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Copyright of African Journal of Reproductive Health is the property of Women's Health & Action Research Centre and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The high under-five mortality rate (U5MR) in Africa is a significant public health concern. Previous studies have found that satellite retrieved light at night (LAN) data with long-term and global coverage can be used as a proxy for socio-economic development and urbanization. Currently, few studies on the effects of LAN on child mortality have been conducted in Africa, a region with varying levels of urbanization between countries. Objective: To quantify the correlation between risk of child mortality and LAN as an indicator of urbanization and economic development in Africa. Methods: Using data from the Demographic and Health Survey (DHS) database conducted in 15 African countries out of 46 countries from 2005 to 2013, this study estimated LAN levels for children based on their year of birth and residential addresses. This study used Cox proportional hazards models to assess the association between LAN and the risk of child mortality in Africa. Results: The mean U5MR was 95 per 1,000 livebirths among the 15 African countries during 2005–2013. After adjusting for covariates, each 10-unit increment in LAN was associated with a 5.3% reduction in the risk of U5MR. The effect estimates were more pronounced in areas with lower LAN. Conclusion: In Africa, the risk of U5MR decreased with increasing LAN, especially in areas with lower LAN. The results suggest that the development of urbanization and socio-economic conditions may be beneficial to child health, especially in regions with low LAN. The use of LAN as a proxy may offer an intriguing approach for identifying areas requiring targeted development in urbanization and socio-economic conditions. [ABSTRACT FROM AUTHOR]

Objective: To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z -score (WHZ) and weight-for-age Z -score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children. Design: Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations. Setting: Community-based, prospective studies from twelve countries in Africa and Asia. Participants: Children aged 6–59 months living in the study areas. Results: For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone. Conclusions: Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions. [ABSTRACT FROM AUTHOR]

In Africa, refusal of COVID-19 and other vaccines is widespread for different reasons, including disbelief in the existence of the virus itself and faith in traditional remedies. In sub-Saharan countries, refusal is often made worse by opposition to vaccines by the religious establishments. This is a pressing problem, as Africa has the highest vaccine-avoidable mortality rate for children under the age of five in the world. Dialogue between those wishing to promote vaccines and those who resist them is essential if the situation is to be improved. This article argues that Western and other aid agencies seeking to promote vaccination programs need to develop a dialogue with resisters, and in this process to embrace and commend the ancient African philosophical tradition of Ubuntu, incorporating it into these programs as a way to overcome such entrenched resistance. The paper concludes with concrete recommendations for how to accomplish this goal. [ABSTRACT FROM AUTHOR]

While several studies have examined the effect of Foreign Direct Investment (FDI) on economic development indicators, most of these studies focused on economic growth with very little attention paid to health outcomes. Moreover, among the studies that took account of health outcomes, none of them investigated the effect of FDI on child health outcomes across a sample of African countries. However, focusing on African countries is very important because sub-Saharan Africa (SSA) has the highest rate of child mortality in the world. This study, therefore, investigates the effect of FDI on child health outcomes in 39 African countries from 1980 to 2018. Neonatal and infant mortality rates are used to proxy child health outcomes. The baseline estimation technique employed is the Fixed Effects (FE) regression. However, to deal with potential endogeneity, we employ the system Generalised Method of Moments (GMM) regression as the robustness estimation technique. Our findings show that, FDI improves child health outcomes, especially through economic growth after controlling for endogeneity. Thus, in African governments' quest to reduce child mortality, a major useful strategy could be attracting more FDI inflows. [ABSTRACT FROM AUTHOR]

This evidence synthesis aimed at assessing the effectiveness of Faith-Based Organisations (FBOs) on Maternal and Child Health (MCH) outcomes; and explore the perceptions and experiences of the users and providers of MCH services delivered by FBOs in Africa. This review considered studies from African countries only. Both reviews and primary studies focusing on MCH services provided by FBOs were considered. Quantitative, qualitative, and mixed methods reviews were included with no restriction on the date and language. Primary outcomes included maternal mortality ratio, neonatal mortality, infant mortality, child mortality, quality of care, views, experiences, and perceptions of users of FBOs. We searched up to November 2020 in the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PROSPERO register, PDQ-evidence, Health Systems Evidence, CINAHL, EMBASE, and PubMed. We searched references cited by similar studies that may be potentially eligible for inclusion. We then updated the search for primary studies from December 2009 - October 2020. One systematic review and six primary studies met the eligibility criteria for inclusion. Methodological quality varied. These observational and qualitative studies found that FBOs offered the following MCH services - training of healthcare workers, obstetric services, health promotion, sexual education, immunization services, and intermittent preventive therapy for malaria. Maternal and Child Health (MCH) services provided by FBO suggest a reduction in maternal morbidity and mortality. Increased uptake of maternal healthcare services, and increased satisfaction were reported by users of care. However, costs of providing these services varied across the studies and users. This review shows that FBOs play an important role in improving access and delivery of MCH services and have the potential of strengthening the health system at large. Rigorous research is needed to ascertain the effectiveness of FBO-based interventions in strengthening the health systems in Africa. [ABSTRACT FROM AUTHOR]

Background: Significant levels of funding have been provided to low- and middle-income countries for development assistance for health, with most funds coming through direct bilateral investment led by the USA and the UK. Direct attribution of impact to large-scale programs funded by donors remains elusive due the difficulty of knowing what would have happened without those programs, and the lack of detailed contextual information to support causal interpretation of changes. Methods: This study uses the synthetic control analysis method to estimate the impact of one donor's funding (United States Agency for International Development, USAID) on under-five mortality across several low- and middle-income countries that received above average levels of USAID funding for maternal and child health programs between 2000 and 2016. Results: In the study period (2000–16), countries with above average USAID funding had an under-five mortality rate lower than the synthetic control by an average of 29 deaths per 1000 live births (year-to-year range of − 2 to − 38). This finding was consistent with several sensitivity analyses. Conclusions: The synthetic control method is a valuable addition to the range of approaches for quantifying the impact of large-scale health programs in low- and middle-income countries. The findings suggest that adequately funded donor programs (in this case USAID) help countries to reduce child mortality to significantly lower rates than would have occurred without those investments. [ABSTRACT FROM AUTHOR]

Despite the commendable progress made in addressing global health challenges and threats such as child mortality, HIV/AIDS, and Tuberculosis, many global health organizations still exhibit a Global North supremacy attitude, evidenced by their choice of leaders and executors of global health initiatives in low- and middle-income countries (LMICs). While efforts by the Global North to support global health practice in LMICs have led to economic development and advancement in locally led research, current global health practices tend to focus solely on intervention outcomes, often neglecting important systemic factors such as intellectual property ownership, sustainability, diversification of leadership roles, and national capacity development. This has resulted in the implementation of practices and systems informed by high-income countries (HICs) to the detriment of knowledge systems in LMICs, as they are deprived of the opportunity to generate local solutions for local problems. From their unique position as international global health fellows located in different African countries and receiving graduate education from a HIC institution, the authors of this viewpoint article assess how HIC institutions can better support LMICs. The authors propose several strategies for achieving equitable global health practices; 1) allocating funding to improve academic and research infrastructures in LMICs; 2) encouraging effective partnerships and collaborations with Global South scientists who have lived experiences in LMICs; 3) reviewing the trade-related aspects of intellectual property Rights (TRIPS) agreement; and 4) achieving equity in global health funding and education resources., Competing Interests: AWW, BEN, JJ, and MK, are current Gilead Global Health fellows in the University of California, Berkeley’s Online/On-campus MPH program and are receiving sponsorship for their graduate studies through the global health program. ENS is a graduate of the University of California, Berkeley School of Public Health. SM is a professor in Epidemiology at the University of California, Berkeley School of Public Health. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright: © 2024 The Author(s).)

