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The Guest Editors for the PLOS Medicine Special Issue on Maternal and Child Health & Nutrition discuss the published research in the context of global priorities for women's and children's health. [ABSTRACT FROM AUTHOR]

During the Millennium Development Goals era of 1990-2015, global mortality in children under the age of five was reduced from 90 to 43 per 1000 live births.1 A series of vertical programmes that promoted immunisation and managed pneumonia and diarrhoea contributed to this dramatic reduction. The health posts are usually staffed by two health extension workers, who spend most of their time involved in outreach activities in the communities. Although these primary care workers provide some preventive and curative services to pregnant women and children, the health centres, which are staffed by midwives and health officers, are the first level that offers delivery services and newborn care by more qualified staff. [Extracted from the article]

Despite its clear biological benefits, many infants globally do not receive exclusive breastfeeding. In a Guest Editorial, Lars Åke Persson discusses what is needed to make breastfeeding the social norm. [ABSTRACT FROM AUTHOR]

Summary This article describes caregivers' strategies for reaching children on the streets and caring for them at institutions of care. Data was collected over a period of two years from 70 caregivers in 35 organisations in Nairobi, Nakuru and Muranga, identified by snowball sampling strategy. Data was collected using a semi-structured topic guide based on issues emerging from earlier studies with street boys. Direct observation, video recording and photography were used to study interactions between the children and their caregivers. Findings Two themes were developed: the “dedicated” caregiver confronting street realities, and making a difference despite the limitations. The way caregivers interacted with the children on the streets and in the institutions influenced the children's decision to leave the streets, to be initiated into residential care, and attend rehabilitation and reintegration programmes. Children were more positive to caregivers who took time to understand them and were soft in establishing rapport with them. Application The results suggest that caregivers' strategies are potential contributors to reversing trends in the street children phenomenon as they influence the children's decision to leave the streets and undergo rehabilitation at institutions of care. We thus recommend development of educational efforts focusing on helping caregivers develop healthy relationships and positive interactions with the children. [ABSTRACT FROM AUTHOR]

Analysing child mortality may enhance our perspective on global achievements in child survival. We used data from surveillance sites in Bangladesh, Nicaragua and Vietnam and Demographic Health Surveys in Rwanda to explore the development of neonatal and under-five mortality. The mortality curves showed dramatic reductions over time, but child mortality in the four countries peaked during wars and catastrophes and was rapidly reduced by targeted interventions, multisectorial development efforts and community engagement.Conclusion: Lessons learned from these countries may be useful when tackling future challenges, including persistent neonatal deaths, survival inequalities and the consequences of climate change and migration. [ABSTRACT FROM AUTHOR]

Background: Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals.Methods: Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model.Results: Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths.Conclusions: Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival. [ABSTRACT FROM AUTHOR]

Background: Cholera outbreaks are a continuing problem in Bangladesh, and the timely detection of an outbreak is important for reducing morbidity and mortality. In Matlab, the ongoing Health and Demographic Surveillance System (HDSS) data records symptoms of diarrhea in children under the age of 5 years at the community level. Cholera surveillance in Matlab currently uses hospital-based data. Objective: The objective of this study is to determine whether increases in cholera in Matlab can be detected earlier by using HDSS diarrhea symptom data in a syndromic surveillance analysis, when compared to hospital admissions for cholera. Methods: HDSS diarrhea symptom data and hospital admissions for cholera in children under 5 years of age over a 2-year period were analyzed with the syndromic surveillance statistical program EARS (Early Aberration Reporting System). Dates when significant increases in either symptoms or cholera cases occurred were compared to one another. Results: The analysis revealed that there were 43 days over 16 months when the cholera cases or diarrhea symptoms increased significantly. There were 8 months when both data sets detected days with significant increases. In 5 of the 8 months, increases in diarrheal symptoms occurred before increases of cholera cases. The increases in symptoms occurred between 1 and 15 days before the increases in cholera cases. Conclusions: The results suggest that the HDSS survey data may be able to detect an increase in cholera before an increase in hospital admissions is seen. However, there was no direct link between diarrheal symptom increases and cholera cases, and this, as well as other methodological weaknesses, should be taken into consideration. [ABSTRACT FROM AUTHOR]

In a Perspective, Lars Åke Persson discusses the need to focus on quality of care to improve maternal, newborn, and child healthcare. [ABSTRACT FROM AUTHOR]

Background: Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid. Methods: Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 μgm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 μgm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 μgm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study. Results: By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively. Conclusions: Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints. [ABSTRACT FROM AUTHOR]

Lars Åke Persson and colleagues conduct a cluster randomised control in northern Vietnam to analyze the effect of the activity of local community-based maternal-and-newborn stakeholder groups on neonatal mortality. Please see later in the article for the Editors' Summary [ABSTRACT FROM AUTHOR]

Oxidative stress is suggested as a potential mechanism in impaired foetal growth, smaller birth size and thus subsequently adult chronic diseases. We have investigated associations between oxidative stress in pregnancy and birth anthropometry (weight, height, head and chest circumferences). In the MINIMat-trial (Maternal and Infant Nutrition Interventions, Matlab) in rural Bangladesh, free 8-iso-prostaglandin F2α (lipid peroxidation) was analysed in pregnancy week 14 and 30 and 8-Hydroxy-2 -Deoxyguanosine (DNA oxidation) in week 19. We found that higher levels of lipid peroxidation in early pregnancy were associated with larger infant size (birth length and chest circumference). In late pregnancy, no clear pattern of associations was found. Increasing level of DNA oxidation was associated with lower birth length in girls but no other associations were found. In conclusion, a higher level of lipid peroxidation in early (but not late) pregnancy was associated with a favourable larger birth size suggesting that timing of lipid peroxidation is of importance. [ABSTRACT FROM AUTHOR]

To estimate the prevalence of infant anaemia and its association with iron deficiency, growth, infection and other micronutrient deficiencies. Using data from MINIMat, a randomized maternal food and micronutrient supplementation trial, we assessed the associations between anaemia (haemoglobin < 105 g/L) in 580 infants at 6 months and deficiencies of iron, vitamin A, vitamin B12, zinc and folate, infection and anthropometric indices. Variables associated with anaemia in bivariate analyses were evaluated in logistic regression models, adjusting for potential confounders. Anaemia was found in 46% of the infants, and among these, 28% had iron deficiency (plasma ferritin <9 μg/L). Elevated C-reactive protein (>10mg/L) (OR = 2.7, 95% CI: 1.6, 4.7), low birthweight (OR = 2.3, 95% CI: 1.5, 3.5) and iron deficiency (OR = 2.2, 95% CI: 1.4, 3.6) were independently associated with increased risk for anaemia. We also observed a seasonal variation in anaemia not mediated through the other factors studied. In a cohort in rural Bangladesh, anaemia at age 6 months was common and associated with infection, low birthweight and iron deficiency. [ABSTRACT FROM AUTHOR]

