal deaths in the urban setting of Pakistan: a hospital-based prospective study

Background

Globally, clinical certification of the cause of neonatal death is not commonly available in developing countries. Under such circumstances it is imperative to use available WHO verbal autopsy tool to ascertain causes of death for strategic health planning in countries where resources are limited and the burden of neonatal death is high. The study explores the diagnostic accuracy of WHO revised verbal autopsy tool for ascertaining the causes of neonatal deaths against reference standard diagnosis obtained from standardized clinical and supportive hospital data.

Methods

All neonatal deaths were recruited between August 2006 –February 2008 from two tertiary teaching hospitals in Province Sindh, Pakistan. The reference standard cause of death was established by two senior pediatricians within 2 days of occurrence of death using the International Cause of Death coding system. For verbal autopsy, trained female community health worker interviewed mother or care taker of the deceased within 2–6 weeks of death using a modified WHO verbal autopsy tool. Cause of death was assigned by 2 trained pediatricians. The performance was assessed in terms of sensitivity and specificity.

Results

Out of 626 neonatal deaths, cause-specific mortality fractions for neonatal deaths were almost similar in both verbal autopsy and reference standard diagnosis. Sensitivity of verbal autopsy was more than 93 % for diagnosing prematurity and 83.5 % for birth asphyxia. However the verbal autopsy didn’t have acceptable accuracy for diagnosing the congenital malformation 57 %. The specificity for all five major causes of neonatal deaths was greater than 90 %.

Conclusion

The WHO revised verbal autopsy tool had reasonable validity in determining causes of neonatal deaths. The tool can be used in resource limited community-based settings where neonatal mortality rate is high and death certificates from hospitals are not available.

Strategies to avert preventable mortality among mothers and children in the Eastern Mediterranean Region: new initiatives, new hope

We conducted an assessment of maternal, newborn and child health and progress towards achieving Millennium Development Goals (MDG) 4 and 5 in the Eastern Mediterranean Region (EMR). We provide recommendations for scaling up and sustaining gains post-2015. Data were obtained from global data repositories. We constructed time trends from 1990 to 2013 and evaluated inequities across the Region. Under-5, neonatal and maternal mortality rates decreased 46%, 35%, and 50% respectively from 1990 to 2013. Pneumonia and diarrhoea accounted for 50% of all post-neonatal deaths; pregnancy- and delivery-related complications were the leading causes of neonatal and maternal deaths. Coverage of maternal, newborn and child health interventions is suboptimal, and poverty, food insecurity and conflict are pervasive across the Region. The EMR has made progress but is unlikely to attain MDG 4 and 5 targets. To sustain and further accelerate gains, the Region must reduce inequities and scale up implementation of recommendations made by the independent Expert Review Group.

The effectiveness of regionalization of perinatal care services--a systematic review

BACKGROUND

Several reports recommend the implementation of perinatal regionalization for improvements in maternal and neonatal outcomes, while research evidence on the effectiveness of perinatal regionalization has been limited. The interventional studies have been assessed for robust evidence on the effectiveness of perinatal regionalization on improving maternal and neonatal health outcomes.

METHODS

Bibliographic databases of Medline, EMbase, EconLit, HMIC have been searched using sensitive search terms for interventional studies that reported important patient or process outcomes. At least two authors assessed eligibility for inclusion and the risk of biases and extracted data from the included studies. As meta-analysis was not possible, a narrative analysis as well as a 'vote-counting' analysis has been conducted for important outcomes.

RESULTS

After initial screenings 53 full text papers were retrieved. Eight studies were included in the review from the USA, Canada and France. Studies varied in their designs, and in the specifications of the intervention and setting. Only three interrupted time series studies had a low risk of bias, of which only one study reported significant reductions in neonatal and infant mortality. Studies of higher risk of bias were more likely to report improvements in outcomes.

CONCLUSIONS

Implementing perinatal regionalization programs is correlated with improvements in perinatal outcomes, but it is not possible to establish a causal link. Despite several high profile policy statements, evidence of effect is weak. It is necessary to assess the effectiveness of perinatal regionalization using robust research designs in a more diverse range of countries.

International standards for early fetal size and pregnancy dating based on ultrasound measurement of crown-rump length in the first trimester of pregnancy

OBJECTIVES

There are no international standards for relating fetal crown-rump length (CRL) to gestational age (GA), and most existing charts have considerable methodological limitations. The INTERGROWTH-21(st) Project aimed to produce the first international standards for early fetal size and ultrasound dating of pregnancy based on CRL measurement.