Study Question: How many twins are born in human populations and how has this changed over recent decades?Summary Answer: Since the 1980s, the global twinning rate has increased by a third, from 9.1 to 12.0 twin deliveries per 1000 deliveries, to about 1.6 million twin pairs each year.What Is Known Already: It was already known that in the 1980s natural twinning rates were low in (East) Asia and South America, at an intermediate level in Europe and North America, and high in many African countries. It was also known that in recent decades, twinning rates have been increasing in the wealthier parts of our world as a result of the rise in medically assisted reproduction (MAR) and delayed childbearing.Study Design, Size, Duration: We have brought together all information on national twinning rates available from statistical offices, demographic research institutes, individual survey data and the medical literature for the 1980-1985 and the 2010-2015 periods.Participants/materials, Setting, Methods: For 165 countries, covering over 99% of the global population, we were able to collect or estimate twinning rates for the 2010-2015 period. For 112 countries, we were also able to obtain twinning rates for 1980-1985.Main Results and the Role Of Chance: Substantial increases in twinning rates were observed in many countries in Europe, North America and Asia. For 74 out of 112 countries the increase was more than 10%. Africa is still the continent with highest twinning rates, but Europe, North America and Oceania are catching up rapidly. Asia and Africa are currently home to 80% of all twin deliveries in the world.Limitations, Reasons For Caution: For some countries, data were derived from reports and papers based on hospital registrations which are less representative for the country as a whole than data based on public administrations and national surveys.Wider Implications Of the Findings: The absolute and relative number of twins for the world as a whole is peaking at an unprecedented level. An important reason for this is the tremendous increase in medically assisted reproduction in recent decades. This is highly relevant, as twin deliveries are associated with higher infant and child mortality rates and increased complications for mother and child during pregnancy and during and after delivery.Study Funding/competing Interest(s): The contribution of CM was partially supported by the European Research Council (ERC) under the European Union's Horizon 2020 Research and Innovation Programme (grant No 681546, FAMSIZEMATTERS), Nuffield College, and the Leverhulme Trust. The contribution of GP was partially supported by the French Agence Nationale de la Recherche (grant No ANR-18-CE36-0007-07). The authors declare no conflict of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

In sub-Saharan Africa (SSA), every 1 in 12 children under five dies every year compared with 1 in 147 children in the high-income regions. Studies have shown an association between birth intervals and pregnancy outcomes such as low birth weight, preterm birth, and intrauterine growth restriction. In this study, we examined the association between birth interval and under-five mortality in eight countries in West Africa. A secondary analysis of the Demographic and Health Survey (DHS) data from eight West African countries was carried out. The sample size for this study comprised 52,877 childbearing women (15-49 years). A bivariate logistic regression analysis was carried out and the results were presented as crude odds ratio (cOR) and adjusted odds ratios (aOR) at 95% confidence interval (CI). Birth interval had a statistically significant independent association with under-five mortality, with children born to mothers who had >2 years birth interval less likely to die before their fifth birthday compared to mothers with ≤2 years birth interval [ cOR = 0.56 ; CI = 0.51 − 0.62 ], and this persisted after controlling for the covariates [ aOR = 0.55 ; CI = 0.50 − 0.61 ]. The country-specific results showed that children born to mothers who had >2 years birth interval were less likely to die before the age of five compared to mothers with ≤2 years birth interval in all the eight countries. In terms of the covariates, wealth quintile, mother's age, mother's age at first birth, partner's age, employment status, current pregnancy intention, sex of child, size of child at birth, birth order, type of birth, and contraceptive use also had associations with under-five mortality. We conclude that shorter birth intervals are associated with higher under-five mortality. Other maternal and child characteristics also have associations with under-five mortality. Reproductive health interventions aimed at reducing under-five mortality should focus on lengthening birth intervals. Such interventions should be implemented, taking into consideration the characteristics of women and their children. [ABSTRACT FROM AUTHOR]

Background: Civil registration and vital statistics (CRVS) systems do not produce comprehensive data on maternal and child deaths in most low- and middle-income countries (LMICs), with most births and deaths which occur outside the formal health system going unreported. Community-based death reporting, investigation and review processes are being used in these settings to augment official registration of maternal and child deaths and to identify death-specific factors and associated barriers to maternal and childcare. This study aims to review how community-based maternal and child death reporting, investigation and review processes are carried out in LMICs. Methods: We conducted a scoping review of the literature published in English from January 2013 to November 2020, searching PubMed, EMBASE, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews, Scopus, and Web of Science databases. We used descriptive analysis to outline the scope, design, and distribution of literature included in the study and to present the content extracted from each article. The scoping review is reported following the PRISMA reporting guideline for systematic reviews. Results: Of 3162 screened articles, 43 articles that described community-based maternal and child death review processes across ten countries in Africa and Asia were included. A variety of approaches were used to report and investigate deaths in the community, including identification of deaths by community health workers (CHWs) and other community informants, reproductive age mortality surveys, verbal autopsy, and social autopsy. Community notification of deaths by CHWs complements registration of maternal and child deaths missed by routinely collected sources of information, including the CRVS systems which mostly capture deaths occurring in health facilities. However, the accuracy and completeness of data reported by CHWs are sub-optimal. Conclusions: Community-based death reporting complements formal registration of maternal and child deaths in LMICs. While research shows that community-based maternal and child death reporting was feasible, the accuracy and completeness of data reported by CHWs are sub-optimal but amenable to targeted support and supervision. Studies to further improve the process of engaging communities in the review, as well as collection and investigation of deaths in LMICs, could empower communities to respond more effectively and have a greater impact on reducing maternal and child mortality. [ABSTRACT FROM AUTHOR]

Reduction of the under-5 mortality rate is a target of the Sustainable Development Goals. Therefore, this study aimed to estimate under-5 child mortality rates in 52 low-migration countries using population data. The study utilized population data from the US Census Bureau from 1990 to 2015. The method involved first estimating mortality rates for countries with negligible net migration and then applying these rates to countries with matching mortality profiles, where it is reasonable to assume that migration is negligible for children under the age of 5 years. The highest child mortality was concentrated in the African region, followed by Asia and the Western region. However, steady progress in child mortality trends was concentrated in low-income countries. This simple method demonstrated that child mortality has significantly improved in high-income countries, followed by middle- and low-income countries. To reduce the under-5 mortality rates even further in these 52 countries, there is a need to accelerate equitable plans and policies related to child health to promote children's longevity and survival. [ABSTRACT FROM AUTHOR]

Background: The Equitable Impact Sensitive Tool (EQUIST) was developed to address the limitations of the traditional cost-effectiveness analysis (CEA) in global health, which often overlooked equity considerations. Its primary aim was to create more effective and efficient health systems by explicitly incorporating equity as a key driver in health policy decisions. This was done in response to the recognition that, while CEA helped reduce mortality rates through interventions like childhood vaccinations, it was insufficient in addressing growing inequalities in health, especially in low-and-middle-income countries (LMICs)., Methods: The development of EQUIST involved a multi-stage process which began in 2011 with the recognition of the need for a more nuanced approach than CEA alone. This led to a proposal for creating a tool that balanced cost-effectiveness with equity. The conceptual framework, developed between March and May 2012, included assessments of intervention efficiency by equity strata, effectiveness, impact, and cost-effectiveness. Key to EQUIST's development was its integration with other data science platforms, notably the Lives Saved Tool and the Marginal Budgeting for Bottlenecks tool, allowing EQUIST to draw on comprehensive data sets and thus enabling a more detailed analysis of health interventions' impacts across different socio-economic strata., Results: EQUIST was validated in 2012 through applications in five representative countries, demonstrating its ability to identify more equitable and cost-effective health interventions which targeted vulnerable populations, leading to more lives saved compared to traditional methods. It was then used to develop investment cases for the Global Financing Facility, resulting in significant funding being made available for maternal and child health programmes. Consequently, EQUIST directly influenced the development of national health policies and resource allocations in over 26 African countries., Conclusions: EQUIST has proven to be a valuable tool in developing health policies that are both cost-effective and equitable. In the future, it will be further integrated with other tools and expanded in scope to address broader health issues, including adolescent health and human immunodeficiency virus/acquired immunodeficiency syndrome programme planning. Overall, EQUIST represents a paradigm shift in global health economics, emphasising the importance of equity alongside cost-effectiveness in health policy decisions. Its development and implementation have had a tangible impact on health outcomes, particularly in LMICs, where it has been instrumental in reducing maternal and child mortality while addressing health inequities., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose the following activities and/or relationships: IR and HC are co-Editors-in-Chief of the Journal of Global Health. Mickey Chopra is a member of the editorial council of the Journal of Global Health. To ensure that any possible conflict of interest relevant to the journal has been addressed, this article was reviewed according to best practice guidelines of international editorial organisations., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

