The Aga Khan Universitys' Institute for Global Health and Development, in collaboartion with the Health Department, Government of Sindh; Policy and Strategic Planning Unit, Government of Punjab; Trust for Vaccine and Immunisation (TVI); and Mother and Child Care Research (MccR) conducted a large scale survey in the provinces of Sndh and Punjab, to assess the health, nutrition, and lifestyle of school-aged children 5 to 9.9 years of age. The study also assessed the association of health and nutritional status with sociodemographic factors (wealth, food insecurity, maternal education and gender), setting (rural vs. urban), in-school vs. out-of-school, and child health (anemia, nutrition status and dietary intake). This survey highlights the burden of malnutrition, dietary and meal patterns, sanitation and hygiene practices, schooling in children living in urban and rural areas of the two provinces in Pakistan. It suggests implementation of large integrated programs to improve health and nutrition outcomes among children, especially who live in the rural areas of Sindh and Punjab. It also suggests need of interventions to improve school attendance and quality education and the development of a comprehensive school health and nutrition program focusing on multitude of issues and including life skills development, health and nutrition education and optimum lifestyle and education behaviors
Maternity care practices have been linked with higher chances of meeting breastfeeding intentions, but this relationship has not been examined using national data on US low-income women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Using data from the WIC Infant and Toddler Feeding Practices Study-2 on 1080 women who intended to breastfeed, we estimated risk ratios for associations between (1) each of 6 maternity care practices supportive of breastfeeding (breastfeeding within 1 hour of birth, showing mothers how to breastfeed, giving only breast milk, rooming-in, breastfeeding on demand, no pacifiers), (2) each practice adjusted for all other practices, and (3) total number of practices experienced with whether women met their intention to feed only breast milk at 1 month old. Models were adjusted for demographics. Findings suggest that women who experienced maternity care practices supportive of breastfeeding were more likely to meet their prenatal breastfeeding intentions, underscoring the importance of breastfeeding support during the birth hospitalization in enabling mothers to achieve their breastfeeding goals.
Prenatal Exposure to Air Pollution and Autism Spectrum Disorder: Sensitive Windows of Exposure and Sex Differencesby Md Mostafijur Rahman et al
The study identified sensitive windows of exposure to regional air pollution and risk of autism spectrum disorder (ASD) and examined sex differences in a large birth cohort. Findings suggest that exposures to PM2.5 in the first two gestational trimesters were associated with increased ASD risk in children, with stronger associations observed for boys. The role of O3 exposure on ASD risk merits further investigation.
Association of Birth During the COVID-19 Pandemic With Neurodevelopmental Status at 6 Months in Infants With and Without In Utero Exposure to Maternal SARS-CoV-2 Infectionby Shuffrey et al
The objective of this study was to examine the associations between maternal SARS-CoV-2 infection during pregnancy, being born during the COVID-19 pandemic regardless of maternal SARS-CoV-2 status, and neurodevelopment at age 6 months. In this study, birth during the pandemic, but not in utero exposure to maternal SARS-CoV-2 infection, was associated with differences in neurodevelopment at age 6 months. These early findings support the need for long-term monitoring of children born during the COVID-19 pandemic.
Association between newborn separation, maternal consent and health outcomes: findings from a longitudinal survey in Kenyaby Kao Nakphong et al
Disrespectful and poor treatment of newborns such as unnecessary separation from parents or failure to obtain parental consent for medical procedures occurs at health facilities across contexts, but little research has investigated the prevalence, risk factors or associated outcomes. This study examined these experiences and associations with healthcare satisfaction, use and breast feeding. Newborns, mothers and families have a right to high-quality, respectful care, including the ability to stay together, be informed and properly consent for care. The implications of these experiences on health outcomes a month or more after discharge illustrate the importance of a positive experience of postnatal care.
Effects of short birth interval on neonatal, infant and under-five child mortality in Ethiopia: a nationally representative observational study using inverse probability of treatment weightingby Shifti DM et al.
The objective of the study was to assess the effect of short birth interval (SBI) on neonatal, infant, and under-five mortality in Ethiopia. Findings suggest that SBI has a significant effect on neonatal, infant and under-five mortality in Ethiopia. Interventions targeting SBI are warranted to reduce neonatal, infant and under-five mortality.