CONTEXT: Violence toward pregnant women is a gross violation of human rights with adverse health consequences for the woman and potentially for her fetus; however, few studies have examined factors associated with such abuse in developing countries or with population-based data. METHODS: A sample of 2,553 ever-pregnant women aged 15-49 from one urban and one rural site in Bangladesh were surveyed in 2001 as part of a World Health Organization multicountry study. Multilevel logistic regression analysis was used to examine factors associated with physical spousal abuse of women during pregnancy. RESULTS: Urban and rural women whose mother or mother-in-law had experienced physical spousal abuse had increased odds of experiencing abuse during pregnancy (odds ratios,2.1-3.4); increased spousal communication was negatively associated with the outcome in both settings (0.6 and 0.7). Among urban women, being older than 19, having a husband with more than 10 years of education and being from certain higher income quartiles were negatively associated with abuse (0.2-0.5); living in a community highly concerned about crime was positively associated with abuse (1.1). Among rural women, being able to depend on natal family support in a crisis was negatively associated with abuse (0.5); being in a marriage that involved dowry demands and being Muslim were positively associated with abuse (1.8 and 3.6, respectively). CONCLUSIONS: The message that a family history of spousal violence increases a daughter's risk of such abuse should be widely communicated. Further research is needed to determine whether increased couple communication reduces the likelihood of violence or whether absence of violence leads to increased couple communication. [ABSTRACT FROM AUTHOR]

Using data from a population-based survey of 2,702 women of reproductive age and from 28 in-depth interviews of abused women conducted during 2000-01, this study explores factors associated with domestic violence in urban and rural Bangladesh. Multilevel analysis revealed that in both residential areas, dowry or other demands in marriage and a history of abuse of the husband's mother by his father increased the risk of violence. Better spousal communication and husband's education beyond the tenth grade decreased the risk of violence. In the urban area, women's being younger than their husband and participating in savings and credit groups increased the risk of abuse, whereas husband's education beyond the sixth grade had a protective effect. In the rural area, women's earning an income increased the risk. These factors are important to consider when designing interventions. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- To study the association between type 1 diabetes risk and previous intake of energy, accounting for body size and previous intake of nutrients and foods, accounting for the energy intake. RESEARCH DESIGN AND METHODS -- We conducted an incident population-based case-referent study in Stockholm, Sweden, including 99 of 100 eligible 7- to 14-year-old diabetic children and 180 of 200 age-, sex-, and area-matched referent children identified through the Swedish population register. Average daily energy and nutrient intake 1 year before diabetes diagnosis/interview was estimated using the food frequency questionnaire with assessment of consumed food amounts. Mean SD scores of growth measurements taken during the last 4 years before the diagnosis were used, Odds ratios (ORs) were calculated by conditional logistic regression. RESULTS -- Average intake of energy, carbohydrate, fat, and protein was significantly higher among the case subjects as well as mean weight-for-age SD score. Higher energy intake and weight-for-age were both associated with increased diabetes risk after adjustment for each other: OR (95% CI) for medium and high levels of energy intake were 1.33 (0.52-3.42) and 5.23 (1.67-16.38), respectively, and for weight-for-age were 3.20 (1.30-7.88) and 3.09 (1.16-8.22), respectively. High intake of carbohydrates, especially disaccharides and sucrose, increased diabetes risk. CONCLUSIONS -- Higher energy intake and larger body size were independently associated with increased diabetes risk. Of the different nutrients, higher intake of carbohydrates, particularly disaccharides and sucrose, increased the risk. Lifestyle habits leading to higher energy intake and more rapid growth in childhood may contribute to the increase of childhood-onset type 1 diabetes by different mechanisms. [ABSTRACT FROM AUTHOR]

Background: Anaemia and iron-deficiency anaemia in women are global problems that are prevalent throughout the reproductive cycle. Data are scarce on whether iron supplementation in pregnancy and puerperium has a sustained effect on haemoglobin concentration. Objective: To assess whether there is a dose effect of iron supplementation in pregnancy and puerperium on haemoglobin 6 weeks after delivery, and compare the effectiveness of daily and weekly dose regimens at 6 weeks postpartum. Design: 50 antenatal centres were assigned randomly to 1×60 mg iron daily or 2×60 mg once weekly. Data are reported for 146 women (daily, n =67; weekly, n =79): haemoglobin, serum ferritin (sFt) and serum transferrin receptors (sTfR) at baseline and at 6 weeks postpartum. Tablet intake was monitored using pill-bottles equipped with electronic counting devices. Results: There was a dose effect of iron supplementation on haemoglobin concentration at 6 weeks postpartum. Endpoint attained haemoglobin, sFt and sTfR did not differ between daily and weekly groups, although a larger increment of sFt was found in the daily group ( p =0.03). Conclusions: Effects of iron supplementation in pregnancy and puerperium were observed at 6 weeks after delivery. The size of the effect was dependent on the number of tablets, not on daily or weekly regimen. It is not known whether the effects of iron supplementation in pregnancy are sustained into the next pregnancy. [ABSTRACT FROM AUTHOR]

The aim of the present study was to suggest a causal model of dental caries and to discuss some quantitative interpretations of this model. Three age groups of children (4, 8 and 13 yr) from three different areas in Sweden were included. The caries status of the children was examined. A 7-day record (4- and 8-yr-olds) and a dietary history (13-yr-olds) were used to estimate food intake. Sociodemographic data and data of caries preventive measures were obtained from parents/children. A causal model of dental caries is suggested and some quantitative interpretations are made by means of path analyses. Hypothetical examples of results of changes in caries determinants are given. [ABSTRACT FROM AUTHOR]

The article reports that maternal undernutrition causes foetal growth restriction and child undernutrition. It notes that undernutrition is an outcome of insufficient food intake, repeated episodes of infectious diseases and other factors that result in underweight for age, shortness for age. It adds that the scope of malnutrition is even more significant in addition to the burden of undernutrition.

An introduction is presented which discusses various topics within the issue including health and survival of premature infants, child mortality and malnutrition in South African countries, and contribution of neonatologist Joy Lawn to make visible women and newborns in low-income countries.