METHODS

Urban areas in eight geographically diverse countries that met strict eligibility criteria were selected for the prospective, population-based recruitment, between 9 + 0 and 13 + 6 weeks' gestation, of healthy well-nourished women with singleton pregnancies at low risk of fetal growth impairment. GA was calculated on the basis of a certain last menstrual period, regular menstrual cycle and lack of hormonal medication or breastfeeding in the preceding 2 months. CRL was measured using strict protocols and quality-control measures. All women were followed up throughout pregnancy until delivery and hospital discharge. Cases of neonatal and fetal death, severe pregnancy complications and congenital abnormalities were excluded from the study.

RESULTS

A total of 4607 women were enrolled in the Fetal Growth Longitudinal Study, one of the three main components of the INTERGROWTH-21(st) Project, of whom 4321 had a live singleton birth in the absence of severe maternal conditions or congenital abnormalities detected by ultrasound or at birth. The CRL was measured in 56 women at < 9 + 0 weeks' gestation; these were excluded, resulting in 4265 women who contributed data to the final analysis. The mean CRL and SD increased with GA almost linearly, and their relationship to GA is given by the following two equations (in which GA is in days and CRL in mm): mean CRL = -50.6562 + (0.815118 × GA) + (0.00535302 × GA(2) ); and SD of CRL = -2.21626 + (0.0984894 × GA). GA estimation is carried out according to the two equations: GA = 40.9041 + (3.21585 × CRL(0.5) ) + (0.348956 × CRL); and SD of GA = 2.39102 + (0.0193474 × CRL).

CONCLUSIONS

We have produced international prescriptive standards for early fetal linear size and ultrasound dating of pregnancy in the first trimester that can be used throughout the world.

A cross sectional study of newborn care practices in Gilgit, Pakistan

OBJECTIVE

The purpose of this article is to explore the traditional newborn-care beliefs and practices and to identify factors that affect newborn health, aiming to design an appropriate, culturally-sensitive and acceptable intervention to reduce neonatal morbidity and mortality.

METHODS

A cross sectional study was conducted in the district of Gilgit in Pakistan. A structured questionnaire was administered to 708 mothers who gave birth to a live child in the past one year. Descriptive and inferential analysis was performed to identify socio-economic and health care factors associated with newborn care practices.

RESULTS

Illiterate mothers were more likely to use harmful newborn care practices, while those seeking health care from private sector were less likely to use harmful newborn care practices. Ninety-four percent of the newborns were given a bath soon after birth, likelihood to be 2 times more amongst illiterate mothers. Cord application was a very common practice, mostly with matti (crashed apricot seed), and a majority of the mothers reported newborn massage generally with mustard oil. The administration of colostrum as the first feed was relatively common in the study area. Twenty-seven percent of mothers reported giving pre-lacteals; from which prominent feeds included salt water (44%) and cow's milk (26%). Initiation of breastfeeding within 1 hour after birth was (71%), while (29%) reported to breastfeed their newborn within 24 hours. Thirty-seven percent newborns were exclusively breastfed for six months.

CONCLUSION

This study underscores the existence and predominance of risky practices in newborn care; that stresses the need for health education programs to ensure safety of the newborn.

A rapid questionnaire assessment of environmental exposures to pregnant women in the INTERGROWTH-21st Project

Impaired fetal growth and preterm birth are the leading causes of neonatal and infant mortality worldwide and there is a growing scientific literature suggesting that environmental exposures during pregnancy may play a causal role in these outcomes. Our purpose was to assess the environmental exposure of the Fetal Growth Longitudinal Study (FGLS) participants in the multinational INTERGROWTH-21(st) Project. First, we developed a tool that could be used internationally to screen pregnant women for such exposures and administered it in eight countries on a subsample (n = 987) of the FGLS participants. The FGLS is a study of fetal growth among healthy pregnant women living in relatively affluent areas, at low risk of adverse pregnancy outcomes and environmental exposures. We confirmed that most women were not exposed to major environmental hazards that could affect pregnancy outcomes according to the protocol's entry criteria. However, the instrument was able to identify some women that reported various environmental concerns in their homes such as peeling paint, high residential density (>1 person per room), presence of rodents or cockroaches (hence the use of pesticides), noise pollution and safety concerns. This screening tool was therefore useful for the purposes of the project and can be used to ascertain environmental exposures in studies in which the primary aim is not focused on environmental exposures. The instrument can be used to identify subpopulations for more in-depth assessment, (e.g. environmental and biological laboratory markers) to pinpoint areas requiring education, intervention or policy change.

