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Bjelakovic G, Nikolova D, Bjelakovic M, Pavlov CS, Sethi NJ, Korang SK, Gluud C. Effects of primary or secondary prevention with vitamin A supplementation on clinically important outcomes: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. BMJ Open 2024; 14:e078053. [PMID: 38816049 PMCID: PMC11141198 DOI: 10.1136/bmjopen-2023-078053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 05/20/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES This systematic review with meta-analyses of randomised trials evaluated the preventive effects of vitamin A supplements versus placebo or no intervention on clinically important outcomes, in people of any age. METHODS We searched different electronic databases and other resources for randomised clinical trials that had compared vitamin A supplements versus placebo or no intervention (last search 16 April 2024). We used Cochrane methodology. We used the random-effects model to calculate risk ratios (RRs), with 95% CIs. We analysed individually and cluster randomised trials separately. Our primary outcomes were mortality, adverse events and quality of life. We assessed risks of bias in the trials and used Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to assess the certainty of the evidence. RESULTS We included 120 randomised trials (1 671 672 participants); 105 trials allocated individuals and 15 allocated clusters. 92 trials included children (78 individually; 14 cluster randomised) and 28 adults (27 individually; 1 cluster randomised). 14/105 individually randomised trials (13%) and none of the cluster randomised trials were at overall low risk of bias. Vitamin A did not reduce mortality in individually randomised trials (RR 0.99, 95% CI 0.93 to 1.05; I²=32%; p=0.19; 105 trials; moderate certainty), and this effect was not affected by the risk of bias. In individually randomised trials, vitamin A had no effect on mortality in children (RR 0.96, 95% CI 0.88 to 1.04; I²=24%; p=0.28; 78 trials, 178 094 participants) nor in adults (RR 1.04, 95% CI 0.97 to 1.13; I²=24%; p=0.27; 27 trials, 61 880 participants). Vitamin A reduced mortality in the cluster randomised trials (0.84, 95% CI 0.76 to 0.93; I²=66%; p=0.0008; 15 trials, 14 in children and 1 in adults; 364 343 participants; very low certainty). No trial reported serious adverse events or quality of life. Vitamin A slightly increased bulging fontanelle of neonates and infants. We are uncertain whether vitamin A influences blindness under the conditions examined. CONCLUSIONS Based on moderate certainty of evidence, vitamin A had no effect on mortality in the individually randomised trials. Very low certainty evidence obtained from cluster randomised trials suggested a beneficial effect of vitamin A on mortality. If preventive vitamin A programmes are to be continued, supporting evidence should come from randomised trials allocating individuals and assessing patient-meaningful outcomes. PROSPERO REGISTRATION NUMBER CRD42018104347.
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Affiliation(s)
- Goran Bjelakovic
- Department of Internal Medicine, Medical Faculty, University of Nis, Nis, Serbia
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Clinic of Gastroenterohepatology, University Clinical Centre, Nis, Serbia
| | - Dimitrinka Nikolova
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Milica Bjelakovic
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Clinic of Gastroenterohepatology, University Clinical Centre, Nis, Serbia
| | - Chavdar S Pavlov
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Gastroenterology, Botkin Hospital, Moscow, Russian Federation
- Department of Therapy, I.M. Sechenov, First Moscow State Medical University, Moscow, Russian Federation
| | - Naqash J Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
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Danso SO, Manu A, Fenty J, Amanga-Etego S, Avan BI, Newton S, Soremekun S, Kirkwood B. Population cause of death estimation using verbal autopsy methods in large-scale field trials of maternal and child health: lessons learned from a 20-year research collaboration in Central Ghana. Emerg Themes Epidemiol 2023; 20:1. [PMID: 36797732 PMCID: PMC9936721 DOI: 10.1186/s12982-023-00120-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Low and middle-income countries continue to use Verbal autopsies (VAs) as a World Health Organisation-recommended method to ascertain causes of death in settings where coverage of vital registration systems is not yet comprehensive. Whilst the adoption of VA has resulted in major improvements in estimating cause-specific mortality in many settings, well documented limitations have been identified relating to the standardisation of the processes involved. The WHO has invested significant resources into addressing concerns in some of these areas; there however remains enduring challenges particularly in operationalising VA surveys for deaths amongst women and children, challenges which have measurable impacts on the quality of data collected and on the accuracy of determining the final cause of death. In this paper we describe some of our key experiences and recommendations in conducting VAs from over two decades of evaluating seminal trials of maternal and child health interventions in rural Ghana. We focus on challenges along the entire VA pathway that can impact on the success rates of ascertaining the final cause of death, and lessons we have learned to optimise the procedures. We highlight our experiences of the value of the open history narratives in VAs and the training and skills required to optimise the quality of the information collected. We describe key issues in methods for ascertaining cause of death and argue that both automated and physician-based methods can be valid depending on the setting. We further summarise how increasingly popular information technology methods may be used to facilitate the processes described. Verbal autopsy is a vital means of increasing the coverage of accurate mortality statistics in low- and middle-income settings, however operationalisation remains problematic. The lessons we share here in conducting VAs within a long-term surveillance system in Ghana will be applicable to researchers and policymakers in many similar settings.
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Affiliation(s)
- Samuel O. Danso
- grid.4305.20000 0004 1936 7988Disease Modelling Research Group, Centre for Dementia Prevention & Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alexander Manu
- Centre for Maternal and Newborn Health, Liverpool School of Hygiene and Tropical Medicine, Liverpool, UK
| | - Justin Fenty
- grid.8991.90000 0004 0425 469XFaculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Liverpool, UK
| | - Seeba Amanga-Etego
- grid.415375.10000 0004 0546 2044Centre for Computing, Kintampo Health Research Centre, Ministry of Health, Kintampo, Ghana
| | - Bilal Iqbal Avan
- grid.8991.90000 0004 0425 469XFaculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Sam Newton
- grid.9829.a0000000109466120School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Seyi Soremekun
- grid.8991.90000 0004 0425 469XFaculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Betty Kirkwood
- grid.8991.90000 0004 0425 469XFaculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Hill Z, Tawiah-Agyemang C, Kirkwood B, Kendall C. Are verbatim transcripts necessary in applied qualitative research: experiences from two community-based intervention trials in Ghana. Emerg Themes Epidemiol 2022; 19:5. [PMID: 35765012 PMCID: PMC9238251 DOI: 10.1186/s12982-022-00115-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
Abstract
Conducting qualitative research within public health trials requires balancing timely data collection with the need to maintain data quality. Verbatim transcription of interviews is the conventional way of recording qualitative data, but is time consuming and can severely delay the availability of research findings. Expanding field notes into fair notes is a quicker alternative method, but is not usually recommended as interviewers select and interpret what they record. We used the fair note methodology in Ghana, and found that where research questions are relatively simple, and interviewers undergo sufficient training and supervision, fair notes can decrease data collection and analysis time, while still providing detailed and relevant information to the study team. Interviewers liked the method and felt it made them more reflective and analytical and improved their interview technique. The exception was focus group discussions, where the fair note approach failed to capture the interaction and richness of discussions, capturing group consensus rather than the discussions leading to this consensus.
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Affiliation(s)
- Zelee Hill
- Institute for Global Health, University College London, 30 Guilford St., London, WC1N 1EH, UK.
| | | | - Betty Kirkwood
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Carl Kendall
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2350, New Orleans, LA, 70112, USA
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4
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Ten Hulzen RD, Wagner IV, Decastro PY, Sullivan JP. Visual field decline and restoration following vitamin A therapy for vitamin A deficiency. Am J Ophthalmol Case Rep 2022; 26:101471. [PMID: 35300401 PMCID: PMC8921295 DOI: 10.1016/j.ajoc.2022.101471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To present a case of nutritional vitamin A deficiency (VAD) that caused bilateral severe dry eye symptoms and progressive visual field contraction over a 13.5-month span resulting in peripheral blindness and nyctalopia, and to document the patient's rapid visual field restoration following vitamin A therapy (VAT). Observations A 34-year-old Haitian woman presented for a glaucoma consultation with the following symptoms in both eyes (OU): painful dry eyes, floaters, nyctalopia, and visual field contraction over eighteen months despite treatment with four anti-glaucoma medications and intraocular pressures (IOP) in the low teens OU. The glaucoma diagnosis was eliminated due to slit lamp examination and OCT imaging, which showed an absence of both optic neuropathy and secondary glaucoma features. The patient's symptoms remained consistent with VAD. The patient's visual field decline was restored with significant documented visual field improvement occurring within only 11 days, and complete visual field restoration within 5.5 months of VAT. Conclusions and Importance Our case demonstrates the critical role of vitamin A in maintaining ocular health and visual field preservation. To our knowledge, this is the second reported case documenting a patient's visual field decline due to VAD, as well as visual field restoration following enteral VAT. As visual outcomes of VAT are significantly underreported in scientific literature, it is imperative that ophthalmologists are aware of its effects.
