Policies for expanding family planning coverage: lessons from five successful countries

Background

Enhancing the design of family planning interventions is crucial for promoting gender equality and improving maternal and child health outcomes. We identified, critically appraised, and synthesized policies and strategies from five selected countries that successfully increased family planning coverage.

Methods

We conducted a policy analysis through a scoping review and document search, focusing on documents published from 1950 to 2023 that examined or assessed policies aimed at enhancing family planning coverage in Brazil, Ecuador, Egypt, Ethiopia, and Rwanda. A search was conducted through PubMed, SCOPUS, and Web of Science. Government documents and conference proceedings were also critically analyzed. National health surveys were analyzed to estimate time trends in demand for family planning satisfied by modern methods (mDFPS) at the national level and by wealth. Changes in the method mix were also assessed. The findings of the studies were presented in a narrative synthesis.

Findings

We selected 231 studies, in which 196 policies were identified. All countries started to endorse family planning in the 1960s, with the number of identified policies ranging between 21 in Ecuador and 52 in Ethiopia. Most of the policies exclusively targeted women and were related to supplying contraceptives and enhancing the quality of the services. Little focus was found on monitoring and evaluation of the policies implemented.

Conclusion

Among the five selected countries, a multitude of actions were happening simultaneously, each with its own vigor and enthusiasm. Our findings highlight that these five countries were successful in increasing family planning coverage by implementing broader multi-sectoral policies and considering the diverse needs of the population, as well as the specific contextual factors at play. Successful policies require a nuanced consideration of how these policies align with each culture's framework, recognizing that both sociocultural norms and the impact of past public policies shape the current state of family planning.

Gene - maltreatment interplay in adult ADHD symptoms: main role of a gene-environment correlation effect in a Brazilian population longitudinal study

Childhood maltreatment correlates with attention-deficit/hyperactivity disorder (ADHD) in previous research. The interaction between ADHD genetic predisposition and maltreatment's impact on ADHD symptom risk remains unclear. We aimed to elucidate this relationship by examining the interplay between a polygenic score for ADHD (ADHD-PGS) and childhood maltreatment in predicting ADHD symptoms during young adulthood. Using data from the 2004 Pelotas (Brazil) birth cohort comprising 4231 participants, we analyzed gene-environment interaction (GxE) and correlation (rGE). We further explored rGE mechanisms through mediation models. ADHD symptoms were assessed at age 18 via self-report (Adult Self Report Scale - ASRS) and mother-reports (Strength and Difficulties Questionnaire - SDQ). The ADHD-PGS was derived from published ADHD GWAS meta-analysis. Physical and psychological child maltreatment was gauged using the Parent-Child Conflict Tactics Scale (CTSPC) at ages 6 and 11, with a mean score utilized as a variable. The ADHD-PGS exhibited associations with ADHD symptoms on both ASRS (β = 0.53; 95% CI: 0.03; 1.03, p = 0.036), and SDQ (β = 0.20; 95% CI: 0.08; 0.32, p = 0.001) scales. The total mean maltreatment score was associated with ADHD symptoms using both scales [(βASRS = 0.51; 95% CI: 0.26;0.77) and (βSDQ = 0.24; 95% CI: 0.18;0.29)]. The ADHD-PGS was associated with total mean maltreatment scores (β = 0.09; 95% CI: 0.01; 0.17; p = 0.030). Approximately 47% of the total effect of ADHD-PGS on maltreatment was mediated by ADHD symptoms at age 6. No evidence supported gene-environment interaction in predicting ADHD symptoms. Our findings underscore the significant roles of genetics and childhood maltreatment as predictors for ADHD symptoms in adulthood, while also indicating a potential evocative mechanism through gene-environment correlation.

Evaluation of genomic factors and early childhood stimulation on intelligence in children from a Brazilian birth cohort: The primary role of independent factors

BACKGROUND

Childhood cognitive abilities are a predictor of health outcomes and adult income potential. Identifying factors associated with childhood intelligence and their interactions is essential in behavioral research. We assessed the impact of genetic variants and early child stimulation (ECS) on child intelligence and examined their possible interaction as potential modifiers of IQ in a population-based longitudinal study.

METHODS

Participants of the 2004 Pelotas Birth Cohort study (N = 4231) underwent intelligent quotient (IQ) by WISC-III assessment at 6 years of age. At 24 and 48-months, mothers answered five ECS marker questions, whose sum was used to create a score. The polygenic score for intelligence (IQ-PGS) was constructed from the GWAS-weighted estimate of cognition. Association was assessed using multiple linear regression models adjusted for maternal, family, and child confounding variables. To explore the possible influence of skin color and ethnoracial classification, the regression models were stratified according to the skin color variable, as a sensitivity analysis.

RESULTS

In the adjusted analysis, IQ-PGS (β = 0.79, 95% confidence interval [95% CI] 0.26;1.31) as well as ECS (β = 2.34; 95% CI: 1.76;2.92) were associated with IQ in this sample. The association between IQ-PGS and IQ was significant only in the white Brazilian group in the sensitivity analysis. However, there was no interaction between IQ-PGS and ECS on IQ (p(IQ-PGS x ECS) = 0.46).