Background: Snakebite and envenomation remains a public health problem with significant morbidity and mortality in children in developing countries. The World Health Organization (WHO) in 2010 developed guidelines for the prevention and management of snakebite in Africa. Aim: The aim of this study was to compare the pattern of first aid treatment among children presenting with snakebite/envenomation with the 2010 WHO guideline for the prevention and clinical management of snakebite in Africa. Patients and Methods: All children who presented with snakebite over a 7-year period in a teaching hospital in Enugu, Nigeria. The first aid treatment given to these children was obtained and was compared with the provisions of the WHO guideline for the prevention and clinical management of snakebite in Africa (2010). Data collected were analyzed using SPSS version 22. Results: Five (71.4%) of the snakebites occurred in the rainy season and in the dark involving the lower limbs in 85.7% of cases. Six (87.5%) of the patients received one form of first aid before presentation to a health facility. None received first aid interventions in line with the WHO recommendation. Topical application of herbal concoctions to the site of the bite (37.5%) was the most common intervention. One (14.3%) of the children was promptly brought to the health facility following snakebite. The interval from bite to presentation to the health facility ranged from 1 to 12 h (median 5 h: 43 min). Conclusion: Huge gaps still exist in the first aid treatment given to snakebite victims compared to the WHO guidelines. [ABSTRACT FROM AUTHOR]

Background: Malaria transmission has recently fallen in many parts of Africa, but systematic descriptions of infection and disease across all age groups are rare. Here, an epidemiological investigation of parasite prevalence, the incidence of fevers associated with infection, severe hospitalized disease and mortality among children older than 6 months and adults on the Kenyan coast is presented. Methods: A prospective fever surveillance was undertaken at 6 out-patients (OPD) health-facilities between March 2018 and February 2019. Four community-based, cross sectional surveys of fever history and infection prevalence were completed among randomly selected homestead members from the same communities. Paediatric and adult malaria at Kilifi county hospital was obtained for the 12 months period. Rapid Diagnostic Tests (CareStart™ RDT) to detect HRP2-specific to Plasmodium falciparum was used in the community and the OPD, and microscopy in the hospital. Crude and age-specific incidence rates were computed using Poisson regression. Results: Parasite prevalence gradually increased from childhood, reaching 12% by 9 years of age then declining through adolescence into adulthood. The incidence rate of RDT positivity in the OPD followed a similar trend to that of infection prevalence in the community. The incidence of hospitalized malaria from the same community was concentrated among children aged 6 months to 4 years (i.e. 64% and 70% of all hospitalized and severe malaria during the 12 months of surveillance, respectively). Only 3.7% (12/316) of deaths were directly attributable to malaria. Malaria mortality was highest among children aged 6 months–4 years at 0.57 per 1000 person-years (95% CI 0.2, 1.2). Severe malaria and death from malaria was negligible above 15 years of age. Conclusion: Under conditions of low transmission intensity, immunity to disease and the fatal consequences of infection appear to continue to be acquired in childhood and faster than anti-parasitic immunity. There was no evidence of an emerging significant burden of severe malaria or malaria mortality among adults. This is contrary to current modelled approaches to disease burden estimation in Africa and has important implications for the targeting of infection prevention strategies based on chemoprevention or vector control. [ABSTRACT FROM AUTHOR]

Background: Most of the world's sickle cell disease (SCD) burden is in Africa, where it is a major contributor to child morbidity and mortality. Despite the low cost of many preventive SCD interventions, insufficient resources have been allocated, and progress in alleviating the SCD burden has lagged behind other public-health efforts in Africa. The recent announcement of massive new funding for research into curative SCD therapies is encouraging in the long term, but over the next few decades, it is unlikely to help Africa's SCD children substantially.Main Discussion: A major barrier to progress has been the absence of large-scale early-life screening. Most SCD deaths in Africa probably occur before cases are even diagnosed. In the last few years, novel inexpensive SCD point-of-care test kits have become widely available and have been deployed successfully in African field settings. These kits could potentially enable universal early SCD screening. Other recent developments are the expansion of the pneumococcal conjugate vaccine towards near-universal coverage, and the demonstrated safety, efficacy, and increasing availability and affordability of hydroxyurea across the continent. Most elements of standard healthcare for SCD children that are already proven to work in the West, could and should now be implemented at scale in Africa. National and continental SCD research and care networks in Africa have also made substantial progress, assembling care guidelines and enabling the deployment and scale-up of SCD public-health systems. Substantial logistical, cultural, and awareness barriers remain, but with sufficient financial and political will, similar barriers have already been overcome in efforts to control other diseases in Africa.Conclusion and Recommendations: Despite remaining challenges, several high-SCD-burden African countries have the political will and infrastructure for the rapid implementation and scale-up of comprehensive SCD childcare programs. A globally funded effort starting with these countries and expanding elsewhere in Africa and to other high-burden countries, including India, could transform the lives of SCD children worldwide and help countries to attain their Sustainable Development Goals. This endeavor would also require ongoing research focused on the unique needs and challenges of SCD patients, and children in particular, in regions of high prevalence. [ABSTRACT FROM AUTHOR]

Background: Improving the coverage of antenatal care is regarded as an important strategy to reduce the risks of maternal and child mortality in low income settings like Gambia. Nonetheless, a large number of countries in Africa, including Gambia, are struggling to attain an optimum level of healthcare utilization among pregnant women. The role of socioeconomic inequalities in maternal healthcare uptake has received little attention in Gambia. To address this evidence gap, the present study analyses nationally representative data to explore the socioeconomic inequalities in the use of maternal healthcare.Methods: Data on women aged 15-49 years (n = 5351) were extracted from the latest round of Gambia Demographic and Health Survey in 2013 for this study. The outcome measures were early and adequate antenatal visit and HIV tests during the last pregnancy. Data were analyzed using descriptive and multivariate regression methods. Socioeconomic status was assessed through the women's education, type of employment, and household wealth quintile.Results: From the total of 5351 participants included in the study, 38.7 and 78.8% of the women had early and adequate ANC visits respectively with a 65.4% HIV test coverage during ANC visits. The odds of early [OR = 1.30, 95% confidence interval (CI) =1.06, 1.59] and adequate [OR = 1.45, 95%CI = 1.15, 1.82] ANC visits were higher in the rural areas compared with urban. Women with secondary [OR = 1.24, 95%CI = 1.04, 1.48] and higher education [OR = 1.80, 95%CI = 1.20, 2.70] had higher odds of making early ANC visits. Women from richest wealth quintile households had significantly higher odds of having early [OR = 1.49, 95%CI = 1.14, 1.95] and adequate ANC visits [OR = 2.06, 95%CI = 1.48, 2.87], but not of having HIV tests. Having access to electronic media showed a positive association with adequate ANC visits [OR = 1.32, 95%CI = 1.08, 1.62] and with taking HIV test during ANC [OR = 1.48, 95%CI = 1.21, 1.80]. A fewer odds of having unintended child was associated with early ANC visit [OR = 0.70, 95%CI = 0.59, 0.84], but positively associated with taking HIV test [OR = 1.75, 95%CI = 1.42, 2.15].Conclusion: A large proportion of women in Gambia were not using antenatal care and HIV tests during pregnancy. There are important sociodemographic differences in using maternal healthcare services such as HIV testing during pregnancy. This calls for strategic direction to promote the utilization of these services. [ABSTRACT FROM AUTHOR]