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Affiliation(s)
- Richard D. Ten Hulzen
- Mayo Clinic Florida, Department of Ophthalmology, 4500, San Pablo Rd S, Jacksonville, FL, USA
- Corresponding author. Mayo Clinic Florida, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Isabella V. Wagner
- Mayo Clinic Florida, Department of Ophthalmology, 4500, San Pablo Rd S, Jacksonville, FL, USA
| | | | - John P. Sullivan
- Southeastern Retina Specialists, 7740 Point Meadows Dr., Jacksonville, FL, USA
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Shannon C, Hurt C, Soremekun S, Edmond K, Newton S, Amenga-Etego S, Tawiah-Agyemang C, Hill Z, Manu A, Weobong B, Kirkwood B, Hurt L. Implementing effective community-based surveillance in research studies of maternal, newborn and infant outcomes in low resource settings. Emerg Themes Epidemiol 2022; 19:1. [PMID: 35022044 PMCID: PMC8756712 DOI: 10.1186/s12982-021-00109-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Globally adopted health and development milestones have not only encouraged improvements in the health and wellbeing of women and infants worldwide, but also a better understanding of the epidemiology of key outcomes and the development of effective interventions in these vulnerable groups. Monitoring of maternal and child health outcomes for milestone tracking requires the collection of good quality data over the long term, which can be particularly challenging in poorly-resourced settings. Despite the wealth of general advice on conducting field trials, there is a lack of specific guidance on designing and implementing studies on mothers and infants. Additional considerations are required when establishing surveillance systems to capture real-time information at scale on pregnancies, pregnancy outcomes, and maternal and infant health outcomes. Main body Based on two decades of collaborative research experience between the Kintampo Health Research Centre in Ghana and the London School of Hygiene and Tropical Medicine, we propose a checklist of key items to consider when designing and implementing systems for pregnancy surveillance and the identification and classification of maternal and infant outcomes in research studies. These are summarised under four key headings: understanding your population; planning data collection cycles; enhancing routine surveillance with additional data collection methods; and designing data collection and management systems that are adaptable in real-time. Conclusion High-quality population-based research studies in low resource communities are essential to ensure continued improvement in health metrics and a reduction in inequalities in maternal and infant outcomes. We hope that the lessons learnt described in this paper will help researchers when planning and implementing their studies.
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Affiliation(s)
- Caitlin Shannon
- Impact and Innovation Team, CARE USA, 115 Broadway, 5th Floor, New York, NY, 10006, USA
| | - Chris Hurt
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Seyi Soremekun
- Maternal and Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Karen Edmond
- Department of Women and Children's Health, Kings College London, Strand, London, WC2R 2LS, UK
| | - Sam Newton
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Seeba Amenga-Etego
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Bono East and Bono Regions, Ghana
| | | | - Zelee Hill
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Alexander Manu
- Department of Epidemiology and Disease Control, School of Public Health, College of Health Sciences, University of Ghana, Legon, P.O. Box LG 25, Accra, Ghana
| | - Ben Weobong
- Department of Social and Behavioural Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Betty Kirkwood
- Maternal and Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Lisa Hurt
- Division of Population Medicine, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
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6
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Newton S, Asbroek GT, Hill Z, Agyemang CT, Soremekun S, Etego SA, Kirkwood B. Maximizing community participation and engagement: lessons learned over 2 decades of field trials in rural Ghana. Emerg Themes Epidemiol 2021; 18:19. [PMID: 34952613 PMCID: PMC8709940 DOI: 10.1186/s12982-021-00110-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful implementation of community-based research is dominantly influenced by participation and engagement from the local community without which community members will not want to participate in research and important knowledge and potential health benefits will be missed. Therefore, maximising community participation and engagement is key for the effective conduct of community-based research. In this paper, we present lessons learnt over two decades of conducting research in 7 rural districts in the Brong Ahafo region of Ghana with an estimated population of around 600,000. The trials which were mainly in the area of Maternal, Neonatal and Child Health were conducted by the Kintampo Health Research Centre (KHRC) in collaboration with the London School of Hygiene and Tropical Medicine (LSHTM). METHODS The four core strategies which were used were formative research methods, the formation of the Information, Education and Communication (IEC) team to serve as the main link between the research team and the community, recruitment of field workers from the communities within which they lived, and close collaboration with national and regional stakeholders. RESULTS These measures allowed trust to be built between the community members and the research team and ensured that potential misconceptions which came up in the communities were promptly dealt with through the IEC team. The decision to place field workers in the communities from which they came and their knowledge of the local language created trust between the research team and the community. The close working relationship between the District health authorities and the Kintampo Health Research Centre supported the acceptance of the research in the communities as the District Health Authorities were respected and trusted. CONCLUSION The successes achieved during the past 2 decades of collaboration between LSHTM and KHRC in conducting community-based field trials were based on involving the community in research projects. Community participation and engagement helped not only to identify the pertinent issues, but also enabled the communities and research team to contribute towards efforts to address challenges.
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Affiliation(s)
- Sam Newton
- School of Public Health, Kwame Nkrumah University of Science and Technology, Private Mail Bag, Kumasi, Ghana.
| | - Guus Ten Asbroek
- Department of Global Health, Amsterdam University Medical Centers, Location AMC, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, 1105 BP, Amsterdam, The Netherlands
| | - Zelee Hill
- Institute of Child Health, Amsterdam, The Netherlands
| | | | - Seyi Soremekun
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Betty Kirkwood
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Kinshella MLW, Omar S, Scherbinsky K, Vidler M, Magee LA, von Dadelszen P, Moore SE, Elango R. Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review, Meta-Analysis and Evidence Map. Nutrients 2021; 13:472. [PMID: 33573262 PMCID: PMC7912620 DOI: 10.3390/nu13020472] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/26/2021] [Indexed: 01/08/2023] Open
Abstract
The placenta is a vital, multi-functional organ that acts as an interface between maternal and fetal circulation during pregnancy. Nutritional deficiencies during pregnancy alter placental development and function, leading to adverse pregnancy outcomes, such as pre-eclampsia, infants with small for gestational age and low birthweight, preterm birth, stillbirths and maternal mortality. Maternal nutritional supplementation may help to mitigate the risks, but the evidence base is difficult to navigate. The primary purpose of this umbrella review is to map the evidence on the effects of maternal nutritional supplements and dietary interventions on pregnancy outcomes related to placental disorders and maternal mortality. A systematic search was performed on seven electronic databases, the PROSPERO register and references lists of identified papers. The results were screened in a three-stage process based on title, abstract and full-text by two independent reviewers. Randomized controlled trial meta-analyses on the efficacy of maternal nutritional supplements or dietary interventions were included. There were 91 meta-analyses included, covering 23 types of supplements and three types of dietary interventions. We found evidence that supports supplementary vitamin D and/or calcium, omega-3, multiple micronutrients, lipid-based nutrients, and balanced protein energy in reducing the risks of adverse maternal and fetal health outcomes. However, these findings are limited by poor quality of evidence. Nutrient combinations show promise and support a paradigm shift to maternal dietary balance, rather than single micronutrient deficiencies, to improve maternal and fetal health. The review is registered at PROSPERO (CRD42020160887).
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
| | - Shazmeen Omar
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
| | - Kerri Scherbinsky
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 0B3, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
| | - Laura A. Magee
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
- Department of Women & Children’s Health, King’s College London, London WC2R 2LS, UK;
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, BC V6Z 2K8, Canada; (M.-L.W.K.); (S.O.); (K.S.); (M.V.); (L.A.M.); (P.v.D.)
- Department of Women & Children’s Health, King’s College London, London WC2R 2LS, UK;
| | - Sophie E. Moore
- Department of Women & Children’s Health, King’s College London, London WC2R 2LS, UK;
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, P.O. Box 273 Banjul, The Gambia
| | - Rajavel Elango
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 0B3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Division of Neonatology, BC Women’s Hospital and Health Centre, Vancouver, BC V6H 3N1, Canada
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Moreno-Fernandez J, Ochoa JJ, Lopez-Frias M, Diaz-Castro J. Impact of Early Nutrition, Physical Activity and Sleep on the Fetal Programming of Disease in the Pregnancy: A Narrative Review. Nutrients 2020; 12:nu12123900. [PMID: 33419354 PMCID: PMC7766505 DOI: 10.3390/nu12123900] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
Early programming is the adaptation process by which nutrition and environmental factors alter development pathways during prenatal growth, inducing changes in postnatal metabolism and diseases. The aim of this narrative review, is evaluating the current knowledge in the scientific literature on the effects of nutrition, environmental factors, physical activity and sleep on development pathways. If in utero adaptations were incorrect, this would cause a mismatch between prenatal programming and adulthood. Adequate caloric intake, protein, mineral, vitamin, and long-chain fatty acids, have been noted for their relevance in the offspring brain functions and behavior. Fetus undernutrition/malnutrition causes a delay in growth and have detrimental effects on the development and subsequent functioning of the organs. Pregnancy is a particularly vulnerable period for the development of food preferences and for modifications in the emotional response. Maternal obesity increases the risk of developing perinatal complications and delivery by cesarean section and has long-term implications in the development of metabolic diseases. Physical exercise during pregnancy contributes to overall improved health post-partum. It is also interesting to highlight the relevance of sleep problems during pregnancy, which influence adequate growth and fetal development. Taking into account these considerations, we conclude that nutrition and metabolic factors during early life play a key role of health promotion and public health nutrition programs worldwide to improve the health of the offspring and the health costs of hospitalization.
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Affiliation(s)
- Jorge Moreno-Fernandez
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, E-18071 Granada, Spain; (J.M.-F.); (M.L.-F.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, E-18071 Granada, Spain
| | - Julio J. Ochoa
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, E-18071 Granada, Spain; (J.M.-F.); (M.L.-F.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, E-18071 Granada, Spain
- Correspondence: ; Tel.: +34-958-241-000 (ext. 20317)
| | - Magdalena Lopez-Frias
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, E-18071 Granada, Spain; (J.M.-F.); (M.L.-F.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, E-18071 Granada, Spain
| | - Javier Diaz-Castro
- Department of Physiology, Faculty of Pharmacy, Campus Universitario de Cartuja, E-18071 Granada, Spain; (J.M.-F.); (M.L.-F.); (J.D.-C.)