CONCLUSIONS

ECS did not modify the impact of genetic potential on intellectual development during childhood, suggesting that genetic factors and ECS exert independent effects on the IQ levels of children.

Comparison of Wealth-Related Inequality in Tetanus Vaccination Coverage before and during Pregnancy: A Cross-Sectional Analysis of 72 Low- and Middle-Income Countries

Immunization of pregnant women against tetanus is a key strategy for reducing tetanus morbidity and mortality while also achieving the goal of maternal and neonatal tetanus elimination. Despite substantial progress in improving newborn protection from tetanus at birth through maternal immunization, umbilical cord practices and sterilized and safe deliveries, inequitable gaps in protection remain. Notably, an infant's tetanus protection at birth is comprised of immunization received by the mother during and before the pregnancy (e.g., through childhood vaccination, booster doses, mass vaccination campaigns, or during prior pregnancies). In this work, we examine wealth-related inequalities in maternal tetanus toxoid containing vaccination coverage before pregnancy, during pregnancy, and at birth for 72 low- and middle-income countries with a recent Demographic and Health Survey or Multiple Indicator Cluster Survey (between 2013 and 2022). We summarize coverage levels and absolute and relative inequalities at each time point; compare the relative contributions of inequalities before and during pregnancy to inequalities at birth; and examine associations between inequalities and coverage levels. We present the findings for countries individually and on aggregate, by World Bank country income grouping, as well as by maternal and neonatal tetanus elimination status, finding that most of the inequality in tetanus immunization coverage at birth is introduced during pregnancy. Inequalities in coverage during pregnancy are most pronounced in low- and lower-middle-income countries, and even more so in countries which have not achieved maternal and neonatal tetanus elimination. These findings suggest that pregnancy is a key time of opportunity for equity-oriented interventions to improve maternal tetanus immunization coverage.

Perception of parents and caregivers about the need for dental appointments for adolescents from a Brazilian birth cohort

OBJECTIVE

To investigate the perception of parents or caregivers regarding the need for dental appointments for adolescents aged 12-13 years and associated factors.

METHODS

Data from the Pelotas 2004 Birth Cohort were used. The outcome variable was the need for dental appointments for young adolescents perceived by parents or caregivers. Demographic and economic exposure variables were obtained from the first (2004) and sixth general follow-up (2015), respectively. The exposure variables 'previous history of dental pain', 'self-rated oral health', clinical variables and the outcome variable were obtained from the second oral health follow-up (2017). Unadjusted and adjusted multivariate Poisson regression analyses provided prevalence ratios (PR) and respective 95% confidence intervals (CI).

RESULTS

At the first oral health follow-up (2009), 1303 five-year-old children were recruited, 996 of whom were reassessed and underwent oral health examinations at 12 and 13 years of age (response rate: 76.4%). The findings showed that 72.4% of parents/caregivers perceived that the adolescents needed dental appointments. No associations were found between the outcome and sociodemographic or economic variables. After adjustments, the outcome remained positively associated with previous history of toothache (PR 1.22; 95% CI 1.14-1.32), self-rated oral health as fair or poor (PR 1.26; 95% CI 1.15-1.39), the presence of dental caries (PR 1.27; 95% CI 1.20-1.38) and severe or disabling malocclusion (PR 1.14; 95% CI 1.05-1.25).

CONCLUSIONS

The perception of parents/caregivers regarding the need for dental appointments on the part of their adolescent sons and daughters was associated with oral health problems, and these findings can serve as the basis for creating and improving oral health programmes that seek a better understanding on the part of parents and caregivers regarding the importance of integral care for their adolescent children.

Early risk factors for conduct problem trajectories from childhood to adolescence: the 2004 Pelotas (BRAZIL) Birth Cohort

Conduct problems are associated with an increased risk of a wide range of physical, mental, and social problems. However, there is still uncertainty about how early risk factors differentiate different developmental patterns of conduct problems and whether findings replicate across diverse social contexts. We aimed to identify developmental trajectories of conduct problems, and test early risk factors, in the 2004 Pelotas Birth Cohort in Brazil. Conduct problems were measured at ages 4, 6, 11, and 15 years from caregiver reports on the Child Behaviour Checklist (CBCL) and Strengths and Difficulties Questionnaire (SDQ). Conduct problem trajectories were estimated using group-based semi-parametric modeling (n = 3938). Multinomial logistic regression was used to examine associations between early risk factors and conduct problem trajectories. We identified four trajectories: three with elevated conduct problems, including early-onset persistent (n = 150; 3.8%), adolescence-onset (n = 286; 17.3%), and childhood-limited (n = 697; 17.7%), and one with low conduct problems (n = 2805; 71.2%). The three elevated conduct problem trajectories were associated with a wide range of sociodemographic risk factors, prenatal smoking, maternal mental health, harsh parenting, childhood trauma, and child neurodevelopmental risk factors. Early-onset persistent conduct problems were particularly associated with trauma, living without a father figure, and attention difficulties. The four trajectories of conduct problems from ages 4 to 15 years in this Brazilian cohort have similar longitudinal patterns to those identified in high-income countries. The results confirm previous longitudinal research and developmental taxonomic theories on the etiology of conduct problems in a Brazilian sample.