The objective of this study is to describe infant mortality among opioid-exposed infants and identify how mortality risk differs in opioid-exposed infants with and without a diagnosis of neonatal opioid withdrawal syndrome (NOWS) compared with infants without opioid exposure. In this study, opioid-exposed infants appeared to be at increased risk of mortality, and the treatments and supports provided to those diagnosed with NOWS may be protective. Interventions to support opioid-exposed maternal-infant dyads are warranted, regardless of the perceived severity of neonatal opioid withdrawal.
Trends in missing females at birth in India from 1981 to 2016: analyses of 2·1 million birth histories in nationally representative surveysby Nandita Saikia et al
The authors sought to document the trends in missing female births, particularly among second and third children, at national and state levels. Findings suggest that in contrast to the substantial improvements in female child mortality in India, missing female births, driven by selective abortion of female fetuses, continues to increase across the states. Inclusion of a question on sex composition of births in the forthcoming census would provide local information on sex-selective abortion in each village and urban area of the country.
The authors assessed the effectiveness of a baby-friendly workplace support intervention on EBF in Kenya. This pre-post intervention study was conducted between 2016 and 2018 on an agricultural farm in Kericho County. The study included 270 and 146 mother-child dyads in the nontreated (preintervention) group and treated (intervention) group, respectively. The prevalence of EBF was higher in the treated group (80.8%) than in the nontreated group (20.2%); corresponding to a fourfold increased probability of EBF [risk ratio (RR) 3.90; 95% confidence interval (CI) 2.95-5.15]. The effect of the intervention was stronger among children aged 3-5 months (RR 8.13; 95% CI 4.23-15.64) than among those aged <3 months (RR 2.79; 95% CI 2.09-3.73). The baby-friendly workplace support intervention promoted EBF especially beyond 3 months in this setting.
Impact of COVID-19 mitigation measures on the incidence of preterm birth: a national quasi-experimental studyby Been et al
The study aimed to study the impact of the COVID-19 mitigation measures implemented in the Netherlands in a stepwise fashion on March 9, March 15, and March 23, 2020, on the incidence of preterm birth. In this national quasi-experimental study, initial implementation of COVID-19 mitigation measures was associated with a substantial reduction in the incidence of preterm births in the following months, in agreement with preliminary observations elsewhere. Integration of comparable data from across the globe is needed to further substantiate these findings and start exploring underlying mechanisms.
In this study, the authors aimed to elucidate best practices regarding infection control in mother–newborn dyads, and identify potential risk factors associated with transmission. Data suggest that perinatal transmission of COVID-19 is unlikely to occur if correct hygiene precautions are undertaken, and that allowing neonates to room in with their mothers and direct breastfeeding are safe procedures when paired with effective parental education of infant protective strategies.
Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-raby Walker et al
The authors aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised. This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. Findings suggests that fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening.
Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazilby Osvaldinete Lopes de Oliveira Silva et al
The objective of this study was to analyse the cost-effectiveness of Baby-Friendly Hospital Initiative (BFHI) in promoting breast-feeding during the first hour of life (BFFHL) and reducing late neonatal mortality. Cost-effectiveness analysis showed that BFHI was highly cost-effective in raising BFFHL by 32·0 % at lower cost in comparison with non-BFHI. In addition, BFHI was cost-effective in reducing late neonatal mortality rate by 13·0 % from all causes and by 13·1 % of infant mortality rate from infections.
A seminar presented by Dr Jalemba Aluvaala in the Centre for Tropical Medicine and Global Health, University of Oxford
In celebration of Global Health Trials' fifth birthday (May 11th 2015) Professor Trudie Lang, Principal Investigator of the programme, talks to us about why Global Health Trials was started, why people should share their experience, and what the future holds.
Demonstrating the Efficacy of the FoneAstra Pasteurization Monitor for Human Milk Pasteurization in Resource-Limited Settingsby Mageshree Naicker, Anna Coutsoudis, Kiersten Israel, Rohit Chaudhri, Noah Perin, Koleka Mlisana
Worldwide, 250,000–280,000 women die during pregnancy and childbirth every year and an estimated 6.55 million children die under the age of five. The majority of maternal deaths occur during or immediately after childbirth, while 43% of child death occurs during the first 28 days of life. However, the progress in limiting these has been slow and sporadic. In this supplement of five papers, teh authors aim to systematically assess and summarize essential interventions for reproductive, maternal, newborn and child health from relevant systematic reviews.