- Institute of Nutrition and Food Technology “José Mataix Verdú”, University of Granada, E-18071 Granada, Spain
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Manfredini M. The effects of nutrition on maternal mortality: Evidence from 19th-20th century Italy. SSM Popul Health 2020; 12:100678. [PMID: 33102681 PMCID: PMC7569323 DOI: 10.1016/j.ssmph.2020.100678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/05/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
The role of nutrition on maternal mortality has been long debated in the historical and scientific literature. Some scholars refute any role of nutrition and diet in the decline of maternal mortality, privileging other causes such as the diffusion of professional midwifery and medical and scientific progress, while others are more open-minded about some possible nutritional effects. The present paper investigates the relationship between maternal mortality and nutrition in Italy between 1887 and 1955 with the purpose to provide new elements and new data to the knowledge of such an association. Using time-series techniques on the official data provided by the National Institute of Statistics, the analysis demonstrates that the trend of maternal mortality was affected by both long- and short-term dynamics of the average daily caloric intake of the Italian population once controlled for the economic situation, here proxied by the annual time series of the GDP per capita. The same analysis clarifies that the impact of nutrition is just one element of a complex picture in which the major role is played by medical advances and scientific progress. The introduction of sulphonamides, in the second half of the thirties of the twentieth century, emerges, in fact, as the turning point in the fight against maternal death. Scientific advances strongly affected the trend of maternal deaths in Italy. Nutrition had a role in the decline of maternal mortality once controlled for GDP per capita. Both the short and long dynamics of daily calorie intake affected maternal mortality. The GDP per capita did not show any significant effect on maternal mortality.
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Affiliation(s)
- Matteo Manfredini
- Department of Chemistry, Life Science, and Environmental Sustainability, Parco Area delle Scienze, 11/A, 43124, Parma, Italy
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10
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Sommer A. An Accidental Nutritionist. Annu Rev Nutr 2020; 40:1-23. [PMID: 32966182 DOI: 10.1146/annurev-nutr-111919-033415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
My career as an accidental nutritionist began with my immersion in cholera control, a cyclone disaster, a smallpox epidemic, and formal training in ophthalmology and epidemiology. Interest in blindness prevention inexplicably led me to (re)pioneer the effects, treatment, and prevention of vitamin A deficiency, while faced with intense criticism by many leading scientists in the nutrition community. The resulting efforts by the World Health Organization and UNICEF in support of programs for the global control of vitamin A deficiency still face vocal opposition by some senior scientists, despite having been estimated to have saved tens of millions of children from unnecessary death and blindness. This entire journey was largely an accident!
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Affiliation(s)
- Alfred Sommer
- School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA;
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11
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Fasawe O, Adekeye O, Carmone AE, Dahunsi O, Kalaris K, Storey A, Ubani O, Wiwa O. Applying a Client-centered Approach to Maternal and Neonatal Networks of Care: Case Studies from Urban and Rural Nigeria. Health Syst Reform 2020; 6:e1841450. [PMID: 33270477 DOI: 10.1080/23288604.2020.1841450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework-Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation-to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services.
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Affiliation(s)
| | | | - Andy E Carmone
- Clinton Health Access Initiative , Boston, Massachusetts, USA
| | | | | | - Andrew Storey
- Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Osy Ubani
- Lagos Mainland Local Government Area (LGA), Lagos State Ministry of Health , Lagos, Nigeria
| | - Owens Wiwa
- Clinton Health Access Initiative , Abuja, Nigeria
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Oh C, Keats EC, Bhutta ZA. Vitamin and Mineral Supplementation During Pregnancy on Maternal, Birth, Child Health and Development Outcomes in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients 2020; 12:E491. [PMID: 32075071 PMCID: PMC7071347 DOI: 10.3390/nu12020491] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/29/2020] [Accepted: 02/05/2020] [Indexed: 12/14/2022] Open
Abstract
Almost two billion people are deficient in key vitamins and minerals, mostly women and children in low- and middle-income countries (LMICs). Deficiencies worsen during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child, but could be mitigated by interventions like micronutrient supplementation. To our knowledge, this is the first systematic review that aimed to compile evidence from both efficacy and effectiveness trials, evaluating different supplementation interventions on maternal, birth, child health, and developmental outcomes. We evaluated randomized controlled trials and quasi-experimental studies published since 1995 in peer-reviewed and grey literature that assessed the effects of calcium, vitamin A, iron, vitamin D, and zinc supplementation compared to placebo/no treatment; iron-folic (IFA) supplementation compared to folic acid only; multiple micronutrient (MMN) supplementation compared to IFA; and lipid-based nutrient supplementation (LNS) compared to MMN supplementation. Seventy-two studies, which collectively involved 314 papers (451,723 women), were included. Meta-analyses showed improvement in several key birth outcomes, such as preterm birth, small-for-gestational age (SGA) and low birthweight with MMN supplementation, compared to IFA. MMN also improved child outcomes, including diarrhea incidence and retinol concentration, which are findings not previously reported. Across all comparisons, micronutrient supplementation had little to no effect on mortality (maternal, neonatal, perinatal, and infant) outcomes, which is consistent with other systematic reviews. IFA supplementation showed notable improvement in maternal anemia and the reduction in low birthweight, whereas LNS supplementation had no apparent effect on outcomes; further research that compares LNS and MMN supplementation could help understand differences with these commodities. For single micronutrient supplementation, improvements were noted in only a few outcomes, mainly pre-eclampsia/eclampsia (calcium), maternal anemia (iron), preterm births (vitamin D), and maternal serum zinc concentration (zinc). These findings highlight that micronutrient-specific supplementation should be tailored to specific groups or needs for maximum benefit. In addition, they further contribute to the ongoing discourse of choosing antenatal MMN over IFA as the standard of care in LMICs.
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Affiliation(s)
- Christina Oh
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (C.O.); (E.C.K.)
| | - Emily C. Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (C.O.); (E.C.K.)
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (C.O.); (E.C.K.)
- Centre of Excellence in Women and Child’s Health, Aga Khan University, Karachi 74800, Pakistan
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Cavallaro FL, Hurt LS, Cresswell JA, Edmond K, Amenga-Etego S, Kirkwood BR, Ronsmans C. Testing the assumptions of an indicator of unmet need for obstetric surgery in Ghana: A cross-sectional study of linked hospital and population-based delivery data. Birth 2019; 46:638-647. [PMID: 31512773 DOI: 10.1111/birt.12452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/16/2019] [Accepted: 08/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life-saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%-2% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications. METHODS We used linked hospital and population-based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education. RESULTS A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women with no AMI diagnosis died of AMI-related causes. Among the 50 148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post-secondary education (P < .001). However, there was no association between AMI-related mortality and education (P = .546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%-0.92%), below the assumed 1% minimum threshold. DISCUSSION Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life-saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.
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Affiliation(s)
- Francesca L Cavallaro
- Institut de Recherche pour le Développement, Institut de Recherche pour le Développement, Paris, France
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14
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Haslam A, Prasad V, Livingston C. Medical reversals in low- and middle-income countries. Int J Health Plann Manage 2019; 35:631-638. [PMID: 31710144 DOI: 10.1002/hpm.2937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Low- to middle-income countries (LMICs) often have limited budgets for health care, and as such, they need to prioritize health care interventions that are evidence based. However, sometimes, interventions are implemented despite a lack of supporting evidence because of a perceived biologic plausibility or because they have worked in other populations. Later, some of these interventions are shown to either lack benefit or are harmful in randomized studies, which we call a medical reversal. MAIN BODY In this paper, we discuss a variety of medical reversals in LMICs, ranging from tuberculosis to nutrition to malaria to septic shock. These practices were previously identified, but we wish to highlight those that are most relevant to LMICs. CONCLUSION Identifying and eliminating these practices will help in better allocation of limited health care resources and dollars in LMICs.
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Affiliation(s)
- Alyson Haslam
- Knight Cancer Institute, Oregon Health & Science University, Oregon, Portland, USA
| | - Vinay Prasad
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Oregon, Portland, USA.,Center for Health Care Ethics, Oregon Health & Science University, Oregon, Portland, USA
| | - Catherine Livingston
- Family Medicine School of Medicine, Oregon Health & Science University, Oregon, Portland, USA
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Gabrysch S, Nesbitt RC, Schoeps A, Hurt L, Soremekun S, Edmond K, Manu A, Lohela TJ, Danso S, Tomlin K, Kirkwood B, Campbell OMR. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials. Lancet Glob Health 2019; 7:e1074-e1087. [PMID: 31303295 PMCID: PMC6639244 DOI: 10.1016/s2214-109x(19)30165-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/12/2019] [Accepted: 03/20/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Maternal and perinatal mortality are still unacceptably high in many countries despite steep increases in facility birth. The evidence that childbirth in facilities reduces mortality is weak, mainly because of the scarcity of robust study designs and data. We aimed to assess this link by quantifying the influence of major determinants of facility birth (cluster-level facility birth, wealth, education, and distance to childbirth care) on several mortality outcomes, while also considering quality of care. METHODS Our study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based cluster-randomised controlled trials in Brong Ahafo, Ghana. In addition, we specifically collected data to assess quality of care at all 64 childbirth facilities in the study area. Outcomes were direct maternal mortality, perinatal mortality, first-day and early neonatal mortality, and antepartum and intrapartum stillbirth. We calculated cluster-level facility birth as the percentage of facility births in a woman's village over the preceding 2 years, and we computed distances from women's regular residence to health facilities in a geospatial database. Associations between determinants of facility birth and mortality outcomes were assessed in crude and multivariable multilevel logistic regression models. We stratified perinatal mortality effects by three policy periods, using April 1, 2005, and July 1, 2008, as cutoff points, when delivery-fee exemption and free health insurance were introduced in Ghana. These policies increased facility birth and potentially reduced quality of care. FINDINGS Higher proportions of facility births in a cluster were not linked to reductions in any of the mortality outcomes. In women who were wealthier, facility births were much more common than in those who were poorer, but mortality was not lower among them or their babies. Women with higher education had lower mortality risks than less-educated women, except first-day and early neonatal mortality. A substantially higher proportion of women living in areas closer to childbirth facilities had facility births and caesarean sections than women living further from childbirth facilities, but mortality risks were not lower despite this increased service use. Among women who lived in areas closer to facilities offering comprehensive emergency obstetric care (CEmOC), emergency newborn care, or high-quality routine care, or to facilities that had providers with satisfactory competence, we found a lower risk of intrapartum stillbirth (14·2 per 1000 deliveries at >20 km from a CEmOC facility vs 10·4 per 1000 deliveries at ≤1 km; odds ratio [OR] 1·13, 95% CI 1·06-1·21) and of composite mortality outcomes than among women living in areas where these services were further away. Protective effects of facility birth were restricted to the two earlier policy periods (from June 1, 2003, to June 30, 2008), whereas there was evidence for higher perinatal mortality with increasing wealth (OR 1·09, 1·03-1·14) and lower perinatal mortality with increasing distance from childbirth facilities (OR 0·93, 0·89-0·98) after free health insurance was introduced in July 1, 2008. INTERPRETATION Facility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births. FUNDING The Baden-Württemberg Foundation, the Daimler and Benz Foundation, the European Social Fund and Ministry of Science, Research, and the Arts Baden-Württemberg, WHO, US Agency for International Development, Save the Children, the Bill & Melinda Gates Foundation, and the UK Department for International Development.