Effect of multiple micronutrient versus iron-folate supplementation during pregnancy on intrauterine growth

This review examines the effects of prenatal multiple micronutrient (MM) supplementation (≥5 micronutrients) on intrauterine growth. We identified publications from 16 randomized controlled trials through PubMed and EMBASE database searches. Meta-analyses were performed by pooling results, and sub-analyses by timing of intervention and amount of iron were also done. The primary outcome measures were birthweight, low birthweight (LBW; <2,500 g) and small for gestational age (SGA). Prenatal MM supplementation significantly reduced the incidence of LBW (risk ratio, RR: 0.86; 95% CI: 0.81-0.92) and SGA (RR: 0.83; 95% CI: 0.73-0.95) compared to iron-folate supplementation; mean birthweight was significantly higher by 55 g for MM with borderline increases in gestational age. MM supplementation was associated with larger decreases in the risk of LBW and SGA in the subgroup of trials that used supplements containing 60 mg of iron, but were not statistically significantly different from those for trials that used 30 mg iron. Prenatal MM supplementation improved intrauterine growth and can be recommended instead of prenatal IFA supplements in settings where micronutrient deficiencies are common.

A cross sectional survey of newborn care practices in rural Sindh, Pakistan: implications for research and policy

INTRODUCTION

Of annual four million neonatal deaths, majority in the developing world, approximately three-quarters die within the first week of life. Pakistan has one of the highest newborn mortality rates.

STUDY DESIGN

We conducted a cross sectional study to assess knowledge, attitudes and practices of women of reproductive age in rural Pakistan.

RESULTS

Of 1490 mothers interviewed, prevalence of newborn care practices ranged between 32% (early bathing of newborn) and 69% (use of traditional cord applications). Uptake of antenatal care services was identified as a strong predictor of good newborn care after controlling for skilled birth attendance, socio-economic status, age of mother and sex of infant (OR = 1.26; 95% CI: 1.00-1.57).

CONCLUSIONS

The association of uptake of antenatal care services with good newborn care highlights the necessity to improve coverage of services with the integration of counseling about newborn care in order to reduce the burden of neonatal morbidity and mortality.

Effect of multiple micronutrient supplementation on pregnancy and infant outcomes: a systematic review

Supplementation with multiple micronutrients (MM) during pregnancy may result in improved pregnancy and infant outcomes. We conducted meta-analyses of randomised controlled trials that evaluated the effects of prenatal supplementation with MM (defined as containing at least five micronutrients and typically included iron or iron and folic acid). The outcomes of interest were low birthweight (<2500 g), birthweight, small-for-gestational age (SGA), gestational age, preterm birth (<37 weeks' gestation), stillbirth and neonatal death, maternal morbidity and mortality. We identified eligible studies through PubMed and EMBASE database searches. Meta-analyses were performed by pooling results for outcomes that were reported from more than one trial and sub-analyses were conducted to evaluate the effect of timing of intervention and amount of iron. We included published results from 16 trials in this review. Compared with control supplementation that was usually iron plus folic acid in most studies, MM supplementation resulted in a significant reduction in the incidence of low birthweight [pooled risk ratio (RR) 0.86; 95% confidence interval (CI) 0.81, 0.91] and SGA (pooled RR 0.83 [95% CI 0.73, 0.95]) and an increase in mean birthweight (weighted mean difference (WMD) 52.6 g [95% CI 43.2 g, 62.0 g]). There was no significant difference in the overall risk of preterm birth, stillbirth, and maternal or neonatal mortality, but we found an increased risk of neonatal death for the MM group compared with iron-folate in the subgroup of five trials that began the intervention after the first trimester (RR 1.38 [95% CI 1.05, 1.81]). None of the studies evaluated maternal morbidity. Compared with iron plus folic acid supplementation alone, prenatal maternal supplementation with MM resulted in a reduction in the incidence of low birthweight and SGA but increased risk of neonatal death in the subgroup of studies that began the intervention after the first trimester.

Factors associated with typhoid relapse in the era of multiple drug resistant strains

Introduction: Typhoid has an estimated global burden of greater than 27 million cases per annum with a clinical relapse rate of 5% to 20%.  Despite the large relapse burden, the factors associated with relapse are largely unknown.  Methodology: We have followed a protocol for the diagnosis and management of pediatric typhoid since 1988.  We report factors associated with relapse of culture-proven enteric fever in 1,650 children presenting to the Aga Khan University Medical Center,  Karachi, Pakistan, over a 15-year period.  Results: In those infected with multiple drug resistant (MDR) strains, factors associated with subsequent relapse include constipation at presentation and presentation within 14 days of fever onset.  Diarrhoea in those children infected with drug sensitive strains had an association with decreased subsequent relapse, as was quinolone therapy. Conclusions: Multiple clinical factors at presentation are associated with subsequent typhoid fever relapse.  These factors may be postulated to be associated with subsequent relapse due to alterations in the reticuloendothelial system organism load.  These data will be valuable in developing algorithms for clinical follow-up in children infected with MDR enteric fever.