Pathways from maternal depression to child resilience: Socioeconomic, family, and individual factors in the 2004 Pelotas (Brazil) birth cohort

Background

The negative impacts of maternal depression on child mental health outcomes are well-documented. However, some children show adaptive functioning following exposure to maternal depression, demonstrating resilience. In a large birth cohort from Brazil, a middle-income country, we examined direct and indirect pathways, considering socioeconomic, family, and individual factors, contributing to the development of resilience.

Methods

Using data from the 2004 Pelotas Birth Cohort (N = 4231), we restricted the sample to those exposed to maternal depression up to age 6 years (depression present at ≥2 out of 5 assessment waves; n = 1132; 50% boys). Resilience was defined as scoring below or equal to the mean of the unexposed group on all four problem subscales of the parent-report Strengths and Difficulties Questionnaire at age 11 years. We examined pathways from socioeconomic status (SES; measured at birth) to resilience via cognitive stimulation (CS) (at 24 and 48 months) and Intelligence quotient (IQ) (at 6 years), and from CS to resilience via IQ, using counterfactual mediation.

Results

A minority of children exposed to maternal depression showed resilience (12.4%). There was evidence of indirect pathways from SES to resilience via CS (odds ratio (OR) = 1.76, 95% confidence interval (CI) 1.02-3.38) and IQ (OR = 1.19, 95% CI 1.01-1.42), such that higher SES was associated with resilience via both higher levels of CS and higher IQ, which, in turn, were each positively associated with resilience. Furthermore, there was evidence of a direct (OR = 1.86, 95% CI 1.01-3.76) and total effect (OR = 1.94, 95% CI 1.05-3.89) of CS on resilience, even after controlling for SES. However, these effects varied depending on how persistent and severe depression was defined.

Conclusions

These findings suggest that CS in early childhood may represent a modifiable protective factor for children exposed to maternal depression and a promising intervention target to promote child resilience in the context of maternal depression exposure.

Maternal depression trajectories in childhood, subsequent maltreatment, and adolescent emotion regulation and self-esteem: the 2004 Pelotas birth cohort

This study aimed to examine the impact of maternal depressive symptoms trajectories on 15-year-old adolescents' self-esteem and emotion regulation and test the mediating role of child maltreatment in this association. The 2004 Pelotas Birth Cohort is an ongoing cohort study originally comprised of 4231 live births in a southern Brazilian city. We examined a subsample of 1949 adolescents at age 15 years. Maternal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale. Trajectories of maternal depression from 3 months until the 11-year follow-up were calculated using a group-based modeling approach. Child maltreatment at age 11 years was measured using the parent-report version of the Parent-Child Conflict Tactics Scale. Adolescent outcomes at age 15 years were assessed by the self-report version of the Rosenberg Self-esteem Scale and the Emotion Regulation Index for Children and Adolescents. Path model analysis was conducted using a structural equation modeling framework in Mplus software. All maternal depression trajectories were negatively associated with offspring self-esteem and emotion regulation compared to the reference group (low depression trajectory). There was a significant indirect effect of maternal depression trajectories on emotion regulation mediated via child maltreatment. No evidence of moderation by sex was found for any pathway. The effects of maternal depression on adolescents' emotion regulation are partly mediated by child maltreatment at age 11.

[Telephone Survey of Risk Factors for Chronic Noncommunicable Diseases During the Pandemic (Covitel): methodological aspects]

This study describes the methodology of the Telephone Survey of Risk Factors for Chronic Noncommunicable Diseases During the Pandemic (Covitel), conducted in Brazil in 2022. Covitel is a population-based survey representing Brazil and its five macroregions (Central-West, Northeast, North, Southeast, and South) and providing information on the impact of the main risk factors for chronic noncommunicable diseases (NCDs) on the adult population aged 18 years or above who live in households served by fixed and mobile telephone lines. This study aims to contribute to the development and monitoring of public policies to promote the population's health and obtain results to contribute to the knowledge of the influence of COVID-19 on risk factors for NCDs in the country. We evaluated 9,000 individuals and collected information on their diet, physical activity, mental health, health status, hypertension, diabetes, depression, and alcohol and tobacco consumption, comparing the pre-pandemic moments and the first quarter of 2022. We also collected information about the population's vaccination schedule and COVID-19 infection history.

Measures of women's empowerment based on individual-level data: a literature review with a focus on the methodological approaches

Background

Quantifying women's empowerment has become the focus of attention of many international organizations and scholars. We aimed to describe quantitative indicators of women's empowerment that are based on individual-level data.

Methods

In this scoping review, we searched PubMed, Scopus, Web of Science, Science Direct, Google, and Google Scholar for publications describing the operationalization of measures of women's empowerment.