Background There are limited data on the epidemiology of very late-onset schizophrenia-like psychosis (VLOSLP) and how this relates to potential risk factors including migration, sensory impairment, traumatic life events, and social isolation. Methods We followed up a cohort of 3 007 378 people living in Sweden, born 1920–1949, from their 60th birthday (earliest: January 15, 1980) until December 30 2011, emigration, death, or first recorded diagnosis of nonaffective psychosis. We examined VLOSLP incidence by age, sex, region of origin, income, partner or child death, birth period, and sensory impairments. Results We identified 14 977 cases and an overall incidence of 37.7 per 100 000 person-years at-risk (95% CI = 37.1–38.3), with evidence that rates increased more sharply with age for women (likelihood ratio test: χ2(6) = 31.56, P <.001). After adjustment for confounders, rates of VLOSLP were higher among migrants from Africa (hazard ratio [HR] = 2.0, 95% CI = 1.4–2.7), North America (HR = 1.4, 95% CI = 1.0–1.9, P =.04), Europe (HR = 1.3, 95% CI = 1.2–1.4), Russian-Baltic regions (HR = 1.6, 95% CI = 1.4–1.9), and Finland (HR = 1.6, 95% CI = 1.5–1.7). VLOSLP risk was highest for those in the lowest income quartile (HR = 3.1, 95% CI = 2.9–3.3). Rates were raised in those whose partner died 2 years before cohort exit (HR = 1.1, 95% CI = 1.0–1.3, P =.02) or whose child died in infancy (HR = 1.2, 95% CI = 1.0–1.4, P =.05), those without a partner (HR = 1.9, 95% CI = 1.8–1.9) or children (HR = 2.4, 95% CI = 2.3–2.5), and those whose child had a psychotic disorder (HR = 2.4, 95% CI = 2.2–2.6). Interpretation We identified a substantial burden of psychosis incidence in old age, with a higher preponderance in women and most migrant groups. Life course exposure to environmental factors including markers of deprivation, isolation, and adversity were associated with VLOSLP risk. [ABSTRACT FROM AUTHOR]

Background: Serious childhood illnesses (SCI), defined as severe pneumonia, severe dehydration, sepsis, and severe malaria, remain major contributors to amenable child mortality worldwide. Inadequate recognition and treatment of SCI are factors that impact child mortality in Botswana. Skills assessments of providers caring for SCI have not been validated in low and middle-income countries. Objective: To establish preliminary inter-rater reliability, validity evidence, and feasibility for an assessment of providers who care for SCI using simulated patients and remote video capture in community clinic settings in Botswana. Methods: This was a pilot study. Four scenarios were developed via a modified Delphi technique and implemented at primary care clinics in Kweneng, Botswana. Sessions were video captured and independently reviewed. Response process and internal structure analysis utilized intra-class correlation (ICC) and Fleiss’ Kappa. A structured log was utilized for feasibility of remote video capture. Results: Eleven subjects participated. Scenarios of Lower Airway Obstruction (ICC = 0.925, 95%CI 0.695–0.998) and Hypovolemic Shock from Severe Dehydration (ICC = 0.892, 95%CI 0.596–0.997) produced excellent ICC among raters while Lower Respiratory Tract Infection (LRTI, ICC = 0, 95%CI -0.034–0.97) and LRTI + Distributive Shock from Sepsis (0.365, 95%CI -0.025–0.967) were poor. Oxygen therapy (0.707), arranging transport (0.706), and fluid administration (0.701) demonstrated substantial task reliability. Conclusions: Initial development of an assessment tool demonstrates many, but not all, criteria for validity evidence. Some scenarios and tasks demonstrate excellent reliability among raters, but others may be limited by manikin design and study implementation. Remote simulation assessment of some skills by clinic-based providers in global health settings is reliable and feasible. [ABSTRACT FROM AUTHOR]

Background: In Equatorial Guinea, malaria continues to be one of the main causes of morbidity and mortality among children. The National Therapeutic Guide established artesunate-amodiaquine (ASAQ) as first-line treatment for uncomplicated malaria, but compliance with this treatment is low. The aim of this study was to assess, for the first time, the performance of public healthcare workers in the diagnosis and treatment of uncomplicated malaria, their compliance with first-line Malaria National Therapeutic Guide and the associated factors. Methods: A cross-sectional survey was conducted at the nine public health facilities in the Bata District of Equatorial Guinea to assess the management of uncomplicated malaria in children < 15 years of age. Bivariate and multivariate statistical analyses were used to determine the recommended treatment compliance and related factors. Results: A total of 227 children with uncomplicated malaria were recorded from 9 public health facilities. Most of the treatments prescribed (83.3%) did not follow the first-line treatment recommended for uncomplicated malaria. The diagnosis was established with parasite confirmation in 182 cases (80.2%). After adjustment for other variables, children under 2 months of age, the use of parasite confirmation to the diagnosis of malaria and being familiar with the national therapeutic guide were significantly associated with the prescription of the first-line recommended treatment. Cases attended at the hospital or in a health facility with ASAQ in the pharmacy at the time of the study were also more likely to be prescribed with the recommended treatment, but with non-significant association after adjustment for other variables. Conclusions: This study identified the factors associated with the low compliance with the first-line treatment by the public healthcare facilities of Bata District of Equatorial Guinea. It seems necessary to improve case management of children with uncomplicated malaria; to reinforce the use of Malaria National Therapeutic Guide and to inform about the danger of using artemisinin monotherapy. Furthermore, it is crucial to provide recommended first-line treatment to the pharmacies of all public health facilities to ensure access to this treatment. [ABSTRACT FROM AUTHOR]

This section offers news briefs on public health. A 7.8 magnitude earthquake with multiple aftershocks struck south-east Turkiye that led to the death of some 34,000 people. A humanitarian response was launched by the World Health Organization and other United Nations partner at the request of the Turkish government. The first outbreak of Marburg virus diseases in Equatorial Guinea was confirmed in the country's western Kie Ntem Province.

Globally, over 200 million women and girls have been subjected to Female Genital Mutilation (FGM). This practice, illegal in most countries, often happens in unsanitary conditions and without clinical supervision with consequent bleeding and infection. However, little is known about its contribution to the global epidemiology of child mortality. We matched data on the proportion of girls of a given age group subject to FGM to age-gender-year specific mortality rates during 1990-2020 in 15 countries where FGM is practised. We used fixed-effects regressions to separate the effect of FGM on mortality-rates from variation in mortality in that country in that year. Using our estimated effect, we calculated total annual excess mortality due to FGM. Our estimates imply that a 50% increase in the number of girls subject to FGM increases their 5-year mortality rate by 0.075 percentage point (95% CI [Formula: see text]-[Formula: see text]). This increased mortality rate translates into an estimated 44,320 excess deaths per year across countries where FGM is practised. These estimates imply that FGM is a leading cause of the death of girls and young women in those countries where it is practised accounting for more deaths than any cause other than Enteric Infections, Respiratory Infections, or Malaria., (© 2023. Springer Nature Limited.)