Background: A routine health information system is one of the essential components of a health system. Interventions to improve routine health information system data quality and use for decision-making in low- and middle-income countries differ in design, methods, and scope. There have been limited efforts to synthesise the knowledge across the currently available intervention studies. Thus, this scoping review synthesised published results from interventions that aimed at improving data quality and use in routine health information systems in low- and middle-income countries. Method: We included articles on intervention studies that aimed to improve data quality and use within routine health information systems in low- and middle-income countries, published in English from January 2008 to February 2020. We searched the literature in the databases Medline/PubMed, Web of Science, Embase, and Global Health. After a meticulous screening, we identified 20 articles on data quality and 16 on data use. We prepared and presented the results as a narrative. Results: Most of the studies were from Sub-Saharan Africa and designed as case studies. Interventions enhancing the quality of data targeted health facilities and staff within districts, and district health managers for improved data use. Combinations of technology enhancement along with capacity building activities, and data quality assessment and feedback system were found useful in improving data quality. Interventions facilitating data availability combined with technology enhancement increased the use of data for planning. Conclusion: The studies in this scoping review showed that a combination of interventions, addressing both behavioural and technical factors, improved data quality and use. Interventions addressing organisational factors were non-existent, but these factors were reported to pose challenges to the implementation and performance of reported interventions. [ABSTRACT FROM AUTHOR]

Aim: This paper aimed to analyse the association between small for size at birth, stunting, recovery from stunting and pubertal development in a rural Bangladeshi cohort.Methods: The participants were 994 girls and 987 boys whose mothers participated in the Maternal and Infant Nutrition Interventions in Matlab trial. The birth cohort was followed from birth to puberty 2001-2017. Pubertal development according to Tanner was self-assessed. Age at menarche was determined and in boys, consecutive height measurements were used to ascertain whether pubertal growth spurt had started. The exposures and outcomes were modelled by Cox's proportional hazards analyses and logistic regression.Results: There was no difference in age at menarche between girls that were small or appropriate for gestational age at birth. Boys born small for gestational age entered their pubertal growth spurt later than those with appropriate weight. Children who were stunted had later pubertal development, age at menarche and onset of growth spurt than non-stunted children. Children who recovered from infant or early childhood stunting had similar pubertal development as non-stunted children.Conclusion: Infant and childhood stunting was associated with a later pubertal development. Recovery from stunting was not associated with earlier puberty in comparison with non-stunted children. [ABSTRACT FROM AUTHOR]

Background: Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid.Methods: Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 μgm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 μgm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 μgm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study.Results: By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively.Conclusions: Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints.Trial Registration: Maternal and Infant Nutrition Interventions, Matlab; ISRCTN16581394 ; Date of registration: Feb 16, 2009. [ABSTRACT FROM AUTHOR]

Epidemiological studies have suggested a negative association between early life arsenic exposure and fetal size at birth, and subsequently with child morbidity and growth. However, our understanding of the relationship between arsenic exposure and morbidity and growth is limited. This paper aims to systematically review original human studies with an analytical epidemiological study design that have assessed arsenic exposure in fetal life or early childhood and evaluated the association with one or several of the following outcomes: fetal growth, birth weight or other birth anthropometry, infant and child growth, infectious disease morbidity in infancy and early childhood. A literature search was conducted in PubMed, TOXLINE, Web of Science, SciFinder and Scopus databases filtered for human studies. Based on the predefined eligibility criteria, two authors independently evaluated the studies. A total of 707 studies with morbidity outcomes were identified, of which six studies were eligible and included in this review. For the growth outcomes, a total of 2959 studies were found and nine fulfilled the criteria and were included in the review. A majority of the papers (10/15) emanated from Bangladesh, three from the USA, one from Romania and one from Canada. All included studies on arsenic exposure and morbidity showed an increased risk of respiratory tract infections and diarrhea. The findings in the studies of arsenic exposure and fetal, infant, and child growth were heterogeneous. Arsenic exposure was not associated with fetal growth. There was limited evidence of negative associations between arsenic exposures and birth weight and growth during early childhood. More studies from arsenic-affected low- and middle-income countries are needed to support the generalizability of study findings. [ABSTRACT FROM AUTHOR]

Introduction: Childhood illnesses, such as acute respiratory illness, fever, and diarrhoea, continue to be public health problems in low-income countries. Detecting spatial variations of common childhood illnesses and service utilisation is essential for identifying inequities and call for targeted actions. This study aimed to assess the geographical distribution and associated factors for common childhood illnesses and service utilisation across Ethiopia based on the 2016 Demographic and Health Survey. Methods: The sample was selected using a two-stage stratified sampling process. A total of 10,417 children under five years were included in this analysis. We linked data on their common illnesses during the last two weeks and healthcare utilisation were linked to Global Positioning System (GPS) information of their local area. The spatial data were created in ArcGIS10.1 for each study cluster. We applied a spatial autocorrelation model with Moran's index to determine the spatial clustering of the prevalence of childhood illnesses and healthcare utilisation. Ordinary Least Square (OLS) analysis was done to assess the association between selected explanatory variables and sick child health services utilisation. Hot and cold spot clusters for high or low utilisation were identified using Getis-Ord Gi*. Kriging interpolation was done to predict sick child healthcare utilisation in areas where study samples were not drawn. All statistical analyses were performed using Excel, STATA, and ArcGIS. Results: Overall, 23% (95CI: 21, 25) of children under five years had some illness during the last two weeks before the survey. Of these, 38% (95%CI: 34, 41) sought care from an appropriate provider. Illnesses and service utilisation were not randomly distributed across the country with a Moran's index 0.111, Z-score 6.22, P<0.001, and Moran's index = 0.0804, Z-score 4.498, P< 0.001, respectively. Wealth and reported distance to health facilities were associated with service utilisation. Prevalence of common childhood illnesses was higher in the North, while service utilisation was more likely to be on a low level in the Eastern, South-western, and the Northern parts of the country. Conclusion: Our study provided evidence of geographic clustering of common childhood illnesses and health service utilisation when the child was sick. Areas with low service utilisation for childhood illnesses need priority, including actions to counteract barriers such as poverty and long distances to services. [ABSTRACT FROM AUTHOR]

Background: Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers. Methods: The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2–59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses. Results: We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention. Conclusion: The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities. Trial registration number: ISRCTN12040912, retrospectively registered on 19/12/ 2017. [ABSTRACT FROM AUTHOR]