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Affiliation(s)
- Sabine Gabrysch
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Research Department 2, Potsdam Institute for Climate Impact Research, Potsdam, Germany; Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Robin C Nesbitt
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Anja Schoeps
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Lisa Hurt
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Seyi Soremekun
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Observational and Pragmatic Research Institute, Singapore
| | - Karen Edmond
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alexander Manu
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Kintampo Health Research Centre, Kintampo, Ghana; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Terhi J Lohela
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany; Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Samuel Danso
- Kintampo Health Research Centre, Kintampo, Ghana; University of Edinburgh Medical School, Edinburgh, UK
| | - Keith Tomlin
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Betty Kirkwood
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Sloan NL, Storey A, Fasawe O, Yakubu J, McCrystal K, Wiwa O, Lothe LJ, Grepstad M. Advancing Survival in Nigeria: A Pre-post Evaluation of an Integrated Maternal and Neonatal Health Program. Matern Child Health J 2019; 22:986-997. [PMID: 29427018 PMCID: PMC5976701 DOI: 10.1007/s10995-018-2476-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction Nigeria contributes more obstetric, postpartum and neonatal deaths and stillbirths globally than any other country. The Clinton Health Access Initiative in partnership with the Nigerian Federal Ministry of Health and the state Governments of Kano, Katsina, and Kaduna implemented an integrated Maternal and Neonatal Health program from July 2014. Up to 90% women deliver at home in Northern Nigeria, where maternal mortality ratio and neonatal mortality rates (MMR and NMR) are high and severe challenges to improving survival exist. Methods Community-based leaders (“key informants”) reported monthly vital events. Pre-post comparisons of later (months 16–18) with conservative baseline (months 7–9) rates were used to assess change in MMR, NMR, perinatal mortality (PMR) and stillbirth. Two-tailed cross-tabulations and unadjusted and adjusted logistic regression analyses were conducted. Results Data on 147,455 births (144,641 livebirths and 4275 stillbirths) were analyzed. At endline (months 16–18), MMR declined 37% (OR 0.629, 95% CI 0.490–0.806, p ≤ 0.0003) vs. baseline 440/100,000 births (months 7–9). NMR declined 43% (OR 0.574, 95% CI 0.503–0.655, p < 0.0001 vs. baseline 15.2/1000 livebirths. Stillbirth rates declined 15% (OR 0.850, 95% CI 0.768–0.941, p = 0.0018) vs. baseline 21.1/1000 births. PMR declined 27% (OR 0.733, 95% CI 0.676–0.795, p < 0.0001) vs. baseline 36.0/1000 births. Adjusted results were similar. Discussion The findings are similar to the Cochrane Review effects of community-based interventions and indicate large survival improvements compared to much slower global and flat national trends. Key informant data have limitations, however, their limitations would have little effect on the results magnitude or significance.
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Affiliation(s)
| | - Andrew Storey
- Clinton Health Access Initiative, 383 Dorcester Avenue, Suite 400, Boston, MA, 02127, USA
| | - Olufunke Fasawe
- Clinton Health Access Initiative, 7B Ganges St. Maitama, Abuja, Nigeria
| | - Jamila Yakubu
- Clinton Health Access Initiative, 7B Ganges St. Maitama, Abuja, Nigeria
| | - Kelly McCrystal
- Clinton Health Access Initiative, 383 Dorcester Avenue, Suite 400, Boston, MA, 02127, USA
| | - Owens Wiwa
- Clinton Health Access Initiative, 7B Ganges St. Maitama, Abuja, Nigeria
| | - Lene Jeanette Lothe
- Norwegian Agency for Development Cooperation, Bygdøy Allé 2, 0257, Oslo, Norway
| | - Mari Grepstad
- Norwegian Agency for Development Cooperation, Bygdøy Allé 2, 0257, Oslo, Norway
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Fox EL, Davis C, Downs SM, Schultink W, Fanzo J. Who is the Woman in Women's Nutrition? A Narrative Review of Evidence and Actions to Support Women's Nutrition throughout Life. Curr Dev Nutr 2018. [PMCID: PMC6349991 DOI: 10.1093/cdn/nzy076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nutrition interventions that target mothers alone inadequately address women's needs across their lives: during adolescence, preconception, and in later years of life. They also fail to capture nulliparous women. The extent to which nutrition interventions effectively reach women throughout the life course is not well documented. In this comprehensive narrative review, we summarized the impact and delivery platforms of nutrition-specific and nutrition-sensitive interventions targeting adolescent girls, women of reproductive age (nonpregnant, nonlactating), pregnant and lactating women, women with young children <5 y, and older women, with a focus on nutrition interventions delivered in low- and middle-income countries. We found that although there were many effective interventions that targeted women's nutrition, they largely targeted women who were pregnant and lactating or with young children. There were major gaps in the targeting of interventions to older women. For the delivery platforms, community-based settings, compared with facility-based settings, more equitably reached women across the life course, including adolescents, women of reproductive age, and older women. Nutrition-sensitive approaches were more often delivered in community-based settings; however, the evidence of their impact on women's nutritional outcomes was less clear. We also found major research and programming gaps relative to targeting overweight, obesity, and noncommunicable disease. We conclude that focused efforts on women during pregnancy and in the first couple of years postpartum fail to address the interrelation and compounding nature of nutritional disadvantages that are perpetuated across many women's lives. In order for policies and interventions to more effectively address inequities faced by women, and not only women as mothers, it is essential that they reflect on how, when, and where to engage with women across the life course.
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Affiliation(s)
- Elizabeth L Fox
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Claire Davis
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Shauna M Downs
- Department of Health Systems and Policy, School of Public Health, Rutgers University, New Brunswick, NJ
| | | | - Jessica Fanzo
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
- Nitze School of Advanced International Studies, Johns Hopkins University, Washington, DC
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Abekah-Nkrumah G, Issiaka S, Virgil L, Ermel J. A review of the process of knowledge transfer and use of evidence in reproductive and child health in Ghana. Health Res Policy Syst 2018; 16:75. [PMID: 30075725 PMCID: PMC6090619 DOI: 10.1186/s12961-018-0350-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 07/13/2018] [Indexed: 04/07/2023] Open
Abstract
Background The paper carries out a situational analysis to examine the production, dissemination and utilisation of reproductive and child health-related evidence to inform policy formulation in Ghana’s health sector. Methods The study used Wald’s model of knowledge production, transfer and utilisation as a conceptual model to collect relevant data via interviews and administration of questionnaire to a network of persons who either previously or currently hold policy-relevant positions in Ghana’s health sector. Additional data was also gathered through a scoping review of the knowledge transfer and research utilisation literature, existing reproductive and child health policies, protocols and guidelines and information available on the websites of relevant institutions in Ghana’s health sector. Results The findings of the study suggest that the health sector in Ghana has major strengths (strong knowledge production capacity, a positive environment for the promotion of evidence-informed policy) and opportunities (access to major donors who have the resources to fund good quality research and access to both local and international networks for collaborative research). What remains a challenge, however, is the absence of a robust institutional-wide mechanism for collating research needs and communicating these to researchers, communicating research findings in forms that are friendlier to policy-makers and the inability to incorporate funding for research into the budget of the health sector. Conclusion The study concludes, admonishing the Ministry of Health and its agencies to leverage on the existing strengths and opportunities to address the identified challenges.