Food fortification is safe and cost-effective in the prevention of micronutrient deficiencies and has been widely practiced in developed countries for well over a century. The findings in this report clearly support the utilization of food fortification strategies at scale, which could build on the recent success of the iodized salt programme. Given the widespread prevalence in Pakistan of deficiencies in iron and in vitamins A and D, food fortification strategies offer a tangible option for delivering these micronutrients on a large scale.
Rates and determinants of seasonal influenza vaccination in pregnancy and association with neonatal outcomesby Jai K Das
There is growing evidence that seasonal influenza vaccination in pregnancy has benefits for mother and baby. The authors in this paper determined influenza vaccination rates among pregnant women during the 2 nonpandemic influenza seasons following the 2009 H1N1 pandemic, explored maternal factors as predictors of influenza vaccination status and evaluated the association between maternal influenza vaccination and neonatal outcomes. This study and others have shown an association between maternal influenza vaccination and improved neonatal outcomes, which supports stronger initiatives to promote vaccination during pregnancy.
Stillbirth is strongly related to impaired fetal growth. However, the relationship between fetal growth and stillbirth is difficult to determine because of uncertainty in the timing of death and confounding characteristics affecting normal fetal growth. The study authors conducted a population-based case–control study of all stillbirths and a representative sample of live births in 59 hospitals in five geographic areas in the US. The study found that stillbirth is associated with both growth restriction and excessive fetal growth. These findings suggest that, contrary to current practices and recommendations, stillbirth prevention strategies should focus on both severe SGA and severe LGA pregnancies.
Accumulating evidence implicates early life factors in the aetiology of non-communicable diseases, including asthma/wheezing disorders. We undertook a systematic review investigating risks of asthma/wheezing disorders in children born preterm, including the increasing numbers who, as a result of advances in neonatal care, now survive very preterm birth.
Though many countries are on-track in reducing poverty, less than a quarter of developing countries are on-track for achieving the goal of halving undernutrition. Maternal undernutrition is widely prevalent among women in the developing countries and encompasses both chronic energy as well as micronutrient deficiencies. Maternal undernutrition leads to intrauterine growth restriction and consequent low birth weight, stunting, wasting, underweight and other micronutrient deficiencies along with conditions predisposing to mortality. There are no effective therapies to reverse intrauterine growth restriction; hence focus should be on preventive strategies. In developing countries, the interventions likely to have the largest impact on intrauterine growth include caloric and micronutrient supplementation before and during pregnancy, coupled with supportive strategies for improving nutrition.
Application of emollients is a widespread traditional newborn care practice in many low and middle-income countries (LMICs) and may have the potential to decrease infection and consequent mortality in preterm neonates. We systematically reviewed literature published up to December 2012 to identify studies describing the effectiveness of emollient therapy.
The recent BMC Public Health supplement “The Lives Saved Tool in 2013: new capabilities and applications” has been published. The series comprise of 30 papers focusing on various domains of maternal child health with a special focus on the interventions reviewed for the prevention and management of childhood diarrhea and penumonia.
A qualitative study exploring factors associated with mothers’ decisions to formula-feed their infants in Newfoundland and Labrador, Canadaby Jai K Das
The primary aim of this qualitative study was to examine individual factors that shaped mothers’ decisions to formula-feed their infants.
Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africaby Jai K Das
Each year at least 1.16 million newborns die in Sub-Saharan Africa. The African region has the highest rates of neonatal mortality in the world, and has shown the slowest progress so far in reducing neonatal deaths. However there is hope. Under the umbrella of the Partnership for Maternal, Newborn and Child Health (PMNCH), 9 organizations, 60 authors and over 40 reviewers, drawn from policymakers and programme leaders for MNCH in Africa, have been involved and contributed to this publication. The book provides an overview of the continuum of care through the lifecycle and opportunities to address gaps at all levels - family and community care, outreach services and health care facilities.