Results

We identified 36 studies published since 2004, half of them since 2019, and most from low- and middle-income countries. Twelve studies were based on data from the Demographic and Health Surveys and used 56 different variables from the questionnaires (ranging from one to 25 per study) to measure the overall empowerment of women 15-49 years. One study focused on rural women, two included married and unmarried women, and one analyzed the couple's responses. Factor analysis and principal component analysis were the most common approaches used. Among the 24 studies based on other surveys, ten analyzed overall empowerment, while the others addressed sexual and reproductive health (4 studies), agriculture (3) and livestock (1), water and sanitation (2), nutrition (2), agency (1), and psychological empowerment (1). These measures were mainly based on data from single countries and factor analysis was the most frequently analytical method used. We observed a diversity of indicator definitions and domains and a lack of consensus in terms of what the proposed indicators measure.

Conclusion

The proposed women's empowerment indicators represent an advance in the field of gender and development monitoring. However, the empowerment definitions used vary widely in concept and in the domains/dimensions considered, which, in turn influence or are influenced by the adopted methodologies. It remains a challenge to find a balance between the need for a measure suitable for comparisons across populations and over time and the incorporation of country-specific elements.

Quality of vital event data for infant mortality estimation in prospective, population-based studies: an analysis of secondary data from Asia, Africa, and Latin America

INTRODUCTION

Infant and neonatal mortality estimates are typically derived from retrospective birth histories collected through surveys in countries with unreliable civil registration and vital statistics systems. Yet such data are subject to biases, including under-reporting of deaths and age misreporting, which impact mortality estimates. Prospective population-based cohort studies are an underutilized data source for mortality estimation that may offer strengths that avoid biases.

METHODS

We conducted a secondary analysis of data from the Child Health Epidemiology Reference Group, including 11 population-based pregnancy or birth cohort studies, to evaluate the appropriateness of vital event data for mortality estimation. Analyses were descriptive, summarizing study designs, populations, protocols, and internal checks to assess their impact on data quality. We calculated infant and neonatal morality rates and compared patterns with Demographic and Health Survey (DHS) data.

RESULTS

Studies yielded 71,760 pregnant women and 85,095 live births. Specific field protocols, especially pregnancy enrollment, limited exclusion criteria, and frequent follow-up visits after delivery, led to higher birth outcome ascertainment and fewer missing deaths. Most studies had low follow-up loss in pregnancy and the first month with little evidence of date heaping. Among studies in Asia and Latin America, neonatal mortality rates (NMR) were similar to DHS, while several studies in Sub-Saharan Africa had lower NMRs than DHS. Infant mortality varied by study and region between sources.

CONCLUSIONS

Prospective, population-based cohort studies following rigorous protocols can yield high-quality vital event data to improve characterization of detailed mortality patterns of infants in low- and middle-income countries, especially in the early neonatal period where mortality risk is highest and changes rapidly.

Agreement between measured weight, height and BMI and Web-based self-reported data in participants of the 1993 Pelotas Birth Cohort, Brazil: a cross-sectional validation study

OBJECTIVE

to evaluate the agreement between measured height, weight, and body mass index (BMI) during the 22-year follow-up of the 1993 Pelotas Birth Cohort, state of Rio Grande do Sul, Brazil, and self-reported data during the online follow-up of the coortesnaweb.

METHODS

this was a cross-sectional validation study; agreement was assessed by means of Lin's concordance correlation coefficient for continuous measures and weighted Kappa for nutritional status; Spearman's rank correlation coefficient was used to estimate the correlation between measurements.

RESULTS

a total of 783 participants were included; it could be seen high correlation and high agreement between the measured height (r = 0.966; ρ = 0.966), weight (r = 0.934; ρ = 0.928), and BMI (r = 0.903; ρ = 0.910) and Web-based self-reported data; there was no correlation between mean difference and the time interval between measurements.

CONCLUSION

using the Internet to collect self-reported anthropometric measurements is as valid as the traditional method.

Recent trends in maternal and child health inequalities in Latin America and the Caribbean: analysis of repeated national surveys

BACKGROUND

Although most Latin American and the Caribbean (LAC) countries made important progress in maternal and child health indicators from the 1990s up to 2010, little is known about such progress in the last decade. This study aims at documenting progress for each country as a whole, and to assess how within-country socioeconomic inequalities are evolving over time.

METHODS

We identified LAC countries for which a national survey was available between 2011-2015 and a second comparable survey in 2018-2020. These included Argentina, Costa Rica, Cuba, the Dominican Republic, Guyana, Honduras, Peru, and Suriname. The 16 surveys included in the analysis collected nationally representative data on 221,989 women and 152,983 children using multistage sampling. Twelve health-related outcomes were studied, seven of which related to intervention coverage: the composite coverage index, demand for family planning satisfied with modern methods, antenatal care (four or more visits and eight or more visits), skilled attendant at birth, postnatal care for the mother and full immunization coverage. Five additional impact indicators were also investigated: stunting prevalence among under-five children, tobacco use by women, adolescent fertility rate, and under-five and neonatal mortality rates. For each of these indicators, average annual relative change rates were calculated between the baseline and endline national level estimates, and changes in socioeconomic inequalities over time were assessed using the slope index of inequality.