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Affiliation(s)
- Gordon Abekah-Nkrumah
- Department of Public Administration and Health Services Management, University of Ghana Business School, P. O. Box 72, Legon, Accra, Ghana.
| | - Sombié Issiaka
- West African Health Organisation, 01 BP 153, Bobo-Dioulasso 01, Burkina Faso
| | - Lokossou Virgil
- West African Health Organisation, 01 BP 153, Bobo-Dioulasso 01, Burkina Faso
| | - Johnson Ermel
- West African Health Organisation, 01 BP 153, Bobo-Dioulasso 01, Burkina Faso
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Prentice S. They Are What You Eat: Can Nutritional Factors during Gestation and Early Infancy Modulate the Neonatal Immune Response? Front Immunol 2017; 8:1641. [PMID: 29234319 PMCID: PMC5712338 DOI: 10.3389/fimmu.2017.01641] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/09/2017] [Indexed: 12/17/2022] Open
Abstract
The ontogeny of the human immune system is sensitive to nutrition even in the very early embryo, with both deficiency and excess of macro- and micronutrients being potentially detrimental. Neonates are particularly vulnerable to infectious disease due to the immaturity of the immune system and modulation of nutritional immunity may play a role in this sensitivity. This review examines whether nutrition around the time of conception, throughout pregnancy, and in early neonatal life may impact on the developing infant immune system.
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Affiliation(s)
- Sarah Prentice
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
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20
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Parker WA, Mchiza ZJ, Sewpaul R, Job N, Chola L, Sithole M, Labadarios D. The impact of sociodemography, diet, and body size on serum retinol in women 16-35 years of age: SANHANES-1. Ann N Y Acad Sci 2017; 1416:48-65. [PMID: 29125179 DOI: 10.1111/nyas.13504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/25/2017] [Accepted: 09/04/2017] [Indexed: 11/30/2022]
Abstract
To determine the current vitamin A status of a nationally representative sample of women aged 16-35 years, compare it with previous national data, and determine the impact of sociodemography, diet, and body size on vitamin A status, we performed secondary analysis of data on South African women who participated in the first South African National Health and Nutrition Examination Survey (SANHANES-1). Vitamin A status was assessed by serum retinol, and the findings are reported as means and prevalences with corresponding 95% confidence intervals. Overall, the age-standardized vitamin A deficiency prevalence was 11.7%, a decrease from previous national data, but serum retinol levels remained lower than in other developing countries. Overall, unweighted, multilevel, multivariate logistic regression showed that vitamin A deficiency was influenced by race only (odds ratio (OR) = 1.89, P = 0.031), while weighted multiple logistic regression for 16- to 18-year-olds showed that vitamin A deficiency was influenced by locality (OR = 9.83, P = 0.005) and household income (intermediate (OR = 0.2, P = 0.022) and upper (OR = 0.25, P = 0.049)). Despite the decreased prevalence, vitamin A deficiency remains a moderate public health problem in the country. Opportunities for targeted interventions have been identified.
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Affiliation(s)
- Whadi-Ah Parker
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Zandile J Mchiza
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Ronel Sewpaul
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Nophiwe Job
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Lumbwe Chola
- PRICELESS SA, University of Witwatersrand School of Public Health, Parktown, South Africa
| | - Moses Sithole
- Centre for Science, Technology and Innovation Indicators, Human Sciences Research Council, Cape Town, South Africa
| | - Demetre Labadarios
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
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21
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Haider BA, Sharma R, Bhutta ZA. Neonatal vitamin A supplementation for the prevention of mortality and morbidity in term neonates in low and middle income countries. Cochrane Database Syst Rev 2017; 2:CD006980. [PMID: 28234402 PMCID: PMC6464547 DOI: 10.1002/14651858.cd006980.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Vitamin A deficiency is a major public health problem in low and middle income countries. Vitamin A supplementation in children six months of age and older has been found to be beneficial, but no effect of supplementation has been noted for children between one and five months of age. Supplementation during the neonatal period has been suggested to have an impact by increasing body stores in early infancy. OBJECTIVES To evaluate the role of vitamin A supplementation for term neonates in low and middle income countries with respect to prevention of mortality and morbidity. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE via PubMed (1966 to 13 March 2016), Embase (1980 to 13 March 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 13 March 2016). We also searched clinical trials databases, conference proceedings and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials. Also trials with a factorial design. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted study data. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence. MAIN RESULTS We included 12 trials (168,460 neonates) in this review, with only a few trials reporting disaggregated data for term infants. Therefore, we analysed data and presented estimates for term infants (when specified) and for all infants.Data for term neonates from three studies did not show a statistically significant effect on the risk of infant mortality at six months in the vitamin A group compared with the control group (typical risk ratio (RR) 0.80; 95% confidence interval (CI) 0.54 to 1.18; I2 = 63%). Analysis of data for all infants from 11 studies revealed no evidence of a significant reduction in the risk of infant mortality at six months among neonates supplemented with vitamin A compared with control neonates (typical RR 0.98, 95% CI 0.89 to 1.07; I2 = 47%). We observed similar results for infant mortality at 12 months of age with no significant effect of vitamin A compared with control (typical RR 1.04, 95% CI 0.94 to 1.15; I2 = 47%). Limited data were available for the outcomes of cause-specific mortality and morbidity, vitamin A deficiency, anaemia and adverse events. AUTHORS' CONCLUSIONS Given the high burden of death among children younger than five years of age in low and middle income countries, and the fact that mortality in infancy is a major contributory cause, it is critical to obtain sound scientific evidence of the effect of vitamin A supplementation during the neonatal period on infant mortality and morbidity. Evidence provided in this review does not indicate a potential beneficial effect of vitamin A supplementation among neonates at birth in reducing mortality during the first six months or 12 months of life. Given this finding and the absence of a clear indication of the biological mechanism through which vitamin A could affect mortality, along with substantial conflicting findings from individual studies conducted in settings with potentially varying levels of maternal vitamin A deficiency and infant mortality, absence of follow-up studies assessing any long-term impact of a bulging fontanelle after supplementation and the finding of a potentially harmful effect among female infants, additional research is warranted before a decision can be reached regarding policy recommendations for this intervention.
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Affiliation(s)
- Batool A Haider
- Harvard School of Public HealthDepartment of Global Health and Population677 Huntington AvenueBostonMAUSA02115
| | - Renee Sharma
- Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
| | - Zulfiqar A Bhutta
- Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
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The Risk of Sexually Transmitted Infection and Its Influence on Condom Use among Pregnant Women in the Kintampo North Municipality of Ghana. JOURNAL OF SEXUALLY TRANSMITTED DISEASES 2017; 2017:8642685. [PMID: 28246570 PMCID: PMC5299183 DOI: 10.1155/2017/8642685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/30/2016] [Accepted: 12/27/2016] [Indexed: 12/20/2022]
Abstract
Sexually transmitted infection (STI) affects the reproductive health of both men and women worldwide. Condoms are important part of the available preventive strategies for STI control. The lack of proper risk-perception continues to impede women's ability to negotiate condom use with their partners. This paper is the outcome of secondary analysis of data collected in a cross-sectional survey that explored the perception of risk of STI and its influence on condom use among 504 pregnant women attending antenatal clinic at two health facilities in the Kintampo North Municipality. Consecutively, three Focus Group Discussions were conducted among 22 pregnant women which was analyzed using thematic analysis technique. Multivariate logistic regression analysis was used to identify possible predictors of condom use and risk of STI. Respondents mean age was 26.0 ± 5.9 years. 47% of respondents self-identified themselves as high risk for contracting STI, 50% of whom were married. High risk status (OR = 2.1, 95% CI: 1.1-4.4), ability to ask for condoms during sex (OR = 0.3, 95% CI: 0.1-0.73), and partner's approval of condom use (OR = 0.2, 95% CI: 0.01-0.05) were independent predictors of condom use. Condom use (OR 2.9 (1.5-5.7); p = 0.001) and marital status (engaged, OR 2.6 (1.5-4.5); p = 0.001) were independent predictors of risk of STI. Women who self-identified themselves as high risk for STI successfully negotiated condom use with their partners. This is however influenced by partner's approval and ability to convince partner to use condoms. Self-assessment of STI risk by women and the cooperation of male partners remain critical.
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Imdad A, Ahmed Z, Bhutta ZA. Vitamin A supplementation for the prevention of morbidity and mortality in infants one to six months of age. Cochrane Database Syst Rev 2016; 9:CD007480. [PMID: 27681486 PMCID: PMC6457829 DOI: 10.1002/14651858.cd007480.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Vitamin A deficiency is a significant public health problem in low- and middle-income countries. Vitamin A supplementation provided to infants less than six months of age is one of the strategies to improve the nutrition of infants at high risk of vitamin A deficiency and thus potentially reduce their mortality and morbidity. OBJECTIVES To evaluate the effect of synthetic vitamin A supplementation in infants one to six months of age in low- and middle-income countries, irrespective of maternal antenatal or postnatal vitamin A supplementation status, on mortality, morbidity and adverse effects. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed (1966 to 5 March 2016), Embase (1980 to 5 March 2016) and CINAHL (1982 to 5 March 2016). We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised or quasi-randomised, individually or cluster randomised trials involving synthetic vitamin A supplementation compared to placebo or no intervention provided to infants one to six months of age were eligible. DATA COLLECTION AND ANALYSIS Two review authors assessed the studies for eligibility and assessed their risk of bias and collected data on outcomes. MAIN RESULTS The review included 12 studies (reported in 22 publications). The included studies assigned 24,846 participants aged one to six months to vitamin A supplementation or control group. There was no effect of vitamin A supplementation for the primary outcome of all-cause mortality based on seven studies that included 21,339 (85%) participants (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.25; I2 = 0%; test for heterogeneity: P = 0.79; quality of evidence: moderate). Also, there was no effect of vitamin A supplementation on mortality or morbidity due to diarrhoea and respiratory tract infection. There was an increased risk of bulging fontanelle within 24 to 72 hours of supplementation in the vitamin A group compared to control (RR 3.10, 95% CI 1.89 to 5.09; I2 = 9%, test for heterogeneity: P = 0.36; quality of evidence: high). There was no reported subsequent increased risk of death, convulsions or irritability in infants who developed bulging fontanelle after vitamin A supplementation, and it resolved in most cases within 72 hours. There was no increased risk of other adverse effects such as vomiting, irritability, diarrhoea, fever and convulsions in the vitamin A supplementation group compared to control. Vitamin A supplementation did not have any statistically significant effect on vitamin A deficiency (RR 0.86, 95% CI 0.70 to 1.06; I2 = 27%; test for heterogeneity: P = 0.25; quality of evidence: moderate). AUTHORS' CONCLUSIONS There is no convincing evidence that vitamin A supplementation for infants one to six months of age results in a reduction in infant mortality or morbidity in low- and middle-income countries. There is an increased risk of bulging fontanelle with vitamin A supplementation in this age group; however, there were no reported subsequent complications because of this adverse effect.