Risk of Early-Onset Neonatal Infection with Maternal Infection or Colonization: A Global Systematic Review and Meta-Analysisby Jai K Das
Neonatal infections cause a significant proportion of deaths in the first week of life, yet little is known about risk factors and pathways of transmission for early-onset neonatal sepsis globally. This review aimed to estimate the risk of neonatal infection (excluding sexually transmitted diseases [STDs] or congenital infections) in the first seven days of life among newborns of mothers with bacterial infection or colonization during the intrapartum period.
The Effect of Intermittent Antenatal Iron Supplementation on Maternal and Infant Outcomes in Rural Viet Nam: A Cluster Randomised Trialby Jai K Das
Intermittent antenatal iron supplementation is an attractive alternative to daily dosing; however, the impact of this strategy on infant outcomes remains unclear. This study compared the effect of intermittent antenatal iron supplementation with daily iron supplementation on maternal and infant outcomes in rural Viet Nam.
This study suggests that to achieve a substantial reduction in maternal mortality, a comprehensive approach to emergency care, and overall improvements in the quality of maternal health care will be needed.
Malnutrition still remains one of the major public health challenges, particularly in developing countries. Major risk factors for undernutrition such as suboptimal breastfeeding and micronutrient deficiencies (vitamin A and zinc) are responsible for more than one-third of all under five child deaths and 11% of the global total disease burden. Several strategies have been employed to supplement micronutrients. These include education, dietary modification, food provision, supplementation and fortification either alone or in combination.
Maternal and child undernutrition Series was launched in The Lancet in 2008. Five years after the initial series, the issue was re-evaluated including the growing problems of overweight and obesity for women and children, and their consequences in low-income and middle-income countries. Many of these countries are said to have the double burden of malnutrition: continued stunting of growth and deficiencies of essential nutrients along with the emerging issue of obesity. The national progress in nutrition programmes and international efforts toward previous recommendations were also evaluated
The Lancet publishes a special themed issue to coincide with the third Women Deliver conference in Kuala Lumpur, Malaysia on May 28–30, 2013. Women Deliver brings together voices from around the world to generate political commitment and resource investments to improve the health and well-being of girls and women and achieve universal access to reproductive health. The studies published in The Lancet's themed issue use different methods to show the multidimensional nature of reproductive health and the influence of social determinants and health systems.
Measuring Coverage in MNCH: Challenges in Monitoring the Proportion of Young Children with Pneumonia Who Receive Antibiotic Treatmentby Jai K Das
Pneumonia remains a major cause of child death globally, and improving antibiotic treatment rates is a key control strategy. The third paper in the PLOS series of 'Measuring Coverage in MNCH', the authors show that the performance of survey tools could be improved by increasing the survey recall period or by improving either overall discriminative power or specificity.
The PLOS Medicine “Measuring Coverage in MNCH” Collection of research studies and reviews presents systematic assessments of the validity of health intervention coverage measurement based on household surveys, the primary method for estimating population-level intervention coverage in low- and middle-income countries. This is the second paper of the collection. It focuses on the development of the indicators and standard measurement tools that are needed to measure coverage of key newborn interventions.
The PLOS Medicine “Measuring Coverage in MNCH” Collection of research studies and reviews presents systematic assessments of the validity of health intervention coverage measurement based on household surveys, the primary method for estimating population-level intervention coverage in low- and middle-income countries. This is the first paper of the collection
The Lancet Series on Childhood Pneumonia and Diarrhoea, led by Aga Khan University, Pakistan, provides evidence for integrated control efforts for childhood pneumonia and diarrhoea.The series of four papers assesses the global burden of these two illnesses and identifies a set of highly cost-effective interventions that can prevent most diarrhoea deaths and nearly two thirds of pneumonia deaths by 2025, if delivered at scale. It also highlights the findings from consultations with several hundred frontline workers in high-burden countries and explores the barriers and enablers they face in dealing with these two diseases and potential ways forward. The final paper represents a call to action and discusses the global and country-level remedies needed to eliminate preventable deaths from these illnesses by 2025.
There have been significant improvements in the performance of the Expanded Programme on Immunization (EPI) in Africa since its inception in 1974. However, there exist wide inter- and intra-country differences.