BACKGROUND: Several metals act as endocrine disruptors, but there are few large longitudinal studies about associations with puberty onset. OBJECTIVES: We evaluated whether early life cadmium, lead, and arsenic exposure was associated with timing of menarche. METHODS: In a mother–child cohort in rural Bangladesh (푛=935), the exposure was assessed by concentrations in maternal erythrocytes in early pregnancy and in girls’ urine at 5 and 10 years of age using inductively coupled plasma mass spectrometry. The girls were interviewed twice, at average ages 13.3 [standard deviation (SD)=0.43] and 13.8 (SD=0.43) y, and the date of menarche, if present, was recorded. Associations were assessed using Kaplan–Meier analysis and multivariable-adjusted Cox regression. RESULTS: In total, 77% of the girls (푛=717) had reached menarche by the second follow-up. The median age of menarche among all girls was 13.0 y (25th–75th percentiles: 12.4–13.7 y). At 10 years of age, median urinary cadmium was 0.25 μg/L (5th–95th percentiles: 0.087–0.72 μg/L), lead 1.6 μg/L (0.70–4.2 μg/L), and arsenic 54 μg/L (19–395 μg/L). Given the same age, girls in the highest quartile of urinary cadmium at 5 and 10 years of age had a lower rate of menarche than girls in the lowest quartile, with an adjusted hazard ratio of (HR) 0.80 (95% CI: 0.62, 1.01) at 5 years of age, and 0.77 (95% CI: 0.60, 0.98) at 10 years of age. This implies that girls in the highest cadmium exposure quartile during childhood had a higher age at menarche. Comparing girls in the highest to the lowest quartile of urinary lead at 10 years of age, the former had a higher rate of menarche [adjusted HR=1.23 (95% CI: 0.97, 1.56)], implying lower age at menarche, whereas there was no association with urinary lead at 5 years of age. Girls born to mothers in the highest quartile of erythrocyte arsenic during pregnancy were less likely to have attained menarche than girls born to mothers in the lowest quartile [adjusted HR= 0.79 (95% CI: 0.62, 0.99)]. No association was found with girls’ urinary arsenic exposure. DISCUSSION: Long-term childhood cadmium exposure was associated with later menarche, whereas the associations with child lead exposure were inconclusive. Maternal exposure to arsenic, but not cadmium or lead, was associated with later menarche. [ABSTRACT FROM AUTHOR]

Background: Facilitation of local women's groups may reportedly reduce neonatal mortality. It is not known whether facilitation of groups composed of local health care staff and politicians can improve perinatal outcomes. We hypothesised that facilitation of local stakeholder groups would reduce neonatal mortality (primary outcome) and improve maternal, delivery, and newborn care indicators (secondary outcomes) in Quang Ninh province, Vietnam.Methods and Findings: In a cluster-randomized design 44 communes were allocated to intervention and 46 to control. Laywomen facilitated monthly meetings during 3 years in groups composed of health care staff and key persons in the communes. A problem-solving approach was employed. Births and neonatal deaths were monitored, and interviews were performed in households of neonatal deaths and of randomly selected surviving infants. A latent period before effect is expected in this type of intervention, but this timeframe was not pre-specified. Neonatal mortality rate (NMR) from July 2008 to June 2011 was 16.5/1,000 (195 deaths per 11,818 live births) in the intervention communes and 18.4/1,000 (194 per 10,559 live births) in control communes (adjusted odds ratio [OR] 0.96 [95% CI 0.73-1.25]). There was a significant downward time trend of NMR in intervention communes (p = 0.003) but not in control communes (p = 0.184). No significant difference in NMR was observed during the first two years (July 2008 to June 2010) while the third year (July 2010 to June 2011) had significantly lower NMR in intervention arm: adjusted OR 0.51 (95% CI 0.30-0.89). Women in intervention communes more frequently attended antenatal care (adjusted OR 2.27 [95% CI 1.07-4.8]).Conclusions: A randomized facilitation intervention with local stakeholder groups composed of primary care staff and local politicians working for three years with a perinatal problem-solving approach resulted in increased attendance to antenatal care and reduced neonatal mortality after a latent period. [ABSTRACT FROM AUTHOR]

Aim: We assessed primary care facility preparedness, health workers’ knowledge and their classification and treatment of possible serious bacterial infection and local bacterial infection in young infants aged 0–59 days. Method: A cross-sectional survey was conducted in four regions of Ethiopia, including 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Registers of 1058 sick young infants were reviewed. Result: Antibiotics to treat possible serious bacterial infection were available in 71% of the health centres and 38% of the health posts. Nine of ten health extension workers and eight of ten health centre staff mentioned at least one sign of possible serious bacterial infection and local bacterial infection. Among the registered cases with signs of bacterial infections, the health extension workers classified 49% as having a possible serious bacterial infection and 88% as local bacterial infection. The health centre staff classified 25% as possible serious bacterial infections and 86% as local bacterial infections. One-fourth (26%) of possible serious bacterial infection received the recommended treatment at health posts and 35% at health centres. Conclusion: Many health posts lacked antibiotics. The classification and treatment of possible serious bacterial infection did not follow guidelines. The lack of medicines and poor adherence compromise the quality of care. [ABSTRACT FROM AUTHOR]

Appropriate feeding behaviours are important for child growth and development. In societies undergoing nutrition transition, new food items are introduced that may be unfavourable for child health. Set in rural Nicaragua, the aim of this study was to describe the infant and young child feeding (IYCF) practices as well as the consumption of highly processed snack foods (HP snacks) and sugar‐sweetened beverages (SSBs). All households with at least one child 0‐ to 35‐month‐old (n = 1371) were visited to collect information on current IYCF practices in the youngest child as well as consumption of SSBs and HP snacks. Breastfeeding was dominant (98%) among 0‐ to 1‐month‐olds and continued to be prevalent (60%) in the second year, while only 34% of the 0‐ to 5‐month‐olds were exclusively breastfed. Complementary feeding practices were deemed acceptable for only 59% of the 6‐ to 11‐month‐old infants, with low dietary diversity reported for 50% and inadequate meal frequency reported for 30%. Consumption of HP snacks and SSBs was frequent and started early; among 6‐ to 8‐month‐olds, 42% and 32% had consumed HP snacks and SSBs, respectively. The difference between the observed IYCF behaviours and World Health Organization recommendations raises concern of increased risk of infections and insufficient intake of micronutrients that may impair linear growth. The concurrent high consumption of SSBs and HP snacks may increase the risk of displacing the recommended feeding behaviours. To promote immediate and long‐term health, growth and development, there is a need to both promote recommended IYCF practices as well as discourage unfavourable feeding behaviours. [ABSTRACT FROM AUTHOR]