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Affiliation(s)
- Aamer Imdad
- Vanderbilt University School of MedicineDepartment of Pediatrics, D. Brent Polk Division of Gastroenterology, Hepatology and NutritionNashvilleTNUSA37212
| | | | - Zulfiqar A Bhutta
- Hospital for Sick ChildrenCenter for Global Child HealthTorontoONCanadaM5G A04
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Baqui AH, Mitra DK, Begum N, Hurt L, Soremekun S, Edmond K, Kirkwood B, Bhandari N, Taneja S, Mazumder S, Nisar MI, Jehan F, Ilyas M, Ali M, Ahmed I, Ariff S, Soofi SB, Sazawal S, Dhingra U, Dutta A, Ali SM, Ame SM, Semrau K, Hamomba FM, Grogan C, Hamer DH, Bahl R, Yoshida S, Manu A. Neonatal mortality within 24 hours of birth in six low- and lower-middle-income countries. Bull World Health Organ 2016; 94:752-758B. [PMID: 27843165 PMCID: PMC5043199 DOI: 10.2471/blt.15.160945] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 05/06/2016] [Accepted: 05/09/2016] [Indexed: 12/02/2022] Open
Abstract
Objective To estimate neonatal mortality, particularly within 24 hours of birth, in six low- and lower-middle-income countries. Methods We analysed epidemiological data on a total of 149 570 live births collected between 2007 and 2013 in six prospective randomized trials and a cohort study from predominantly rural areas of Bangladesh, Ghana, India, Pakistan, the United Republic of Tanzania and Zambia. The neonatal mortality rate and mortality within 24 hours of birth were estimated for all countries and mortality within 6 hours was estimated for four countries with available data. The findings were compared with published model-based estimates of neonatal mortality. Findings Overall, the neonatal mortality rate observed at study sites in the six countries was 30.5 per 1000 live births (range: 13.6 in Zambia to 47.4 in Pakistan). Mortality within 24 hours was 14.1 per 1000 live births overall (range: 5.1 in Zambia to 20.1 in India) and 46.3% of all neonatal deaths occurred within 24 hours (range: 36.2% in Pakistan to 65.5% in the United Republic of Tanzania). Mortality in the first 6 hours was 8.3 per 1000 live births, i.e. 31.9% of neonatal mortality. Conclusion Neonatal mortality within 24 hours of birth in predominantly rural areas of six low- and lower-middle-income countries was higher than model-based estimates for these countries. A little under half of all neonatal deaths occurred within 24 hours of birth and around one third occurred within 6 hours. Implementation of high-quality, effective obstetric and early newborn care should be a priority in these settings.
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Affiliation(s)
- Abdullah H Baqui
- International Center for Maternal and Newborn Health, Johns Hopkins University, Baltimore, United States of America (USA)
| | - Dipak K Mitra
- International Center for Maternal and Newborn Health, Johns Hopkins University, Baltimore, United States of America (USA)
| | - Nazma Begum
- International Center for Maternal and Newborn Health, Johns Hopkins University, Baltimore, United States of America (USA)
| | - Lisa Hurt
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | - Seyi Soremekun
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, England
| | - Karen Edmond
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Betty Kirkwood
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, England
| | - Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Sarmila Mazumder
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Muhammad Imran Nisar
- Department of Paediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Fyezah Jehan
- Department of Paediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Muhammad Ilyas
- Department of Paediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Murtaza Ali
- Department of Paediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Imran Ahmed
- Department of Paediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Department of Paediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sajid B Soofi
- Department of Paediatric and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sunil Sazawal
- International Center for Maternal and Newborn Health, Johns Hopkins University, Baltimore, United States of America (USA)
| | - Usha Dhingra
- International Center for Maternal and Newborn Health, Johns Hopkins University, Baltimore, United States of America (USA)
| | - Arup Dutta
- Center for Public Health Kinetics, New Delhi, India
| | - Said M Ali
- Public Health Laboratory Ivo de Carneri, Pemba, United Republic of Tanzania
| | - Shaali M Ame
- Public Health Laboratory Ivo de Carneri, Pemba, United Republic of Tanzania
| | | | | | | | - Davidson H Hamer
- Center for Global Health and Development, Boston University, Boston, USA
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Alexander Manu
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
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Hodgins S, Tielsch J, Rankin K, Robinson A, Kearns A, Caglia J. A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations. PLoS One 2016; 11:e0160562. [PMID: 27537281 PMCID: PMC4990268 DOI: 10.1371/journal.pone.0160562] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support. METHODS In this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies. RESULTS In the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to ¼ of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25-30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude. CONCLUSIONS Simple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage.
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Affiliation(s)
- Stephen Hodgins
- Saving Newborn Lives, Save the Children/ US, Washington, D.C., United States of America
| | - James Tielsch
- Milken Institute School of Public Health, George Washington University, Washington, D.C., United States of America
| | - Kristen Rankin
- Saving Newborn Lives, Save the Children/ US, Washington, D.C., United States of America
| | - Amber Robinson
- Department of Life Sciences, Brunel University London, London, United Kingdom
| | - Annie Kearns
- Human Care Systems, Boston, Massachusetts, United States of America
| | - Jacquelyn Caglia
- T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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The influence of distance and quality of care on place of delivery in rural Ghana. Sci Rep 2016; 6:30291. [PMID: 27506292 PMCID: PMC4978958 DOI: 10.1038/srep30291] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/22/2016] [Indexed: 11/09/2022] Open
Abstract
Facility delivery is an important aspect of the strategy to reduce maternal and newborn mortality. Geographic access to care is a strong determinant of facility delivery, but few studies have simultaneously considered the influence of facility quality, with inconsistent findings. In rural Brong Ahafo region in Ghana, we combined surveillance data on 11,274 deliveries with quality of care data from all 64 delivery facilities in the study area. We used multivariable multilevel logistic regression to assess the influence of distance and several quality dimensions on place of delivery. Women lived a median of 3.3 km from the closest delivery facility, and 58% delivered in a facility. The probability of facility delivery ranged from 68% among women living 1 km from their closest facility to 22% among those living 25 km away, adjusted for confounders. Measured quality of care at the closest facility was not associated with use, except that facility delivery was lower when the closest facility provided substandard care on the EmOC dimension. These results do not imply, however, that we should increase geographic accessibility of care without improving facility quality. While this may be successful in increasing facility deliveries, such care cannot be expected to reduce maternal and neonatal mortality.
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Manu A, Hill Z, ten Asbroek AHA, Soremekun S, Weobong B, Gyan T, Tawiah-Agyemang C, Danso S, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Increasing access to care for sick newborns: evidence from the Ghana Newhints cluster-randomised controlled trial. BMJ Open 2016; 6:e008107. [PMID: 27297006 PMCID: PMC4916576 DOI: 10.1136/bmjopen-2015-008107] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To evaluate the impact of Newhints community-based surveillance volunteer (CBSV) assessments and referrals on access to care for sick newborns and on existing inequities in access. DESIGN We evaluated a prospective cohort nested within the Newhints cluster-randomised controlled trial. SETTING Community-based intervention involving more than 750 000, predominantly rural, population in seven contiguous districts in the Brong-Ahafo Region, Ghana. PARTICIPANTS Participants were recently delivered women (from more than 120 000 women under surveillance) and their 16 168 liveborn babies. Qualitative in-depth interviews with referral narratives (IDIs) were conducted with 92 mothers, CBSVs and health facility front-desk and maternity/paediatrics ward staff. INTERVENTIONS Newhints trained and effectively supervised 475 CBSVs (existing within the Ghana Health Service) in 49 of 98 supervisory zones (clusters) to assess and refer newborns with any of the 10-key-danger signs to health facilities within the first week after birth; promote independent care seeking for sick newborns and problem-solve around barriers between November 2008 and December 2009. PRIMARY OUTCOMES The main evaluation outcomes were rates of compliance with referrals and independent care seeking for newborn illnesses. RESULTS Of 4006 sampled, 2795 (69.8%) recently delivered women received CBSV assessment visits and 279 (10.0%) newborns were referred with danger signs. Compliance with referrals was unprecedentedly high (86.0%) with women in the poorest quintile (Q1) complying better than the least poor (Q5):87.5%(Q1) vs 69.7%(Q5); p=0.038. Three-quarters went to hospitals; 18% were admitted and 58% received outpatient treatment. Some (24%) mothers were turned away at facilities and follow-on IDIs showed that some of these untreated babies subsequently died. Independent care seeking for severe newborn illness increased from 55.4% in control to 77.3% in Newhints zones, especially among Q1 where care seeking almost doubled (95.0% vs 48.6%; RR=1.94 (1.32, 2.84); p=0.001). Rates were the highest among rural residents but urban residents complied quicker. CONCLUSIONS Home visits are feasible and a potentially pro-poor approach to link sick newborns to facilities. Its effectiveness in improving survival hinges on matched improvement in facility quality of care. TRIAL REGISTRATION NUMBER NCT00623337.