Background: Africa has the highest rates of child mortality. Little is known about outcomes after hospitalization for children with very severe anemia. Objective: To determine one year mortality and predictors of mortality in Tanzanian children hospitalized with very severe anemia. Methods: We conducted a prospective cohort study enrolling children 2–12 years hospitalized from August 2014 to November 2014 at two public hospitals in northwestern Tanzania. Children were screened for anemia and followed until 12 months after discharge. The primary outcome measured was mortality. Predictors of mortality were determined using Cox regression analysis. Results: Of the 505 children, 90 (17.8%) had very severe anemia and 415 (82.1%) did not. Mortality was higher for children with very severe anemia compared to children without over a one year period from admission, 27/90 (30.0%) vs. 59/415 (14.2%) respectively (Hazard Ratio (HR) 2.42, 95% Cl 1.53–3.83). In-hospital mortality was 11/90 (12.2%) and post-hospital mortality was 16/79 (20.2%) for children with very severe anemia. The strongest predictors of mortality were age (HR 1.01, 95% Cl 1.00–1.03) and decreased urine output (HR 4.30, 95% Cl 1.04–17.7). Conclusions: Children up to 12 years of age with very severe anemia have nearly a 30% chance of mortality following admission over a one year period, with over 50% of mortality occurring after discharge. Post-hospital interventions are urgently needed to reduce mortality in children with very severe anemia, and should include older children. [ABSTRACT FROM AUTHOR]

Background: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up. [ABSTRACT FROM AUTHOR]

Background: Vital registration data outlining causes of deaths (CoD) are important for a sustainable health system, targeted interventions and other relevant policies. There is data paucity on vital registration systems in developing countries. We assessed the leading causes and proportions of under-five deaths, and particularly those related to pneumococcal infections in Yaoundé, Cameroon, using hospital registration data. Methods: A retrospective case-finding observational study design was used to access and identify data on 817 death cases in children under-five years of age recorded in health facilities in Yaoundé, within the period January 1, 2006 and December 31, 2012. Patients’ files were randomly selected and needed information including demographic data, date of admission, clinical and laboratory diagnosis, principal and/or underlying causes of death were abstracted into structured case report forms. The International Classification of Diseases and Clinical Modifications 10th revision (ICD-10-CM) codes (ICD10Data.com 2017 edition) were used to classify the different CoD, retrospectively. Ascertainment of CoD was based on medical report and estimates were done using the Kaplan-Meier procedure and descriptive statistics. Results: Of the 817 death records assessed, malaria was the leading CoD and was responsible for 17.5% of cases. Meningitis was the second largest CoD with 11.0%; followed by sepsis (10.0%), Streptococcus pneumoniae infections (8.3%), malnutrition (8.3%), gastro-enteritis / diarrhoea (6.2%), anaemia (6.1%) and HIV (3.5%), respectively. Conclusion: The main CoD in this population are either treatable or vaccine-preventable; a trend consistent with previous reports across developing countries. Besides, the health effects from non-communicable infections should not be neglected. Therefore, scaling-up measures to reduce causes of under-five deaths will demand sustainable efforts to enhance both treatment and disease prevention strategies, to avoid a decline in the progress towards reducing under-five deaths by 2/3 from the 1990 baseline. [ABSTRACT FROM AUTHOR]

• Clostridium difficile is more prevalent in children presenting with diarrhea than Rotavirus in Kenya. • Majority of the children with diarrhea were co-infected with C. difficile and Rotavirus. • There is a need to test for the presence of C. difficile and others in the diagnostic workup of children with diarrhea. • A comprehensive research on epidemiology of C. difficile in children with diarrhea is urgently needed. Diarrhea causes significant morbidity and mortality among children worldwide. Regions most affected by diarrhea include Sub-Saharan Africa and Southeast Asia, where antibiotics are in common use and can make children more vulnerable to Clostridium difficile and pathogens that are not affected by these drugs. Indeed, C. difficile is a major diarrhea-associated pathogen and poses a significant threat to vulnerable and immunocompromised populations. Yet, little is known about the role and epidemiology of C. difficile in diarrhea-associated illness among young children. As a result, C. difficile is often neglected in regions such as Sub-Saharan Africa that are most impacted by childhood diarrhea. The purpose of this study was to establish the frequency of C. difficile in young children (<5 years) with diarrhea. Children presenting with diarrhea at a national hospital in Kenya from 2015 to 2018 were enrolled consecutively. Following informed consent by a parent or legal guardian, stool samples were obtained from the children and demographic data were collected. The stools were examined for the presence of four common pathogens known to cause diarrhea: C. difficile , rotavirus, Cryptosporidium parvum , and Giardia lamblia. C. difficile was verified by toxigenic culture and PCR. The presence of C. parvum and/or G. lamblia was determined using the ImmunoCard STAT! Crypto/Giardia Rapid assay. Rotavirus was detected by ELISA. The study population comprised 157 children; 62.4% were male and 37.6% were female and their average age was 12.4 months. Of the 157 stool specimens investigated, 37.6% were positive for C. difficile , 33.8% for rotavirus, 5.1% for Cryptosporidium , and 5.1% for Giardia. PCR analysis identified at least one of the C. difficile -specific - genes (tcdA , tcdB , or tcdC). Further, 57.6% of the stools had C. difficile colonies bearing a frame-shift deletion in the tcdC gene, a mutation associated with increased toxin production. The frequency of C. difficile was 32.6% in children ≤12 months old and increased to 46.6% in children 12–24 months old. In Kenyan children presenting with diarrhea, C. difficile is more prevalent than rotavirus or Cryptosporidium , two leading causes of childhood diarrhea. These findings underscore the need to better understand the role of C. difficile in children with diarrhea, especially in areas with antibiotic overuse. Understanding C. difficile epidemiology and its relationship to co-infecting pathogens among African children with diarrhea will help in devising ways of reducing diarrhea-associated illness. [ABSTRACT FROM AUTHOR]

Nontyphoidal Salmonellae commonly cause invasive disease in African children that is often fatal. The clinical diagnosis of these infections is hampered by the absence of a clear clinical syndrome. Drug resistance means that empirical antibiotic therapy is often ineffective and currently no vaccine is available. The study objective was to identify risk factors for mortality among children presenting to hospital with invasive Salmonella disease in Africa. We conducted a prospective study enrolling consecutive children with microbiologically-confirmed invasive Salmonella disease admitted to Queen Elizabeth Central Hospital, Blantyre, in 2006. Data on clinical presentation, co-morbidities and outcome were used to identify children at risk of inpatient mortality through logistic-regression modeling. Over one calendar year, 263 consecutive children presented with invasive Salmonella disease. Median age was 16 months (range 0–15 years) and 52/256 children (20%; 95%CI 15–25%) died. Nontyphoidal serovars caused 248/263 (94%) of cases. 211/259 (81%) of isolates were multi-drug resistant. 251/263 children presented with bacteremia, 6 with meningitis and 6 with both. Respiratory symptoms were present in 184/240 (77%; 95%CI 71–82%), 123/240 (51%; 95%CI 45–58%) had gastrointestinal symptoms and 101/240 (42%; 95%CI 36–49%) had an overlapping clinical syndrome. Presentation at <7 months (OR 10.0; 95%CI 2.8–35.1), dyspnea (OR 4.2; 95%CI 1.5–12.0) and HIV infection (OR 3.3; 95%CI 1.1–10.2) were independent risk factors for inpatient mortality. Invasive Salmonella disease in Malawi is characterized by high mortality and prevalence of multi-drug resistant isolates, along with non-specific presentation. Young infants, children with dyspnea and HIV-infected children bear a disproportionate burden of the Salmonella-associated mortality in Malawi. Strategies to improve prevention, diagnosis and management of invasive Salmonella disease should be targeted at these children. [ABSTRACT FROM AUTHOR]

Background: Despite substantial financial contributions by the United States President's Malaria Initiative (PMI) since 2006, no studies have carefully assessed how this program may have affected important population-level health outcomes. We utilized multiple publicly available data sources to evaluate the association between introduction of PMI and child mortality rates in sub-Saharan Africa (SSA).Methods and Findings: We used difference-in-differences analyses to compare trends in the primary outcome of under-5 mortality rates and secondary outcomes reflecting population coverage of malaria interventions in 19 PMI-recipient and 13 non-recipient countries between 1995 and 2014. The analyses controlled for presence and intensity of other large funding sources, individual and household characteristics, and country and year fixed effects. PMI program implementation was associated with a significant reduction in the annual risk of under-5 child mortality (adjusted risk ratio [RR] 0.84, 95% CI 0.74-0.96). Each dollar of per-capita PMI expenditures in a country, a measure of PMI intensity, was also associated with a reduction in child mortality (RR 0.86, 95% CI 0.78-0.93). We estimated that the under-5 mortality rate in PMI countries was reduced from 28.9 to 24.3 per 1,000 person-years. Population coverage of insecticide-treated nets increased by 8.34 percentage points (95% CI 0.86-15.83) and coverage of indoor residual spraying increased by 6.63 percentage points (95% CI 0.79-12.47) after PMI implementation. Per-capita PMI spending was also associated with a modest increase in artemisinin-based combination therapy coverage (3.56 percentage point increase, 95% CI -0.07-7.19), though this association was only marginally significant (p = 0.054). Our results were robust to several sensitivity analyses. Because our study design leaves open the possibility of unmeasured confounding, we cannot definitively interpret these results as causal.Conclusions: PMI may have significantly contributed to reducing the burden of malaria in SSA and reducing the number of child deaths in the region. Introduction of PMI was associated with increased coverage of malaria prevention technologies, which are important mechanisms through which child mortality can be reduced. To our knowledge, this study is the first to assess the association between PMI and all-cause child mortality in SSA with the use of appropriate comparison groups and adjustments for regional trends in child mortality. [ABSTRACT FROM AUTHOR]