Background: To operationalize the post-MDG agenda, there is a need to evaluate the effects of health interventions on equity. The aim of this study is to evaluate the effect on equity in neonatal survival of the NeoKIP trial (ISRCTN44599712), a population-based, cluster-randomized intervention trial with facilitated local stakeholder groups for improved neonatal survival in Quang Ninh province in northern Vietnam. Methods: Semi-structured interviews were conducted with all mothers experiencing neonatal mortality and a random sample of 6% of all mothers with a live birth in the study area during the study period (July 2008-June 2011). Multilevel regression analyses were performed, stratifying mothers according to household wealth, maternal education and mother’s ethnicity in order to assess impact on equity in neonatal survival. Findings: In the last year of study the risk of neonatal death was reduced by 69% among poor mothers in the intervention area as compared to poor mothers in the control area (OR 0.31, 95% CI 0.15–0.66). This pattern was not evident among mothers from non-poor households. Mothers with higher education had a 50% lower risk of neonatal mortality if living in the intervention area during the same time period (OR 0.50, 95% CI 0.28–0.90), whereas no significant effect was detected among mothers with low education. Interpretation: The NeoKIP intervention promoted equity in neonatal survival based on wealth but increased inequity based on maternal education. [ABSTRACT FROM AUTHOR]

Aim: Rwanda has invested heavily in improving maternal and child health, but knowledge is limited regarding social equity in perinatal survival. We analysed whether perinatal mortality risks differed between social groups in hospitals in the country's capital.Methods: A case-control study was carried out on singleton births aged at least 22 weeks of gestation and born in district or tertiary referral hospitals in Kigali from July 2013 to May 2014. Perinatal deaths were recorded as they occurred, with the next two surviving neonates born in the same hospital selected as controls. Conditional logistic regression was used to determine social determinants of perinatal death after adjustments for potential confounders.Results: We analysed 234 perinatal deaths and 468 controls. Rural residence was linked to an increased risk of perinatal death (OR = 3.31, 95% CI 1.43-7.61), but maternal education or household asset score levels were not. Having no health insurance (OR = 2.11, 95% CI 0.91-4.89) was associated with an increased risk of perinatal death, compared to having community health insurance.Conclusion: Living in a rural area and having no health insurance were associated with an increased risk of perinatal mortality rates in the Rwandan capital, but maternal education and household assets were not. [ABSTRACT FROM AUTHOR]

Objective: To analyse the effect of community-based counselling on feeding patterns during the first 12 weeks after birth, and to study whether the effect differs by maternal HIV status, educational level or household wealth.Design: Cluster-randomized trial with fifteen clusters in each arm to evaluate an integrated package providing two pregnancy and five postnatal home visits delivered by community health workers. Infant feeding data were collected using 24 h recall of nineteen food and fluid items.Setting: A township near Durban, South Africa.Subjects: Pregnant women (1894 intervention and 2243 control) aged 17 years or more.Results: Twelve weeks after birth, 1629 (intervention) and 1865 (control) mother-infant pairs were available for analysis. Socio-economic conditions differed slightly across intervention groups, which were considered in the analyses. There was no effect on early initiation of breast-feeding. At 12 weeks of age the intervention doubled exclusive breast-feeding (OR=2·29; 95 % CI 1·80, 2·92), increased exclusive formula-feeding (OR=1·70; 95 % CI 1·28, 2·27), increased predominant breast-feeding (OR=1·71; 95 % CI 1·34, 2·19), decreased mixed formula-feeding (OR=0·68; 95 % CI 0·55, 0·83) and decreased mixed breast-feeding (OR=0·54; 95 % CI 0·44, 0·67). The effect on exclusive breast-feeding at 12 weeks was stronger among HIV-negative mothers than HIV-positive mothers (P=0·01), while the effect on mixed formula-feeding was significant only among HIV-positive mothers (P=0·03). The effect on exclusive feeding was not different by household wealth or maternal education levels.Conclusions: A perinatal intervention package delivered by community health workers was effective in increasing exclusive breast-feeding, exclusive formula-feeding and decreasing mixed feeding. [ABSTRACT FROM AUTHOR]

Background Socio-economic resources may be associated with infant feeding in complex patterns in societies undergoing a nutrition transition. This study evaluates associations of housing quality, food security and maternal education to the World Health Organization (WHO) feeding recommendations and to consumption of highly processed snacks (HP snacks) and sugar-sweetened beverages (SSBs) in rural Nicaragua. Methods Data were collected from May to November 2009, with mothers of 0- to 35-month-olds being asked about young child feeding using a food frequency questionnaire. A validated questionnaire was used to assess household food insecurity and data were collected on maternal education and housing quality. Pearson's chi-squared test was used to compare proportions and determine associations between the resources and young child feeding. The three socio-economic resources and other confounders were introduced to multivariate logistic regression analyses to assess the independent contribution of the resources to the feeding practices and consumption of HP snacks and SSBs. Results Mothers with the lowest education level were more likely to be exclusively breastfeeding (EBF) their infants (OR not EBF: 0.19; 95% CI: 0.07, 0.51), whilst mothers of 6- to 35- month-olds in the lowest education category had more inadequate dietary diversity (DD) (OR for not meet DD: 2.04; 95% CI: 1.36, 3.08), were less likely to consume HP snacks (OR for HP snacks: 0.47; 95% CI: 0.32, 0.68) and SSBs (OR for SSBs: 0.68; 95% CI: 0.46, 0.98), compared to mothers with the highest level of education. Similarly, children residing in households with the highest food insecurity were also more prone to have inadequate dietary diversity (OR for not meet DD: 1.47; 95% CI: 1.05, 2.05). The odds for double burden of suboptimal feeding (concurrent inadequate diet and consumption of HP snacks/SSBs) were significantly lower in children of least educated mothers (OR: 0.64; 95% CI: 0.44, 0.92). Conclusions Higher level of education was associated with both more and less adherence to the WHO recommended feeding practices as well as with more consumption of HP snacks and SSBs. Regardless of educational strata, the children in the community were exposed to suboptimal feeding practices conducive to both under- as well as overnutrition. [ABSTRACT FROM AUTHOR]