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Affiliation(s)
- Alexander Manu
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Zelee Hill
- Faculty of Population Health Sciences, Institute of Global Health, University College London, London, UK
| | | | - Seyi Soremekun
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Benedict Weobong
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Thomas Gyan
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Charlotte Tawiah-Agyemang
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Samuel Danso
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Seeba Amenga-Etego
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Seth Owusu-Agyei
- Department of Maternal, Newborn and Adolescent Health cluster, Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Betty R Kirkwood
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Lohela TJ, Nesbitt RC, Manu A, Vesel L, Okyere E, Kirkwood B, Gabrysch S. Competence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana. BMJ Open 2016; 6:e010963. [PMID: 27297010 PMCID: PMC4916610 DOI: 10.1136/bmjopen-2015-010963] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. DESIGN Cross-sectional Health Facility Assessment linked to population-based surveillance data. SETTING 7 districts in Brong Ahafo region, Ghana. PARTICIPANTS Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. PRIMARY OUTCOME MEASURES Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. RESULTS Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores. CONCLUSIONS Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care. TRIAL REGISTRATION NUMBER NCT00623337.
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Affiliation(s)
- Terhi Johanna Lohela
- Department of Public Health, University of Helsinki, Helsinki, Finland
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
| | | | - Alexander Manu
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Linda Vesel
- Innovations for Maternal, Newborn and Child Health, Concern Worldwide US, New York, New York, USA
- Health Section, Programme Division, UNICEF Headquarters, New York, New York, USA
| | - Eunice Okyere
- Department of Public Health, Flinders University, Adelaide, South Australia, Australia
- Ghana Health Service, Kintampo Health Research Centre, Kintampo, Ghana
| | - Betty Kirkwood
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sabine Gabrysch
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
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Stevens GA, Bennett JE, Hennocq Q, Lu Y, De-Regil LM, Rogers L, Danaei G, Li G, White RA, Flaxman SR, Oehrle SP, Finucane MM, Guerrero R, Bhutta ZA, Then-Paulino A, Fawzi W, Black RE, Ezzati M. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. LANCET GLOBAL HEALTH 2016; 3:e528-36. [PMID: 26275329 DOI: 10.1016/s2214-109x(15)00039-x] [Citation(s) in RCA: 308] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/15/2015] [Accepted: 04/29/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Vitamin A deficiency is a risk factor for blindness and for mortality from measles and diarrhoea in children aged 6-59 months. We aimed to estimate trends in the prevalence of vitamin A deficiency between 1991 and 2013 and its mortality burden in low-income and middle-income countries. METHODS We collated 134 population-representative data sources from 83 countries with measured serum retinol concentration data. We used a Bayesian hierarchical model to estimate the prevalence of vitamin A deficiency, defined as a serum retinol concentration lower than 0·70 μmol/L. We estimated the relative risks (RRs) for the effects of vitamin A deficiency on mortality from measles and diarrhoea by pooling effect sizes from randomised trials of vitamin A supplementation. We used information about prevalences of deficiency, RRs, and number of cause-specific child deaths to estimate deaths attributable to vitamin A deficiency. All analyses included a systematic quantification of uncertainty. FINDINGS In 1991, 39% (95% credible interval 27-52) of children aged 6-59 months in low-income and middle-income countries were vitamin A deficient. In 2013, the prevalence of deficiency was 29% (17-42; posterior probability [PP] of being a true decline=0·81). Vitamin A deficiency significantly declined in east and southeast Asia and Oceania from 42% (19-70) to 6% (1-16; PP>0·99); a decline in Latin America and the Caribbean from 21% (11-33) to 11% (4-23; PP=0·89) also occurred. In 2013, the prevalence of deficiency was highest in sub-Saharan Africa (48%; 25-75) and south Asia (44%; 13-79). 94 500 (54 200-146 800) deaths from diarrhoea and 11 200 (4300-20 500) deaths from measles were attributable to vitamin A deficiency in 2013, which accounted for 1·7% (1·0-2·6) of all deaths in children younger than 5 years in low-income and middle-income countries. More than 95% of these deaths occurred in sub-Saharan Africa and south Asia. INTERPRETATION Vitamin A deficiency remains prevalent in south Asia and sub-Saharan Africa. Deaths attributable to this deficiency have decreased over time worldwide, and have been almost eliminated in regions other than south Asia and sub-Saharan Africa. This new evidence for both prevalence and absolute burden of vitamin A deficiency should be used to reconsider, and possibly revise, the list of priority countries for high-dose vitamin A supplementation such that a country's priority status takes into account both the prevalence of deficiency and the expected mortality benefits of supplementation. FUNDIN Bill & Melinda Gates Foundation, Grand Challenges Canada, UK Medical Research Council.
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Affiliation(s)
- Gretchen A Stevens
- Department of Health Statistics and Information Systems, World Health Organization, Geneva, Switzerland
| | - James E Bennett
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Quentin Hennocq
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Yuan Lu
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Lisa Rogers
- Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Guangquan Li
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Richard A White
- Department of Infectious Disease Epidemiology, Division of Infectious Disease Control and Department of Health Statistics, Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Seth R Flaxman
- School of Computer Science & Heinz College, Carnegie Mellon University, Pittsburgh, PA, USA
| | | | | | - Ramiro Guerrero
- PROESA-Research Center for Social Protection and Health Economics, Universidad Icesi, Cali, Colombia
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
| | - Robert E Black
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Majid Ezzati
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK.
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Asante KP, Kinney P, Zandoh C, Vliet EV, Nettey E, Abokyi L, Owusu-Agyei S, Jack D. CHILDHOOD RESPIRATORY MORBIDITY AND COOKING PRACTICES AMONG HOUSEHOLDS IN A PREDOMINANTLY RURAL AREA OF GHANA. Afr J Infect Dis 2016; 10:102-110. [PMID: 28480444 PMCID: PMC5411984 DOI: 10.21010/ajid.v10i2.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Household air pollution is a leading risk factor for respiratory morbidity and mortality in developing countries where biomass fuel is mainly used for cooking. Materials and Method: A household cross-sectional survey was conducted in a predominantly rural area of Ghana in 2007 to determine the prevalence of respiratory symptoms and their associated risk factors. Household cooking practices were also assessed as part of the survey. Results: Household heads of twelve thousand, three hundred and thirty-three households were interviewed. Fifty-seven percent (7006/12333) of these households had at least one child less than five years of age. The prevalence of symptoms of acute lower respiratory infections (ALRI) was 13.7% (n= 957, 95% CI 12.8 – 15.5%). A majority (77.8%, 95% CI, 77.7 - 78.5%) of households used wood as their primary fuel. Majority of respondents who used wood as their primary fuel obtained them by gathering wood from their neighborhood (95.6%, 9177/9595) and used a 3-stone local stove for cooking (94.9%, 9101/9595). In a randomly selected subset of respondents, females were the persons who mostly gathered firewood from the fields (90.8%, 296/326) and did the cooking (94.8%, 384/406) for the household. Conclusion: Symptoms of ALRI reported by caregivers is high in the Kintampo area of Ghana where biomass fuel use is also high. There is the need to initiate interventions that use improved cook stoves and to test the health benefits of such interventions.
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Affiliation(s)
- Kwaku Poku Asante
- Kintampo Health Research Centre, Ghana Health Research Centre, P. O. Box 200, Kintampo, Ghana
| | - Patrick Kinney
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, 722 West 168th Street, Room 1104ENew York, NY 10032
| | - Charles Zandoh
- Kintampo Health Research Centre, Ghana Health Research Centre, P. O. Box 200, Kintampo, Ghana
| | - Eleanne Van Vliet
- Kintampo Health Research Centre, Ghana Health Research Centre, P. O. Box 200, Kintampo, Ghana
| | - Ernest Nettey
- Kintampo Health Research Centre, Ghana Health Research Centre, P. O. Box 200, Kintampo, Ghana
| | - Livesy Abokyi
- Kintampo Health Research Centre, Ghana Health Research Centre, P. O. Box 200, Kintampo, Ghana
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Research Centre, P. O. Box 200, Kintampo, Ghana
| | - Darby Jack
- Department of Environmental Health Sciences, Mailman School of Public Health at Columbia University, 722 West 168th Street, Room 1104ENew York, NY 10032
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Abstract
BACKGROUND In areas where vitamin A deficiency (VAD) is a public health concern, the maternal dietary intake of vitamin A may be not sufficient to meet either the maternal nutritional requirements, or those of the breastfed infant, due the low retinol concentrations in breast milk. OBJECTIVES To evaluate the effects of vitamin A supplementation for postpartum women on maternal and infant health. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 February 2016), LILACS (1982 to December 2015), Web of Science (1945 to December 2015), and the reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or cluster-randomised trials that assessed the effects of vitamin A supplementation for postpartum women on maternal and infant health (morbidity, mortality and vitamin A nutritional status). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias and checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Fourteen trials of mainly low or unclear risk of bias, enrolling 25,758 women and infant pairs were included. The supplementation schemes included high, single or double doses of vitamin A (200,000 to 400,000 internation units (IU)), or 7.8 mg daily beta-carotene compared with placebo, no treatment, other (iron); or higher (400,000 IU) versus lower dose (200,000 IU). In all trials, a considerable proportion of infants were at least partially breastfed until six months. Supplement (vitamin A as retinyl, water-miscible or beta-carotene) 200,000 to 400,000 IU versus control (placebo or no treatment) Maternal: We did not find evidence that vitamin A supplementation reduced maternal mortality at 12 months (hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.44 to 2.21; 8577 participants; 1 RCT, moderate-quality evidence). Effects were less certain at six months (risk ratio (RR) 0.50, 95% CI 0.09 to 2.71; 564 participants; 1 RCT; low-quality evidence). The effect on maternal morbidity (diarrhoea, respiratory infections, fever) was uncertain because the quality of evidence was very low (50 participants, 1 RCT). We found insufficient evidence that vitamin A increases abdominal pain (RR 1.28, 95% CI 0.95 to 1.73; 786 participants; 1 RCT; low-quality evidence). We found low-quality evidence that vitamin A supplementation increased breast milk retinol concentrations by 0.20 µmol/L at three to three and a half months (mean difference (MD) 0.20 µmol/L, 95% CI 0.08 to 0.31; 837 participants; 6 RCTs). Infant: We did not find evidence that vitamin A supplementation reduced infant mortality at two to 12 months (RR 1.08, 95% CI 0.77 to 1.52; 6090 participants; 5 RCTs; low-quality evidence). Effects on morbidity (gastroenteritis at three months) was uncertain (RR 6.03, 95% CI 0.30 to 121.82; 84 participants; 1 RCT; very low-quality evidence). There was low-quality evidence for the effect on infant adverse outcomes (bulging fontanelle at 24 to 48 hours) (RR 2.00, 95% CI 0.61 to 6.55; 444 participants; 1 RCT). Supplement (vitamin A as retinyl) 400,000 IU versus 200,000 IUThree studies (1312 participants) were included in this comparison. None of the studies assessed maternal mortality, maternal morbidity or infant mortality. Findings from one study showed that there may be little or no difference in infant morbidity between the doses (diarrhoea, respiratory illnesses, and febrile illnesses) (312 participants, data not pooled). No firm conclusion could be drawn on the impact on maternal and infant adverse outcomes (limited data available).The effect on breast milk retinol was also uncertain due to the small amount of information available. AUTHORS' CONCLUSIONS There was no evidence of benefit from different doses of vitamin A supplementation for postpartum women on maternal and infant mortality and morbidity, compared with other doses or placebo. Although maternal breast milk retinol concentrations improved with supplementation, this did not translate to health benefits for either women or infants. Few studies reported on maternal and infant mortality and morbidity. Future studies should include these important outcomes.