RESULTS

Progress over time and the magnitude of inequalities varied according to country and indicator. For countries and indicators where baseline levels were high, as Argentina, Costa Rica and Cuba, progress was slow and inequalities small for most indicators. Countries that still have room for improvements, such as Guyana, Honduras, Peru and Suriname, showed faster progress for some but not all indicators, although also had wider inequalities. Among the countries studied, Peru was the top performer in terms of increasing coverage and reducing inequalities over time, followed by Honduras. Declines in family planning and immunization coverage were observed in some countries, and the widest inequalities were present for adolescent fertility and antenatal care coverage with eight or more visits.

CONCLUSIONS

Although LAC countries are well placed in terms of current levels of health indicators compared to most low- and middle-income countries, important inequalities remain, and reversals are being observed in some areas. More targeted efforts and actions are needed in order to leave no one behind. Monitoring progress with an equity lens is essential, but this will require further investment in conducting surveys routinely.

Trends and inequities in adolescent childbearing in Latin American and Caribbean countries across generations and over time: a population-based study

BACKGROUND

Latin America and the Caribbean present the second highest adolescent fertility rate in the world, only after sub-Saharan Africa, and have reached the third position globally in the incidence of motherhood in adolescence. We aimed to explore trends and inequities in adolescent childbearing in the region.

METHODS

We used nationally representative household surveys from Latin American and Caribbean countries to address trends in early childbearing (proportion of women having their first livebirth before age 18 years) over generations and in adolescent fertility rates (AFRs; livebirths per 1000 women aged 15-19 years) over time. For early childbearing, we analysed the most recent survey conducted since 2010 from 21 countries (2010-20); for AFR, we analysed nine countries with two or more surveys, with the most recent being conducted from 2010 onwards. For both indicators, variance-weighted least-square regression was used to estimate the average absolute changes (AACs) at the national level and by wealth (bottom 40% vs top 60%), urban versus rural residence, and ethnicity.

FINDINGS

Among 21 countries studied, we noted a decrease in early childbearing along generations in 13 of them, with declines varying from -0·6 percentage points (95% CI -1·1 to -0·1) in Haiti to -2·7 percentage points (-4·0 to -1·4) in Saint Lucia. We observed increases over generations in Colombia (1·2 percentage points [0·8 to 1·5]) and Mexico (1·3 percentage points [0·5 to 2·0]) and no changes in Bolivia and Honduras. The fastest early childbearing decline occurred among rural women, whereas no clear pattern was observed for wealth groups. Decreasing estimates from oldest to youngest generations were found among Afro-descendants and non-Afro-descendant and non-indigenous groups, but results were mixed for indigenous people. All nine countries with data for AFR presented reductions over time (-0·7 to -6·5 births per 1000 women per year), with the steepest declines observed in Ecuador, Guyana, Guatemala, and the Dominican Republic. In general, adolescents in rural areas and the poorest adolescents had the largest reductions in AFR. If current trends persist, by 2030 most countries will present AFR values ranging between 45 and 89 births per 1000 women, with notable wealth-related inequalities.

INTERPRETATION

Our results indicate a reduction in AFR in Latin American and Caribbean countries that was not necessarily accompanied by a decrease in early childbearing overall. Large inequalities both between countries and within countries were observed, with no clear reduction over time. Understanding trends in adolescent childbearing and its determinants is essential for planning and designing programmes to ensure the desired reductions in rates and gaps across population subgroups.

FUNDING

PAHO, Bill & Melinda Gates Foundation, and Wellcome Trust.

TRANSLATIONS

For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Impact of covid-19 pandemic over depressive symptoms among mothers from a population-based birth cohort in southern brazil

PURPOSE

Our aim was to assess the impact of COVID-19 on depressive symptoms among mothers from a population-based birth cohort in Pelotas, Southern Brazil.

METHODS

A subgroup of mothers from the Pelotas 2004 Birth Cohort was assessed pre-pandemic (November,2019 to March,2020) and mid-pandemic (August-December,2021). In both follow-ups, depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Pre-pandemic (T₁) and pandemic-related predictors (T₂) were analyzed. Prevalence of depression (EPDS score ≥ 13) at T₁ and T₂ were compared with chi-square test. Changes in EPDS from T₁ to T₂ were estimated by multivariate latent change score modelling.

RESULTS

1,550 women were assessed. Prevalence of depression increased 38.1% (from 18.9% at T₁ to 26.1% at T₂) (p < 0.001). At T₁, higher schooling, higher family income and being employed or working were related to lower EPDS, whereas being beneficiary of a cash transfer program and a larger number of people living in the household predicted higher EPDS. The deterioration of ones' own perception of quality of overall health (β = 0.191; SE = 0.028; p < 0.001) and worst family financial situation due to the pandemic (β = 0.083; SE = 0.024; p = 0.001) predicted the increase in EPDS from T₁ to T₂.