The study examined the impact of food security on child mortality (infant mortality and under-five mortality), using a dynamic panel data analysis for 114 countries for the period 1995-2009 by considering a wide range of controlled variables such as income, social indicators and policy variables. Th e result suggests that food security has a negative impact on child mortality for all countries and even more impact on child mortality within the food insecure African countries. Therefore, based on the findings of the study; it is recommended that an increase in food security is indeed a positive policy option, particularly within the food insecure African countries, since it ensures a decrease in child mortality within these countries. [ABSTRACT FROM AUTHOR]

Reductions in under-five mortality in Africa have not been sufficient to meet the Millennium Development Goal #4 (MDG#4) of reducing under-five mortality by two-thirds by 2015. Nevertheless, 12 African countries have met MDG#4. We undertook a four country study to examine barriers and facilitators of child survival prior to 2015, seeking to better understand variability in success across countries. The current analysis presents indicator, national document, and qualitative data from key informants and community women describing the factors that have enabled Zambia to successfully reduce under-five mortality over the last 15 years and achieve MDG#4. Results identified a Zambian national commitment to ongoing reform of national health strategic plans and efforts to ensure universal access to effective maternal, neonatal and child health (MNCH) interventions, creating an environment that has promoted child health. Zambia has also focused on bringing health services as close to the family as possible through specific community health strategies. This includes actively involving community health workers to provide health education, basic MNCH services, and linking women to health facilities, while supplementing community and health facility work with twice-yearly Child Health Weeks. External partners have contributed greatly to Zambia's MNCH services, and their relationships with the government are generally positive. As government funding increases to sustain MNCH services, national health strategies/plans are being used to specify how partners can fill gaps in resources. Zambia's continuing MNCH challenges include basic transportation, access-to-care, workforce shortages, and financing limitations. We highlight policies, programs, and implementation that facilitated reductions in under-five mortality in Zambia. These findings may inform how other countries in the African Region can increase progress in child survival in the post-MDG period. [ABSTRACT FROM AUTHOR]

Background: Civil wars and wars between states have occurred less frequently since the start of the 21st century, but civil insecurity outside the contexts of official wars continues to plague many parts of the world. The nutritional consequences of civil insecurity may disproportionately affect children, especially if experienced during sensitive developmental periods. Objectives: This study estimated the associations between localized nonviolent and violent civil insecurity during key child nutritional periods and subsequent height-for-age z scores (HAZs) in 145,948 children born between 1998 and 2014 in Africa and examined the type of place of residence as a mediating factor. Design: A collection of 61 geo-referenced Demographic and Health Surveys implemented between 1998 and 2014 were merged with data from the high-resolution Armed Conflict Location and Event Data Project to construct a repeat cross-sectional database, which was analyzed by using a difference-in-differences model with maternal fixed-effects. Results: Exposure to 1 nonviolent localized civil insecurity event (mean ± SD: 0.42 ± 1.87 events) during pregnancy for children living in rural areas was associated with a reduction of 0.01 SD in HAZ (P = 0.024). Exposure to 5 localized civil conflict fatalities (mean ± SD: 1.41 ± 10.21 fatalities) for children living in rural areas during the complementary feeding stage was associated with a 0.002-SD decrease in HAZ (P = 0.030). There were no measurable associations between civil insecurity and child heights in urban areas, even though children in urban areas experience more civil insecurity. Conclusions: Exposure to both violent and nonviolent civil insecurity had negative associations with subsequent HAZ, but only in rural areas. The associations found were small in magnitude but still meaningful from a child-development perspective, because these events do not necessarily occur in the context of official wars, they are often nonviolent, and they are endemic to the region. [ABSTRACT FROM AUTHOR]

Background: A high twinning rate and an increased risk of mortality among twins contribute to the high burden of infant mortality in Africa. This study examined the contribution of twins to neonatal and post-neonatal mortality in The Gambia, and evaluated factors that contribute to the excess mortality among twins.Methods: We analysed data from the Basse Health and Demographic Surveillance System (BHDSS) collected from January 2009 to December 2013. Demographic and epidemiological variables were assessed for their association with mortality in different age groups.Results: We included 32,436 singletons and 1083 twins in the analysis (twining rate 16.7/1000 deliveries). Twins represented 11.8 % of all neonatal deaths and 7.8 % of post-neonatal deaths. Mortality among twins was higher than in singletons [adjusted odds ratio (AOR) 4.33 (95 % CI: 3.09, 6.06) in the neonatal period and 2.61 (95 % CI: 1.85, 3.68) in the post-neonatal period]. Post-neonatal mortality among twins increased in girls (P for interaction = 0.064), being born during the dry season (P for interaction = 0.030) and lacking access to clean water (P for interaction = 0.042).Conclusion: Mortality among twins makes a significant contribution to the high burden of neonatal and post-neonatal mortality in The Gambia and preventive interventions targeting twins should be prioritized. [ABSTRACT FROM AUTHOR]

Background: In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. To avert overuse of blood products, the World Health Organisation advocates a conservative transfusion policy and recommends iron, folate and anti-helminthics at discharge. Outcomes are unsatisfactory with high rates of in-hospital mortality (9-10%), 6-month mortality and relapse (6%). A definitive trial to establish best transfusion and treatment strategies to prevent both early and delayed mortality and relapse is warranted.Methods/design: TRACT is a multicentre randomised controlled trial of 3954 children aged 2 months to 12 years admitted to hospital with severe anaemia (haemoglobin < 6 g/dl). Children will be enrolled over 2 years in 4 centres in Uganda and Malawi and followed for 6 months. The trial will simultaneously evaluate (in a factorial trial with a 3 x 2 x 2 design) 3 ways to reduce short-term and longer-term mortality and morbidity following admission to hospital with severe anaemia in African children. The trial will compare: (i) R1: liberal transfusion (30 ml/kg whole blood) versus conservative transfusion (20 ml/kg) versus no transfusion (control). The control is only for children with uncomplicated severe anaemia (haemoglobin 4-6 g/dl); (ii) R2: post-discharge multi-vitamin multi-mineral supplementation (including folate and iron) versus routine care (folate and iron) for 3 months; (iii) R3: post-discharge cotrimoxazole prophylaxis for 3 months versus no prophylaxis. All randomisations are open. Enrolment to the trial started September 2014 and is currently ongoing. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons. Secondary outcomes include mortality, morbidity (haematological correction, nutritional and infectious), safety and cost-effectiveness.Discussion: If confirmed by the trial, a cheap and widely available 'bundle' of effective interventions, directed at immediate and downstream consequences of severe anaemia, could lead to substantial reductions in mortality in a substantial number of African children hospitalised with severe anaemia every year, if widely implemented.Trial Registration: Current Controlled Trials ISRCTN84086586 , Approved 11 February 2013. [ABSTRACT FROM AUTHOR]