In experimental studies, several polycyclic aromatic hydrocarbons (PAHs) have shown endocrine disrupting properties, but very few epidemiological studies have examined their impact on pubertal development and results have been heterogenous. To explore if maternal PAH exposure during pregnancy was associated with the offspring's timing of pubertal onset. We studied 582 mother-daughter dyads originating from a population-based cohort in a rural setting in Bangladesh. Maternal urinary samples, collected in early pregnancy (on average, gestational week 8), were analyzed for monohydroxylated metabolites of phenanthrene (1-OH-Phe, Σ2-,3-OH-Phe, and 4-OH-Phe), fluorene (Σ2-,3-OH-Flu), and pyrene (1-OH-Pyr) using liquid chromatography with tandem mass spectrometry (LC-MS/MS). The girls were interviewed on two separate occasions concerning date of menarche, as well as breast and pubic hair development according to Tanner. Associations were assessed using Kaplan-Meier analysis and multivariable-adjusted Cox proportional hazards regression or ordered logistic regression. In early pregnancy, the mothers' median urinary concentrations of Σ1-,2-,3-,4-OH-Phe, Σ2-,3-OH-Flu, and 1-OH-Pyr were 3.25 ng/mL, 2.0 ng/mL, and 2.3 ng/mL respectively. At the second follow-up, 78 % of the girls had reached menarche, and the median age of menarche was 12.7 ± 0.81 years. Girls whose mothers belonged to the second and third quintiles of ΣOH-Phe metabolites had a higher rate of menarche, indicating a younger menarcheal age (HR 1.39; 95 % CI 1.04, 1.86, and HR 1.41; 95 % CI 1.05, 1.88, respectively), than girls of mothers in the lowest quintile. This trend was not observed in relation to either breast or pubic hair development. None of the other maternal urinary PAH metabolites or the sum of all thereof in early pregnancy were associated with age at menarche or pubertal stage. Indications of non-monotonic associations of prenatal phenanthrene exposure with the daughters' age of menarche were found, warranting further investigation. [ABSTRACT FROM AUTHOR]

Background: Millennium Development Goal 1 encourages local initiatives for the eradication of extreme poverty. However, monitoring is indispensable to insure that actions performed at higher policy levels attain success. Poverty in rural areas in low- and middle-income countries remains chronic. Nevertheless, a rural area (Cuatro Santos) in northern Nicaragua has made substantial progress toward poverty eradication by 2015. We examined the level of poverty there and described interventions aimed at reducing it. Methods: Household data collected from a Health and Demographic Surveillance System was used to analyze poverty and the transition out of it, as well as background information on family members. In the follow-up, information about specific interventions (i.e., installation of piped drinking water, latrines, access to microcredit, home gardening, and technical education) linked them to the demographic data. A propensity score was used to measure the association between the interventions and the resulting transition from poverty. Results: Between 2004 and 2009, poverty was reduced as a number of interventions increased. Although microcredit was inequitably distributed across the population, combined with home gardening and technical training, it resulted in significant poverty reduction in this rural area. Conclusions: Sustainable interventions reduced poverty in the rural areas studied by about one- third. [ABSTRACT FROM AUTHOR]

Background: Nicaragua has made progress in the reduction of the under-five mortality since 1980s. Data for the national trends indicate that this poor Central American country is on track to reach the Millennium Development Goal-4 by 2015. Despite this progress, neonatal mortality has not showed same progress. The aim of this study is to analyse trends and social differentials in neonatal and under-five mortality in a Nicaraguan community from 1970 to 2005. Methods: Two linked community-based reproductive surveys in 1993 and 2002 followed by a health and demographic surveillance system providing information on all births and child deaths in urban and rural areas of León municipality, Nicaragua. A total of 49 972 live births were registered. Results: A rapid reduction in under-five mortality was observed during the late 1970s (from 103 deaths/1000 live births) and the 1980s, followed by a gradual decline to the level of 23 deaths/1000 live births in 2005. This community is on track for the Millennium Development Goal 4 for improved child survival. However, neonatal mortality increased lately in spite of a good coverage of skilled assistance at delivery. After some years in the 1990s with a very small gap in neonatal survival between children of mothers of different educational levels this divide is increasing. Conclusions: After the reduction of high under-five mortality that coincided with improved equity in survival in this Nicaraguan community, the current challenge is the neonatal mortality where questions of an equitable perinatal care of good quality must be addressed. [ABSTRACT FROM AUTHOR]

Knowledge about the impact of maternal food and micronutrient supplementation on infant micronutrient status is limited. We examined the effect of maternal food and micronutrient supplementation on infant micronutrient status in the Maternal and Infant Nutrition Interventions in Matlab Trial. Pregnant women (n = 4436) were randomized to Early or Usual promotion of enrollment in a food supplementation program. In addition, they were randomly allocated to 1 of the following 3 types of daily micronutrient supplements provided from wk 14 of gestation to 3 mo postpartum: 1) folic acid and 30 mg iron (Fe30Fol); 2) folic acid and 60 mg iron; or 3) a multiple micronutrient including folic acid and 30 mg iron (MMS). At 6 mo, infant blood samples (n = 1066) were collected and analyzed for hemoglobin and plasma ferritin, zinc, retinol, vitamin B-12, and folate. The vitamin B-12 concentration differed between the micronutrient supplementation groups (P =0.049). The prevalence of vitamin B-12 deficiency was lower in the MMS group (26. 1%) than in the Fe3OFol group 136.5%) (P = 0.003). The prevalence of zinc deficiency was lower in the Usual food supplementation group 154.1 %) than in the Early group (60.2%) (P = 0.046). There were no other differential effects according to food or micronutrient supplementation groups. We conclude that maternal multiple micronutrient supplementation may have a beneficial effect on vitamin B-12 status in infancy. [ABSTRACT FROM AUTHOR]

There is a concern that exclusive breast-feeding (EBF) for 6 mo may lead to iron and zinc deficiency in low-birth weight (LBW) infants. We assessed the association between duration of EBF and infant iron and zinc status in the Maternal and Infant Nutrition Interventions in Matlab trial, Bangladesh, stratified for normal birth weigh (NBW) and LBW. Duration of EBF was classified into EBF <4 mo and EBF 4-6 mo based on monthly recalls of foods introduced to the infant. Blood samples collected at 6 mo were analyzed for plasma zinc (n = 1032), plasma ferritin (n = 10401, and hemoglobin (Hb) (n = 791). Infants EBF 4-6 mo had a higher mean plasma zinc concentration (9.9 ± 2.3 μmol/L) than infants EBF <4mo (9.5 ± 2.0 μmol/L) (P < 0.01). This association was apparent in only the NBW strata and was not reflected in a lower prevalence of zinc deficiency. Duration of EBF was not associated with concentration of plasma ferritin, Hb concentration, or prevalence of iron deficiency or anemia in any strata. Regardless of EBF duration, the prevalence of zinc deficiency, iron deficiency, and anemia was high in infants in this population and strategies to prevent deficiency are needed. [ABSTRACT FROM AUTHOR]