CONCLUSION

Almost two years after the beginning of the pandemic, the prevalence of depressive symptoms among the women was higher than before the pandemic. The deterioration of ones' own perception of quality of overall health and worst family financial situation due to the pandemic are proxies for the effect of COVID-19 pandemic (the true exposure of interest) in the women mental health.

Time trends in ethnic inequalities in child health and nutrition: analysis of 59 low and middle-income countries

BACKGROUND

Although ethnicity is a key social determinant of health, there are no global analyses aimed at identifying countries that succeeded in reducing ethnic gaps in child health and nutrition.

METHODS

We identified 59 low and middle-income countries with at least two surveys since 2010 providing information on ethnicity or language and on three outcomes: under-five mortality, child stunting prevalence and a composite index (CCI) based on coverage with eight maternal and child health interventions. Firstly, we calculated population-weighted and unweighted measures of inequality among ethnic or language groups within each country. These included the mean difference from the overall national mean (absolute inequality), mean ratio relative to the overall mean (relative inequality), and the difference and ratio between the best- and worst-performing ethnic groups. Second, we examined annual changes in these measures in terms of annual absolute and relative changes. Thirdly, we compared trends for each of the three outcome indicators and identified exemplar countries with marked progress in reducing inequalities.

RESULTS

For each outcome indicator, annual changes in summary measures tended to show moderate (Pearson correlation coefficients of 0.4 to 0.69) or strong correlations (0.7 or higher) among themselves, and we thus focused on four of the 12 measures: absolute and relative annual changes in mean differences and ratios from the overall national mean. On average, absolute ethnic or language group inequalities tended to decline slightly for the three outcomes, and relative inequality declined for stunting and CCI, but increased for mortality. Correlations for annual trends across the three outcomes were inconsistent, with several countries showing progress in terms of one outcome but not in others. Togo and Uganda showed with the most consistent progress in reducing inequality, whereas the worst performers were Nigeria, Moldova, Kyrgyzstan, Sao Tome and Principe, and Burkina Faso.

CONCLUSIONS

Although measures of annual changes in ethnic or language group inequalities in child health were consistently correlated within each outcome, analyses of such inequalities should rely upon multiple measures. Countries showing progress in one child health outcome did not necessarily show improvements in the remaining outcomes. In-depth analyses at country level are needed to understand the drivers of success in reducing ethnic gaps.

Inequalities in Immunization against Maternal and Neonatal Tetanus: A Cross-Sectional Analysis of Protection at Birth Coverage Using Household Health Survey Data from 76 Countries

Substantial progress in maternal and neonatal tetanus elimination has been made in the past 40 years, with dramatic reductions in neonatal tetanus incidence and mortality. However, twelve countries have still not achieved maternal and neonatal tetanus elimination, and many countries that have achieved elimination do not meet key sustainability thresholds to ensure long-lasting elimination. As maternal and neonatal tetanus is a vaccine-preventable disease (with coverage of the infant conferred by maternal immunization during and prior to pregnancy), maternal tetanus immunization coverage is a key metric for monitoring progress towards, equity in, and sustainability of tetanus elimination. In this study, we examine inequalities in tetanus protection at birth, a measure of maternal immunization coverage, across 76 countries and four dimensions of inequality via disaggregated data and summary measures of inequality. We find that substantial inequalities in coverage exist for wealth (with lower coverage among poorer wealth quintiles), maternal age (with lower coverage among younger mothers), maternal education (with lower coverage among less educated mothers), and place of residence (with lower coverage in rural areas). Inequalities existed for all dimensions across low- and lower-middle-income countries, and across maternal education and place of residence across upper-middle-income countries. Though global coverage changed little over the time period 2001-2020, this obscured substantial heterogeneity across countries. Notably, several countries had substantial increases in coverage accompanied by decreases in inequality, highlighting the need for equity considerations in maternal and neonatal tetanus elimination and sustainability efforts.

What are the sources of contraceptives for married and unmarried adolescents: Health services or friends? Analysis of 59 low- and middle-income countries

Background

Despite the efforts to promote universal coverage for family planning, inequalities are still high in several countries. Our aim was to identify which sources of contraceptives women mostly rely on in low- and middle-income countries (LMICs). We also explored the different sources according to age and marital status.

Methods

We used data from national health surveys carried out in 59 LMICs since 2010. Among all sexually active women at reproductive age, we explored inequalities in demand for family planning satisfied by modern methods (mDFPS) and in the source of modern contraceptives according to women's age, classified as: 15-19, 20-34, or 35-49 years of age. Among adolescents, mDFPS and source of method were explored by marital status, classified as married or in union and not married nor in a union.