Maternal, newborn, and child health indices in Nigeria vary widely across geopolitical zones and between urban and rural areas, mostly due to variations in the availability of skilled attendance at birth. To improve these indices, the Midwives Service Scheme (MSS) in Nigeria engaged newly graduated, unemployed, and retired midwives to work temporarily in rural areas. This paper describes the structure, processes, challanges and the outcomes acheived through MSS.
Comprehensive Approach to Improving Maternal Health and Achieving MDG 5: Report from the Mountains of Lesothoby Jai K Das
The emerging consensus is that improvement in women's health cannot be made through simple, vertical strategies; rather, it requires broad-based health system strengthening at every level of care, from the community to the clinic to the hospital. This paper reports experience in rural Lesotho, where a pilot program was implemented that provided comprehensive care of pregnant women from the community to the health center level, linking key primary care services (include HIV testing and treatment) to antenatal care (ANC) and facility-based delivery.
Comparing HIV prevalence estimates from prevention of mother-to-child HIV transmission programme and the antenatal HIV surveillance in Addis Abababy Jai K Das
Currently multiple vertical and integrated programs are running concurrently to provide estimates for HIV prevalances in epidemic areas. These programs require careful evaluations and comparisons.This study was conducted in Addis Ababa to compare HIV prevalence estimates from routine PMTCT programme and antenatal surveillance with the aim to come up with evidence based recommendation.
Repository on maternal child health: Health portal to improve access to information on maternal child health in Indiaby Jai K Das
This article describes a health portal developed in India aimed at providing one-stop access to efficiently search, organize and share maternal child health information relevant from public health perspective in the country.
Previously we have shared the guidelines pertaining to the early initiation and continuation of breast feeding and complementary feeding for newborns and infants. However there are concerns regarding breast feeding for women living with HIV. In particular, evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding. This evidence has major implications for how women living with HIV might feed their infants, and how health workers should counsel these mothers. In light of this, the World Health Organization (WHO) commenced a guideline development process, culminating in a Guideline Development Group meeting in Geneva on 22–23 October 2009. We share here the revised guidelines by WHO for principles and recommendations for infant feeding inthe context of HIV.
Kangaroo mother care to reduce morbidity and mortality and improve growth in low birth weight infants-The Guidelinesby Jai K Das
For many small preterm infants, receiving prolonged medical care is important. However, kangaroo mother care (KMC) is an effective way to meet baby’s needs for warmth, breastfeeding, protection from infection, stimulation, safety and love. Kangaroo mother care is care of preterm infants carried skin-to-skin with the mother. It is a powerful, easy-to-use method to promote the health and well-being of infants born preterm as well as full-term. We share the WHO guidleines regarding KMC.
Low birth weight (LBW) has been defined by the World Health Organization (WHO) as weight at birthless than 2500 g. LBW infants are at higher risk of early growth retardation, infectious disease, developmental delay and death during infancy and childhood. Experience from developed and low- and middle-income countries has clearly shown that appropriate care of LBW infants, including feeding, temperature maintenance, hygienic cord and skin care, and early detection and treatment of complications, can substantially reduce mortality in this highly vulnerable group. Interventions to improve feeding are likely to improve the immediate and longerterm health and well-being of the individual infant and have a significant impact on neonatal and infant mortality levels in the population. We share the WHO guidelines for feeeding in LBW infants.
About one third of deaths in children under 5 years of age are due to underlying undernutrition, which includes stunting, severe wasting, deficiencies of vitamin A and zinc, and suboptimum breastfeeding. Childhood malnutrition is prevalent in low and middle income countries (LMICs). According to an estimate, 19.4% of children <5 years of age in these countries are underweight (weight-for-age Z score <-2) and about 29.9% are stunted in the year 2011 (height-for-age Z score <-2). The prevalence of both underweight and stunting was highest in Africa and South-Central Asia and stunting and wasting along with intrauterine growth restriction (IUGR) are responsible for about 2.1 million deaths worldwide in children <5 years of age. It is well recognized that the period of 6-24 months of age is one of the most critical time periods in the growth of the infant. The incidence of stunting is the highest in this period as children have high demand for nutrients and there are limitations in the quality and quantity of available foods, especially after exclusive breastfeeding.