Nearly all African countries have recently implemented some form of integrated community case management of childhood illness (iCCM), a strategy aimed at reducing child mortality by providing curative care for common yet fatal childhood illnesses. This case study describes the evolution of iCCM at the global level using the theory of epistemic communities first outlined by Haas, which explains how international policy coordination on technical issues takes place via transnational expert networks. We draw from in-depth interviews with global policy-makers (n = 25), a document review (n = 72) and co-authorship network analysis of scientific articles on iCCM. We find that members of the iCCM epistemic community were mainly mid- to upper-level technical officers working in the headquarters of large norm-setting bodies, implementing partners, funders and academic/research groups in global health. Already linked by pre-existing relationships, the epistemic community was consolidated as conflicts were overcome through structural changes in the network (including or excluding some members), changes in the state of technology or scientific evidence, shifting funding considerations, and the development of consensus through argument, legitimation and other means. Next, the epistemic community positioned iCCM as a preferred solution via three causal dynamics outlined by Haas: (1) responding to decision-makers' uncertainty about how to reduce child mortality after previous policies proved insufficient, (2) using sophisticated analytic tools to link the problem of child mortality to iCCM as a solution and (3) gaining buy-in from major norm-setting bodies and financial and institutional support from large implementing agencies. Applying the epistemic communities framework to the iCCM case study reveals the strengths and weaknesses of a focused policy enterprise with highly specialized and homogenous disciplinary origins, allowing for efficient sharing of complex, high-level scientific information, but possibly excluding voices with relevant methodological, operational or country-level perspectives. [ABSTRACT FROM AUTHOR]

Background: Worldwide, a total of 6.282 million deaths occurred among children aged less than 5 years in 2013. About 47.4 % of those were borne by the 47 Member States of the World Health Organization (WHO) African Region. Sadly, even as we approach the end date for the 2015 Millennium Development Goals (MDGs), only eight African countries are on track to achieve the MDG 4 target 4A of reducing under-five mortality by two thirds between 1990 and 2015. The post-2015 Sustainable Development Goal (SDG) 3 target is "by 2030, end preventable deaths of new-borns and children under 5 years of age". There is urgent need for increased advocacy among governments, the private sector and development partners to provide the resources needed to build resilient national health systems to deliver an integrated package of people-centred interventions to end preventable child morbidity and mortality and other structures to address all the basic needs for a healthy population. The specific objective of this study was to estimate expected/future productivity losses from child deaths in the WHO African Region in 2013 for use in advocacy for increased investments in child health services and other basic services that address children's welfare.Methods: A cost-of-illness method was used to estimate future non-health GDP losses related to child deaths. Future non-health GDP losses were discounted at 3 %. The analysis was undertaken with the countries categorized under three income groups: Group 1 consisted of nine high and upper middle income countries, Group 2 of 13 lower middle income countries, and Group 3 of 25 low income countries. One-way sensitivity analysis at 5 % and 10 % discount rates assessed the impact of the expected non-health GDP loss.Results: The discounted value of future non-health GDP loss due to the deaths of children under 5 years old in 2013 will be in the order of Int$ 150.3 billion. Approximately 27.3 % of the loss will be borne by Group 1 countries, 47.1 % by Group 2 and 25.7 % by Group 3. The average non-health GDP lost per child death will be Int$ 174 310 for Group 1, Int$ 57 584 for Group 2 and Int$ 25 508 for Group 3.Conclusions: It is estimated that the African Region will incur a loss of approximately 6 % of its non-health GDP from the future years of life lost among the 2 976 000 child deaths that occurred in 2013. Therefore, countries and development partners should in solidarity sustainably provide the resources essential to build resilient national health systems and systems to address the determinants of health and meet the other basic needs such as for clothing, education, food, shelter, sanitation and clean water to end preventable child morbidity and mortality. [ABSTRACT FROM AUTHOR]

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Background: Mortality in paediatric emergency care units in Africa often occurs within the first 24 h of admission and remains high. Alongside effective triage systems, a practical clinical bedside risk score to identify those at greatest risk could contribute to reducing mortality. Methods: Data collected during the Fluid As Expansive Supportive Therapy (FEAST) trial, a multi-centre trial involving 3,170 severely ill African children, were analysed to identify clinical and laboratory prognostic factors for mortality. Multivariable Cox regression was used to build a model in this derivation dataset based on clinical parameters that could be quickly and easily assessed at the bedside. A score developed from the model coefficients was externally validated in two admissions datasets from Kilifi District Hospital, Kenya, and compared to published risk scores using Area Under the Receiver Operating Curve (AUROC) and Hosmer-Lemeshow tests. The Net Reclassification Index (NRI) was used to identify additional laboratory prognostic factors. Results: A risk score using 8 clinical variables (temperature, heart rate, capillary refill time, conscious level, severe pallor, respiratory distress, lung crepitations, and weak pulse volume) was developed. The score ranged from 0-10 and had an AUROC of 0.82 (95 % CI, 0.77-0.87) in the FEAST trial derivation set. In the independent validation datasets, the score had an AUROC of 0.77 (95 % CI, 0.72-0.82) amongst admissions to a paediatric high dependency ward and 0.86 (95 % CI, 0.82-0.89) amongst general paediatric admissions. This discriminative ability was similar to, or better than other risk scores in the validation datasets. NRI identified lactate, blood urea nitrogen, and pH to be important prognostic laboratory variables that could add information to the clinical score. Conclusions: Eight clinical prognostic factors that could be rapidly assessed by healthcare staff for triage were combined to create the FEAST Paediatric Emergency Triage (PET) score and externally validated. The score discriminated those at highest risk of fatal outcome at the point of hospital admission and compared well to other published risk scores. Further laboratory tests were also identified as prognostic factors which could be added if resources were available or as indices of severity for comparison between centres in future research studies. [ABSTRACT FROM AUTHOR]

Aim To accelerate progress in reducing child mortality, many countries in sub-Saharan Africa have adopted and scaled-up integrated community case management (iCCM) programs targeting the three major infectious killers of children under-five. The programs train lay community health workers to assess, classify and treat uncomplicated cases of pneumonia with antibiotics, malaria with antimalarial drugs and diarrhea with Oral Rehydration Salts (ORS) and zinc. Although management of these conditions with the respective appropriate drugs has proven efficacious in randomized trials, the effectiveness of large iCCM scale-up programs in reducing child mortality is yet to be demonstrated. This paper reviews recent experience in documenting and attributing changes in under-five mortality to the specific interventions of a variety of iCCM programs. Methods Eight recent studies have been identified and assessed in terms of design, mortality measurement and results. Impact of the iCCM program on mortality among children age 2-59 months was assessed through a difference in differences approach using random effect Poisson regression. Results Designs used by these studies include cluster randomized trials, randomized stepped-wedge and quasi-experimental trials. Child mortality is measured through demographic surveillance or household survey with full birth history conducted at the end of program implementation. Six of the eight studies showed a higher decline in mortality among children 2-59 months in program areas compared to comparison areas, although this acceleration was statistically significant in only one study with a decline of 76% larger in intervention than in comparison areas. Conclusion Studies that evaluate large scale iCCM programs and include assessment of mortality impact must ensure an appropriate design. This includes required sample sizes and sufficient number of program and comparison districts that allow adequate inference and attribution of impact. In addition, large-scale program utilization, and a significant increase in coverage of care seeking and treatment of targeted childhood illnesses are preconditions to measurable mortality impact. Those issues need to be addressed before large investments in assessing changes in child mortality is undertaken, or the results of mortality impact evaluation will most likely be inconclusive. [ABSTRACT FROM AUTHOR]

Competing Interests: We declare no competing interests.