Results

mDFPS was lower among adolescents than among adult women in 28 of the 59 countries. The lowest levels of mDFPS among adolescents were identified in Albania (6.1%) and Chad (8.2%). According to adolescents' marital status, the pattern of inequalities in mDFPS varied widely between regions, with married and unmarried adolescents showing similar levels of coverage in Latin America and the Caribbean, higher coverage among unmarried adolescents in Africa, and lower coverage among unmarried adolescents in Asia. Public and private health services were the main sources, with a lower share of the public sector among adolescents in almost all countries. The proportion of adolescents who obtained their contraceptives in the public sector was lower among unmarried girls than married ones in 31 of the 38 countries with data. Friends or relatives were a more significant source of contraceptives among unmarried compared to married adolescents in all regions.

Conclusions

Our findings indicate lower levels of mDFPS and lower use of the public sector by adolescents, especially unmarried girls. More attention is needed to provide high-quality and affordable family planning services for adolescents, especially for those who are not married.

A novel shape-based approach to identify gestational age-adjusted growth patterns from birth to 11 years of age

Child growth patterns assessment is critical to design public health interventions. However, current analytical approaches may overlook population heterogeneity. To overcome this limitation, we developed a growth trajectories clustering pipeline that incorporates a shape-respecting distance, baseline centering (i.e., birth-size normalized trajectories) and Gestational Age (GA)-correction to characterize shape-based child growth patterns. We used data from 3945 children (461 preterm) in the 2004 Pelotas Birth Cohort with at least 3 measurements between birth (included) and 11 years of age. Sex-adjusted weight-, length/height- and body mass index-for-age z-scores were derived at birth, 3 months, and at 1, 2, 4, 6 and 11 years of age (INTERGROWTH-21st and WHO growth standards). Growth trajectories clustering was conducted for each anthropometric index using k-means and a shape-respecting distance, accounting or not for birth size and/or GA-correction. We identified 3 trajectory patterns for each anthropometric index: increasing (High), stable (Middle) and decreasing (Low). Baseline centering resulted in pattern classification that considered early life growth traits. GA-correction increased the intercepts of preterm-born children trajectories, impacting their pattern classification. Incorporating shape-based clustering, baseline centering and GA-correction in growth patterns analysis improves the identification of subgroups meaningful for public health interventions.

Linear growth and relative weight gain in childhood and bone mass in adolescence: findings from the Pelotas (Brazil) 2004 birth cohort

With the objective to investigate the relationship of weight and height growth with bone mass at 11 years, we found that boys who grew in weight and height, especially at 48 months, and girls, who grew in weight at 24 months and height at 11 years, gained more bone mass.

PURPOSE

To investigate independent relationships of linear growth and relative weight gain during defined periods of infancy, childhood, and early adolescence with areal bone mineral density (aBMD) of three sites at 11 years.

METHODS

Data on weight and length/height were obtained at birth, 3, 12, and 24 months, and the ages of 4, 6, and 11. The outcome was whole body, femoral neck, and lumbar spine aBMD (g/cm2) measured at 11 years using dual-energy X-ray absorptiometry. The effects of weight gain and linear growth were analyzed using conditional relative weight and conditional length/height. Associations between conditional growth and outcomes were analyzed using linear regression, adjusted for multiple confounders.

RESULTS

Individuals with data available for exposures and bone outcomes were 2875 and comprised the sample. For boys, the greatest magnitude of increase for whole body and height gain was at 48 months (β 0.014, 95% CI 0.010; 0.018). For girls, higher aBMD was observed for those with greater height gain at 11 years, representing for lumbar spine an increase of 0.056 g/cm2 (95% CI 0.050; 0.062). For body weight, among boys, the greatest magnitude in the whole body was also associated with weight gain at 48 months (β 0.014, 95% CI 0.010; 0.018). For girls, the highest coefficient was at 24 months, representing for lumbar spine an increase of 0.028 g/cm2, (95% CI 0.021; 0.035).

CONCLUSION

Positive associations were demonstrated between length/height and weight gain and aBMD in both sexes, with emphasis on girls' aBMD in response to the linear growth achieved mainly at 11 years.

Early initiation of breastfeeding is inversely associated with public and private c-sections in 73 lower- and middle-income countries

Although studies in low- and middle-income countries (LMICs) have examined the effects of c-sections on early initiation of breastfeeding (EIBF), the role of the place of birth has not yet been investigated. Therefore, we tested the association between EIBF and the type of delivery by place of birth. Data from 73 nationally representative surveys carried out in LMICs between 2010 and 2019 comprised 408,013 women aged 15 to 49 years. Type of delivery by place of birth was coded in four categories: home vaginal delivery, institutional vaginal delivery, c-section in public, and c-section in private health facilities. We calculated the weighted mean prevalence of place of birth and EIBF by World Bank country income groups. Adjusted Poisson regression (PR) was fitted taking institutional vaginal delivery as a reference. The overall prevalence of EIBF was significantly lower among c-section deliveries in public (PR = 38%; 95% CI 0.618-0.628) and private facilities (PR = 45%; 95% CI 0.54-0.566) compared to institutional vaginal deliveries. EIBF in c-sections in public facilities was slightly higher in lower-middle (PR = 0.650, 95% CI 0.635-0.665) compared to low (PR = 0.544, 95% CI 0.521-0.567) and upper-middle income countries (PR = 0.612, 95% CI 0.599-0.626). EIBF was inversely associated with c-section deliveries compared to institutional vaginal deliveries, especially in private facilities compared to public ones.