Abstract: It is known that a high fraction of methylarsonate (MA) in urine is a risk modifying factor for several arsenic induced health effects, including skin lesions, and that men are more susceptible for developing skin lesions than women. Thus, we aimed at elucidating the interaction between gender and arsenic metabolism for the risk of developing skin lesions. This study is part of a population-based case-referent study concerning the risk for skin lesions in relation to arsenic exposure via drinking water carried out in Matlab, a rural area 53km south-east of Dhaka, Bangladesh. We randomly selected 526 from 1579 referents and all 504 cases for analysis of arsenic metabolites in urine using HPLC coupled to inductively coupled plasma mass spectrometry (HPLC-HG-ICPMS). The present study confirm previous studies, with the risk for skin lesions being almost three times higher in the highest tertile of %MA (adjusted OR 2.8, 95% CI: 1.9–4.2, p < 0.001) compared to the lowest tertile. The present study is the first to show that the well documented higher risk for men to develop arsenic-related skin lesions compared to women is mainly explained by the less efficient methylation of arsenic, as defined by a higher fraction of MA and lower fraction of DMA in the urine, among men. Our previously documented lower risk for skin lesions in individuals exposed since infancy, or before, was found to be independent of the observed arsenic methylation efficiency. Thus, it can be speculated that this is due to a programming effect of arsenic in utero. [Copyright &y& Elsevier]

Background: General iron supplementation to prevent iron deficiency in infants who are iron sufficient when starting supplementation may adversely affect their health. Objective: A secondary analysis to explore the effect of iron supplementation on iron-replete (IR; Hb ≥113 g/L and S-ferritin ≥33 μg/L) or non-iron-replete 6-month-old Indonesian infants participating in a large, randomized trial on iron and zinc supplementation. Results: Among the iron-supplemented IR (Fe-IR, n = 80) infants S-ferritin was, compared to non-iron-supplemented (NS) IR infants (NS–IR, n = 74), significantly higher (47.5 vs. 20.7 μg/L, p = 0.04), and S-zinc significantly lower (9.7 vs. 10.5 μmol/L, p = 0.04). Haemoglobin concentration (Hb) did not differ between the Fe-IR and NS–IR groups. Change in weight-for-age z-score (WAZ) from 6 to 12 months and mean WAZ at 12 months was lower in the Fe-IR group compared to the NS-IR group (−1.45 vs. −1.03, p < 0.001 and −1.97 vs. −1.60, p < 0.001, respectively). There was no difference in morbidity between groups. Iron supplementation of non-iron-replete infants increased Hb and S-ferritin, but did not affect S-zinc or anthropometrical indices. Conclusion: In our study, iron supplementation of IR infants affected WAZ adversely, whereas iron supplementation to non-iron-replete infants did not affect growth. These results support a cautious approach to iron supplementation of IR infants. [ABSTRACT FROM AUTHOR]

Aim: To assess whether violence against women was associated with increased mortality risks for their daughters and sons before the age of 5. Methods: Secondary analysis of longitudinal data from rural Bangladesh of 2691 live-born children in relation to their mother's experience of physical, sexual and emotional partner violence and level of controlling behaviour in marriage. Analyses were adjusted for potential confounders and stratified by gender. Result: Under five-mortality was 88 per 1000 in this cohort. Overall, there was no association between different forms of violence against women and under-five mortality. However, more educated women had an increased risk of under-five deaths of their female offspring if ever exposed to severe physical violence (adjusted hazard ratio 2.2, 95% CI 1.06–4.50) or to a high level of controlling behaviour in marriage (adjusted hazard ratio 2.5, 95% CI 1.30–4.90). Controlling behaviour in marriage increased the hazard ratios in a dose–response manner. Increased mortality risks were neither shown for offspring of women with low or no education nor for boys in any educational group. Conclusion: Severe physical violence and controlling behaviour in marriage were associated with higher under-five mortality among daughters of educated mothers in rural Bangladesh, indicating gender-biased consequences of partner violence for child mortality. [ABSTRACT FROM AUTHOR]

Abstract: This paper is about how street boys described their experiences of sexually transmitted infections and the care they sought in Nakuru, Kenya. The data were collected over a six-month period at a Soup Kitchen frequented by street children aged 5 to 18 years. Data were generated using participant observation of 115 children; group discussions with 12 boys; interviews with 20 boys; 17 key informant interviews; two home visits; and clinical records of five boys that had sexually transmitted infections. The findings revealed who the boys'' sexual partners were, their sexual practices, and their pattern of condom use, their experience of sexually transmitted infections, how they communicate symptoms and when and how they seek care. Lack of money for treatment delayed care seeking. The study also indicated the existence of strong bonds and support networks as a survival strategy on the streets. In conclusion, understanding the ways the street boys experience, reason and communicate their symptoms as well as their support networks is useful in the prevention of sexually transmitted infections and the promotion of their general health and wellbeing. Moreover, eliminating the barrier to health care is imperative for the sustainable provision of care to this vulnerable group of children. [Copyright &y& Elsevier]

This study aims to estimate the prevalence and characteristics of partner abuse during pregnancy as well as to investigate associated social factors in León, Nicaragua. Cross-sectional community-based study. All pregnant women from 50 randomly selected geographical clusters out of 208 in the municipality of León, Nicaragua. A total of 478 pregnant women were included; only one woman refused to participate. The domestic violence questionnaire from the WHO-co-ordinated Multi-Country Study on Women's Health and Life Events was used with each participant being interviewed twice during pregnancy. Prevalence and characteristics of partner violence during pregnancy. The prevalence of emotional, physical and sexual abuse during pregnancy was 32.4%, 13.4% and 6.7%, respectively. Seventeen percent reported experience of all three forms of violence. Two-thirds of the victims reported repeated abuse. Half of the abused women had experienced punches and kicks directed towards the abdomen and 93% had been injured. Most women had not sought health care in relation to the abuse, but those who did were usually hospitalised. Factors such as women's age below 20 years, poor access to social resources and high levels of emotional distress were independently associated with violence during pregnancy. Violence against pregnant women in Nicaragua is common and often repeated. Although these women have poor access to social resources and high levels of emotional distress, they are rarely assisted by the health services. Innovative strategies are needed to provide support and counselling. [ABSTRACT FROM AUTHOR]