Preconception care is biomedical, behavioural, and social health interventions provided to women and couples before conception. This service is sometimes prioritised for women at high risk for adverse pregnancy outcomes. Evidence revealed that only very few women in Africa with severe chronic conditions receive or seek preconception care advice and assessment for future pregnancy. Thus, this study aimed to explore the perceptions and practice of preconception care by healthcare workers and high-risk women in Kwa-Zulu-Natal, South Africa. This exploratory, descriptive qualitative study utilised individual in-depth interviews to collect data from 24 women at high risk of adverse pregnancy outcomes and five healthcare workers. Thematic analysis was conducted using Nvivo version 12. Five main themes that emerged from the study include participants' views, patients' access to information, practices, and perceived benefits of preconception care. The healthcare workers were well acquainted with the preconception care concept, but the women had inconsistent acquaintance. Both groups acknowledge the role preconception care can play in the reduction of maternal and child mortality. A recommendation is made for the healthcare workers to use the 'One key' reproductive life plan question as an entry point for the provision of preconception care. [ABSTRACT FROM AUTHOR]

The authors discuss the emergence of, and the need for, community health worker programs to strengthen health surveillance and health systems after the Ebola outbreak in low-income countries from 2013-2016. Topics discussed include the impact of the Ebola outbreak in Guinea, Liberia and Sierra Leone, the role of community health workers when an outbreak has been identified, and key developments needed for resilient health systems.

The WHO Global Initiative for Childhood Cancer launched in 2018 will translate into an additional one million lives saved or a survival rate of at least 60% for children with cancer to be attained by 2030. This new target represents a doubling of the global cure rate for children with cancer. African children with cancer will be amongst the global group which will benefit from an improved cancer care and better outcome. [ABSTRACT FROM AUTHOR]

Background: Verbal autopsy is the main method used in countries with weak civil registration systems for estimating community causes of neonatal and 1-59-month-old deaths. However, validation studies of verbal autopsy methods are limited and assessment has been dependent on hospital-based studies, with uncertain implications for its validity in community settings. If the distribution of community deaths by cause was similar to that of facility deaths, or could be adjusted according to related demographic factors, then the causes of facility deaths could be used to estimate population causes., Methods: Causes of neonatal and 1-59-month-old deaths from verbal/social autopsy (VASA) surveys in four African countries were estimated using expert algorithms (EAVA) and physician coding (PCVA). Differences between facility and community deaths in individual causes and cause distributions were examined using chi-square and cause-specific mortality fractions (CSMF) accuracy, respectively. Multinomial logistic regression and random forest models including factors from the VASA studies that are commonly available in Demographic and Health Surveys were built to predict population causes from facility deaths., Results: Levels of facility and community deaths in the four countries differed for one to four of 10 EAVA or PCVA neonatal causes and zero to three of 12 child causes. CSMF accuracy for facility compared to community deaths in the four countries ranged from 0.74 to 0.87 for neonates and 0.85 to 0.95 for 1-59-month-olds. Crude CSMF accuracy in the prediction models averaged 0.86 to 0.88 for neonates and 0.93 for 1-59-month-olds. Adjusted random forest prediction models increased average CSMF accuracy for neonates to, at most, 0.90, based on small increases in all countries., Conclusions: There were few differences in facility and community causes of neonatal and 1-59-month-old deaths in the four countries, and it was possible to project the population CSMF from facility deaths with accuracy greater than the validity of verbal autopsy diagnoses. Confirmation of these findings in additional settings would warrant research into how medical causes of deaths in a representative sample of health facilities can be utilized to estimate the population causes of child death.

Background: This study sought to identify, as far as possible, the extent of the specialist children's nursing workforce in five selected African countries. Strengthening children's nursing training has been recommended as a primary strategy to reduce the under-five mortality rate in African nations. However, information about the extent of the specialist children's nursing workforce in this region is not routinely available. Developing an accurate depiction of the specialist children's nursing workforce is a necessary step towards optimising children's health service delivery.Methods: This study used a convergent parallel mixed methods design, incorporating quantitative (surveys) and qualitative (questionnaire and interview) components, to generate data addressing three related questions: how many children's nurses are believed to be in practice nationally, how many such nurses are recorded on the national nursing register and how many children's nurses are being produced through training annually.Results: Data provide insights into reported children's nursing workforce capacity, training activity and national training output in the five countries. Findings suggest there are approximately 3728 children's nurses across the five countries in this study, with the majority in South Africa. A total of 16 educational programmes leading to a qualification in paediatric nursing or child health nursing are offered by 10 institutions across the countries in this study, with Kenya, Malawi and Zambia having one institution each and South Africa hosting seven. Data suggest that existing human resources for health information systems do not currently produce adequate information regarding the children's nursing workforce. Analysis of qualitative data elicited two themes: the role of children's nurses and their position within health systems, and the capacity of HRH information systems to accurately reflect the specialist children's nursing workforce.Conclusion: The data generated provide an initial indication of the size of the children's nursing workforce in these five countries, as well as an overview of associated training activity. We hope that they can start to inform discussion about what would represent a viable and sustainable regional children's nursing workforce for the future. [ABSTRACT FROM AUTHOR]

Child mortality is a major public health problem in sub‐Saharan Africa and is influenced by nutritional status. A conceptual framework was proposed to explain factors related to undernutrition. Previously proposed conceptual frameworks for undernutrition do not consider child mortality and describe factors related to undernutrition from a qualitative viewpoint only. A structural equation modelling approach was applied to the data from World Bank and FAO databases collected from over 37 sub‐Saharan countries from 2000 to the most recent update. Ten food groups, exclusive breastfeeding, poverty and illiteracy rates, and environmental hygiene were investigated in relation to underweight, stunting, low birthweight, and child mortality. Standardized beta coefficient was reported, and graphical models were used to depict the relations among factors related to under‐five mortality in sub‐Saharan Africa. Child mortality in sub‐Saharan Africa ranged between 76 and 127 × 1,000. In the same period, low birthweight rate was about 14%. Poverty and illiteracy are confirmed to affect health resources, which in turn influenced nutritional status and child mortality. Among nutritional factors, exclusive breastfeeding had a greater influence than food availability. Low birthweight, more than underweight and stunting, influenced child mortality. Structural equation modelling is a suitable way to disentangle the complex quantitative framework among factors determining child mortality in sub‐Saharan Africa. Acting on poverty at the base appear to be the more effective strategy along with improvement of breastfeeding practice and improvement of hygiene conditions. [ABSTRACT FROM AUTHOR]

Background: There is an increasing recognition that children remain at elevated risk of death following discharge from health facilities in resource-poor settings. Diarrhea has previously been highlighted as a risk factor for post-discharge mortality.Methods: A retrospective cohort study was conducted to estimate the incidence and demographic, clinical, and biochemical features associated with inpatient and 1-year post-discharge mortality amongst children aged 2-59 months admitted with diarrhea from 2007 to 2015 at Kilifi County Hospital and who were residents of Kilifi Health and Demographic Surveillance System (KHDSS). Log-binomial regression was used to identify risk factors for inpatient mortality. Time at risk was from the date of discharge to the date of death, out-migration, or 365 days later. Post-discharge mortality rate was computed per 1000 child-years of observation, and Cox proportion regression used to identify risk factors for mortality.Results: Two thousand six hundred twenty-six child KHDSS residents were admitted with diarrhea, median age 13 (IQR 8-21) months, of which 415 (16%) were severely malnourished and 130 (5.0%) had a positive HIV test. One hundred twenty-one (4.6%) died in the hospital, and of 2505 children discharged alive, 49 (2.1%) died after discharge: 21.4 (95% CI 16.1-28.3) deaths per 1000 child-years. Admission with signs of both diarrhea and severe pneumonia or severe pneumonia alone had a higher risk of both inpatient and post-discharge mortality than admission for diarrhea alone. There was no significant difference in inpatient and post-discharge mortality between children admitted with diarrhea alone and those with other diagnoses excluding severe pneumonia. HIV, low mid-upper arm circumference (MUAC), and bacteremia were associated with both inpatient and post-discharge mortality. Signs of circulatory impairment, sepsis, and abnormal electrolytes were associated with inpatient but not post-discharge mortality. Prior admission and lower chest wall indrawing were associated with post-discharge mortality but not inpatient mortality. Age, stuntedness, and persistent or bloody diarrhea were not associated with mortality before or after discharge.Conclusions: Our results accentuate the need for research to improve the uptake and outcomes of services for malnutrition and HIV as well as to elucidate causal pathways and test interventions to mitigate these risks. [ABSTRACT FROM AUTHOR]