Associations between childhood trauma and childhood psychiatric disorders in Brazil: a population-based, prospective birth cohort study

BACKGROUND

Childhood trauma is a proposed transdiagnostic risk factor for psychopathology, but epidemiological evidence from low-income and middle-income countries (LMICs) is scarce. We investigated associations between trauma and child psychiatric disorders in a birth cohort in Brazil.

METHODS

The 2004 Pelotas Birth Cohort is an ongoing, population-based, prospective birth cohort, including all hospital births occurring between Jan 1 and Dec 31, 2004, in the city of Pelotas, Brazil. When the children were aged 6 and 11 years, trained psychologists administered the Development and Well-Being Assessment clinical interview to caregivers to assess current child psychiatric disorders (anxiety disorders, mood disorders, ADHD and hyperactivity disorders, and conduct and oppositional disorders), and lifetime trauma exposure (ie, experiencing or witnessing life-threatening events) including interpersonal and non-interpersonal events. Analyses used multiple imputation and logistic regression models.

OUTCOMES

Of 4263 live births, 4231 children were included in the study sample, and 4229 (2195 [51·9%] boys and 2034 [48·1%] girls; 2581 [61·7%] with White mothers and 1600 [38·3%] with Black or mixed race mothers) were included in the imputed analyses. 1154 (34·3%) of 3367 children with complete data at age 11 years had been exposed to trauma by that age. After adjusting for confounders, at age 6 years, trauma was associated with increased odds of anxiety disorders (adjusted odds ratio 1·79 [95% CI 1·33-2·42]) and any psychiatric disorder (1·59 [1·22-2·06]), and at age 11 years, with any psychiatric disorder (1·45 [1·17-1·79]) and all four specific diagnostic classes of anxiety disorders (1·47 [1·04-2·09]), mood disorders (1·66 [1·08-2·55]), ADHD and hyperactivity disorders (1·47 [1·01-2·13]), and conduct and oppositional disorders (1·76 [1·19-2·61]). Interpersonal trauma and non-interpersonal trauma were each associated with increased odds of multiple psychiatric disorders, even when adjusting for their co-occurrence.

INTERPRETATION

A considerable mental health burden associated with childhood trauma is already evident by middle childhood in this sample from Brazil. Evidence-based efforts to reduce the incidence of childhood trauma in Brazil and address its consequences are urgently needed.

FUNDING

Children's Pastorate, WHO, National Support Program for Centres of Excellence, Brazilian National Research Council, Brazilian Ministry of Health, São Paulo Research Foundation, University of Bath, Wellcome Trust.

TRANSLATION

For the Portuguese translation of the abstract see Supplementary Materials section.

Disparities in early initiation of breast feeding and prelacteal feeding: A study of low- and middle-income countries

BACKGROUND

Early initiation of breast feeding (EIBF) reduces the risk of neonatal mortality. However, only 45% of newborns are breast-fed within the first hour after birth and prelacteal feeding (PLF) is widely prevalent in low- and middle-income countries (LMICs).

OBJECTIVE

To assess within- and between-country disparities in EIBF and PLF practices by household wealth and place of birth and to investigate the national-level correlation between these feeding indicators in LMICs.

METHODS

Data from Demographic Health Surveys and Multiple Indicator Cluster Surveys (2010-2019) in 76 LMICs were used to investigate within-country disparities in EIBF, any PLF, milk-based prelacteal feeding (MPLF), and water-based prelacteal feeding (WPLF) by wealth quintiles and place of childbirth (institutional [private or public sector] or in-home) for children under two years. We examined the between-country Pearson's correlation between EIBF and types of PLF, later adjusted for per capita gross domestic product (GDP).

RESULTS

No clear wealth-related differences were found for EIBF and WPLF; however, any PLF and MPLF were significantly higher in children belonging to the richest 20% of households but are also prevalent among lower income groups. Prevalence of any PLF was higher among institutional births in all LMICs, but especially for MPLF in private sector deliveries in East Asia & the Pacific, Eastern Europe & Central Asia, and Latin America & the Caribbean. WPLF was more common in all African regions. EIBF was inversely correlated with any PLF (r = -0.59, 95% CI -0.72, -0.42), MPLF (r = -0.41, 95% CI -0.58, -0.21) and WPLF (r = -0.34, 95% CI -0.53, -0.13). Adjustment for log-GDP did not affect the magnitude and direction of the results.

CONCLUSION

Clear prorich disparities exist in the prevalence of PLF, especially MPLF. Children born in private sector facilities are more likely to receive MPLF. EIBF is negatively associated with PLF practices in LMICs. The promotion of better early feeding practices is urgent to achieve the Sustainable Development Goal to reduce neonatal mortality to 12 deaths per 1000 live births.