Background: Community health workers and volunteers are vital for the achievement of Universal Health Coverage also in low-income countries. Ethiopia introduced community volunteers called women's development group leaders in 2011. These women have responsibilities in multiple sectors, including promoting health and healthcare seeking. Objective: We aimed to explore women's development group leaders' and health workers' perceptions on these volunteers' role in maternal, neonatal and child healthcare. Methods: A qualitative study was conducted with in-depth interviews and focus group discussions with women's development group leaders, health extension workers, health center staff, and woreda and regional health extension experts. We adapted a framework of community health worker performance, and explored perceptions of the women's development group program: inputs, processes and performance. Interviews were recorded, transcribed, and coded prior to translation and thematic analysis. Results: The women's development group leaders were committed to their health-related work. However, many were illiterate, recruited in a sub-optimal process, had weak supervision and feedback, lacked training and incentives and had weak knowledge on danger signs and care of neonates. These problems demotivated these volunteers from engaging in maternal, neonatal and child health promotion activities. Health extension workers faced difficulties in managing the numerous women's development group leaders in the catchment area. Conclusion: The women's development group leaders showed a willingness to contribute to maternal and child healthcare but lacked support and incentives. The program requires some redesign, effective management, and should offer enhanced recruitment, training, supervision, and incentives. The program should also consider continued training to develop the leaders' knowledge, factor contextual influences, and be open for local variations. [ABSTRACT FROM AUTHOR]

This paper focuses on the difficulty of capturing child war trauma: the appropriateness of a standardized trauma questionnaire and the value of recruiting multiple reports. Three independent assessments of the war exposure of 75 Bosnian refugee children and teenage youths (aged 1-20), resettled in Sweden, are compared: clinician assessment based upon a semistructured interview with the family, child self-report on the Harvard Trauma Questionnaire (HTQ) and parent report on the same questionnaire. Parent and clinician reports show marked group similarities but differ often with regard to the individual child. Clinician score reveals a social class gradient not visible on the HTQ. Parent and teenager assessments correlate strongly on total exposure but diverge markedly on specific events. Discrepancy derives as frequently from events affirmed by teenager alone as by parent alone. Primary school children, on the other hand, systematically offer a less-detailed account of their own war exposure. In summary, original HTQ functions "quite well" as a standardized questionnaire, but a Bosnian-specific version would expectedly afford greater validity and capture social class differences in child exposure. For teenagers, the value of multiple informants appears evident; for primary school children, a more adequately age-adjusted procedure remains the first priority. [ABSTRACT FROM AUTHOR]

Objectives. This study assessed the effect of poverty and social inequity on infant mortality risks in Nicaragua from 1988 to 1993 and the preventive role of maternal education. Methods. A cohort analysis of infant survival, based on reproductive histories of a representative sample of 10 867 women aged 15 to 49 years in Leon, Nicaragua, was conducted. A total of 7073 infants were studied; 342 deaths occurred during 6394 infant-years of follow-up. Outcome measures were infant mortality rate (IMR) and relative mortality risks for different groups. Results. IMR was 50 per 1000 live births. Poverty, expressed as unsatisfied basic needs (UBN) of the household, increased the risk of infant death (adjusted relative risk [RR] = 1.49; 95% confidence interval [CI] = 1.15, 1.92). Social inequity, expressed as the contrast between the household UBN and the predominant UBN of the neighborhood, further increased the risk (adjusted RR = 1.74; 95% CI = 1.12, 2.71). A protective effect of the mother's educational level was seen only in poor households. Conclusions. Apart from absolute level of poverty, social inequity may be an independent risk factor for infant mortality in a low-income country. In poor households, female education may contribute to preventing infant mortality. (Am J Public Health. 2000;90: 64-69) [ABSTRACT FROM AUTHOR]

Background: Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers' ability to correctly classify common childhood illnesses in four regions of Ethiopia. Methods: Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline. Results: Health extensions workers' consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers' sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89–100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81–2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81–2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77–3.92]. Conclusion: This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers. Trial registration: ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912. [ABSTRACT FROM AUTHOR]

Many routine health information systems (RHIS) show persistent gaps between recording and reporting data and their effective use in solving problems. Strengthening RHIS has become a global priority to track and address national health goals. In Ethiopia, the Ministry of Health and Bill & Melinda Gates Foundation introduced the Operational Research and Coaching for Analysts (ORCA) capacity development project, co-designed with the London School of Hygiene & Tropical Medicine, which delivered training, coaching and mentoring support. We present the development, experiences, and perceptions of ORCA as a mechanism to enhance data quality, analysis, interpretation and use. ORCA integrated capacity development activities into national data analysts' routine workload over a period of 2 years. Participating analysts were drawn from across the Ministry of Health directorates and two of its closely aligned agencies: the Ethiopian Public Health Institute and the Ethiopian Pharmaceutical Supply Agency. We used mixed methods (knowledge questionnaire, semi-structured interviews, programme records) to document the fidelity, feasibility, reach, and acceptability of ORCA and identify early signs of improved knowledge and changing institutional practices. Thirty-six participants completed the programme. Working in interdisciplinary groups on specific national health indicators, they received training workshops and support for study design, fieldwork, and analysis to build skills in assessing data quality and interpreting findings relevant to policy. Personal development grants and laptops provided incentives for sustained engagement. Participants appreciated ORCA's applied and practical approach as well as good communication from administrators and clear links to national strategy. They also expressed frustration with delays, difficulties prioritising project work over routine responsibilities, and lack of formal accreditation. Knowledge and analytic skills increased and participants were able to integrate experiences from the project into their future work. Health system managers saw potential in longer-term improvements in data analysis and application to policy, although no clear changes were observed yet. [ABSTRACT FROM AUTHOR]

Background: Care-seeking for sick children at the Ethiopian primary health care level is low. This problem may partly be due to unfavorable community perceptions of the quality of care provided. There is, however, limited knowledge on the quality of the clinical assessment and management provided by the health extension workers at the health posts. This study aimed to examine the quality of clinical assessment, classification and management provided to sick under-five children by health extension workers in four regions of Ethiopia. Methods: Clinical observations of 620 consultations of sick children by health extension workers were conducted from December 2016 to February 2017. A clinical pathway analysis was performed to analyze whether sick children were appropriately assessed, classified and managed according to the integrated Community Case Management guidelines. Results: Most sick children presented with complaints of cough (58%), diarrhea (36%), and fever (26%).Three quarters of children with respiratory complaints had their respiratory rate counted (74%, 95% CI 69–78), while a third (33%, 95% CI 27–40) of children with diarrhea were assessed for dehydration. Half (53%, 95% CI 49–57) of the sick children were assessed for general danger signs, while a majority (89%, 95% CI 86–92) had their arm circumference measured for malnutrition. Half of the sick children received some treatment and less than one-fifth were referred according to the integrated Community Case management guidelines. Comprehensive counseling was provided to 38% (95% CI 35–42) of the caregivers. Conclusion: The Ethiopian health extension workers' clinical assessment, classification and management of sick children did to a large extent not follow the clinical guidelines. This lack of adherence could lead to misdiagnoses and lack of potentially life-saving treatments. [ABSTRACT FROM AUTHOR]