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Affiliation(s)
- Julicristie M Oliveira
- School of Applied Sciences, University of CampinasRua Pedro Zaccaria, 1300LimeiraSão PauloBrazil13484‐350
| | - Roman Allert
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgBWGermany79110
- University Hospital Frankfurt, Goethe UniversityDepartment of Obstetrics and GynaecologyTheodor‐Stern‐Kai 7FrankfurtHessenGermany60596
| | - Christine E East
- Monash University/Monash HealthSchool of Nursing and Midwifery/Maternity Services246 Clayton RoadClaytonVictoriaAustralia3168
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Bartlett LA, LeFevre AE, Mir F, Soofi S, Arif S, Mitra DK, Quaiyum MA, Shakoor S, Islam MS, Connor NE, Winch PJ, Reller ME, Shah R, El Arifeen S, Baqui AH, Bhutta ZA, Zaidi A, Saha S, Ahmed SA. The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan. Reprod Health 2016; 13:16. [PMID: 26916141 PMCID: PMC4766721 DOI: 10.1186/s12978-016-0124-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/25/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk. METHODS/DESIGN The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics. DISCUSSION This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.
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Affiliation(s)
- L A Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - A E LeFevre
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - F Mir
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - S Soofi
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - S Arif
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - D K Mitra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - M A Quaiyum
- Centre for Reproductive Health, icddr,b, Dhaka, Bangladesh.
| | - S Shakoor
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - M S Islam
- Department of Microbiology, The Child Health Research Foundation, Dhaka Shishu Hospital, Dhaka, Bangladesh.
| | - N E Connor
- Department of Microbiology, The Child Health Research Foundation, Dhaka Shishu Hospital, Dhaka, Bangladesh.
| | - P J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - M E Reller
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - R Shah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - S El Arifeen
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh.
| | - A H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Z A Bhutta
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - A Zaidi
- Department of Paediatrics and Child Health, Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | - S Saha
- Department of Microbiology, The Child Health Research Foundation, Dhaka Shishu Hospital, Dhaka, Bangladesh.
| | - S A Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Klevor MK, Haskell MJ, Lartey A, Adu-Afarwuah S, Zeilani M, Dewey KG. Lipid-Based Nutrient Supplements Providing Approximately the Recommended Daily Intake of Vitamin A Do Not Increase Breast Milk Retinol Concentrations among Ghanaian Women. J Nutr 2016; 146:335-42. [PMID: 26740682 DOI: 10.3945/jn.115.217786] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 11/30/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vitamin A deficiency remains a global public health problem. Daily supplementation with a lipid-based nutrient supplement (LNS) has potential for increasing milk vitamin A concentrations. OBJECTIVE The objective of this study was to determine whether daily supplementation with approximately the recommended daily intake of vitamin A in an LNS or a multiple-micronutrient supplement (MMN) during pregnancy and the first 6 mo postpartum has an effect on breast milk retinol concentration at 6 mo postpartum. METHODS Women ≤20 wk pregnant (n = 1320) were randomly assigned to receive either the MMN providing 18 micronutrients, including 800 μg retinol equivalents of vitamin A, or the LNS with the same nutrients as the MMN group, plus 4 minerals and macronutrients, until 6 mo postpartum; a control group received iron and folic acid during pregnancy and a placebo (calcium tablet) during the first 6 mo postpartum. Breast milk samples collected at 6 mo postpartum were analyzed for retinol and fat concentrations by HPLC and creamatocrit, respectively, in a subsample of 756 women. RESULTS The breast milk retinol concentration was (mean ± SD) 56.3 ± 2.1 nmol/g fat, with no significant differences between groups [iron and folic acid (n = 243): 59.1 ± 2.8; MMN (n = 260): 55.4 ± 2.5; LNS (n = 253): 54.7 ± 2.5 nmol/g fat; P = 0.45], regardless of whether the woman had or had not received a high-dose vitamin A supplement (200,000 IU) soon after childbirth. Around 17% of participants had low milk retinol (≤28 nmol/g fat). We estimated that 41% of infants were potentially receiving vitamin A at amounts above the Tolerable Upper Intake Level (600 μg retinol activity equivalents/d), with no group differences in percentages with low or high milk retinol concentration. CONCLUSION Daily consumption of approximately the recommended intake of vitamin A did not increase breast milk retinol concentrations in this sample of Ghanaian women. This trial was registered at clinicaltrials.gov as NCT00970866.
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Affiliation(s)
- Moses K Klevor
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA; Department of Nutrition and Food Science, University of Ghana, Accra, Ghana; and
| | - Marjorie J Haskell
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana; and
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana; and
| | | | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA;
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McCauley ME, van den Broek N, Dou L, Othman M. Vitamin A supplementation during pregnancy for maternal and newborn outcomes. Cochrane Database Syst Rev 2015; 2015:CD008666. [PMID: 26503498 PMCID: PMC7173731 DOI: 10.1002/14651858.cd008666.pub3] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection. OBJECTIVES To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies. SELECTION CRITERIA All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear. 1) Vitamin A alone versus placebo or no treatmentOverall, when trial results are pooled, vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.65 to 1.20; four trials Ghana, Nepal, Bangladesh, UK, high quality evidence), perinatal mortality (RR 1.01, 95% CI 0.95 to 1.07; one study, high quality evidence), neonatal mortality, stillbirth, neonatal anaemia, preterm birth (RR 0.98, 95% CI 0.94 to 1.01, five studies, high quality evidence), or the risk of having a low birthweight baby.Vitamin A supplementation reduces the risk of maternal night blindness (RR 0.79, 95% CI 0.64 to 0.98; two trials). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.45, 95% CI 0.20 to 0.99, five trials; South Africa, Nepal, Indonesia, Tanzania, UK, low quality evidence) and maternal anaemia (RR 0.64, 95% CI 0.43 to 0.94; three studies, moderate quality evidence). 2) Vitamin A alone versus micronutrient supplements without vitamin AVitamin A alone compared to micronutrient supplements without vitamin A does not decrease maternal clinical infection (RR 0.99, 95% CI 0.83 to 1.18, two trials, 591 women). No other primary or secondary outcomes were reported 3) Vitamin A with other micronutrients versus micronutrient supplements without vitamin AVitamin A supplementation (with other micronutrients) does not decrease perinatal mortality (RR 0.51, 95% CI 0.10 to 2.69; one study, low quality evidence), maternal anaemia (RR 0.86, 95% CI 0.68 to 1.09; three studies, low quality evidence), maternal clinical infection (RR 0.95, 95% CI 0.80 to 1.13; I² = 45%, two studies, low quality evidence) or preterm birth (RR 0.39, 95% CI 0.08 to 1.93; one study, low quality evidence).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, 95% CI 0.47 to 0.96; one study, 594 women). AUTHORS' CONCLUSIONS The pooled results of three large trials in Nepal, Ghana and Bangladesh (with over 153,500 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However, the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal night blindness, maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.
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Affiliation(s)
- Mary E McCauley
- Liverpool School of Tropical MedicineCentre for Maternal and Newborn Health, Department of International Public HealthPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | - Nynke van den Broek
- Liverpool School of Tropical MedicineCentre for Maternal and Newborn Health, Department of International Public HealthPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Mohammad Othman
- Faculty of Medicine, Albaha UniversityDepartment of Obstetrics and GynaecologyAlbahaSaudi Arabia
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Weobong B, ten Asbroek AHA, Soremekun S, Gram L, Amenga-Etego S, Danso S, Owusu-Agyei S, Prince M, Kirkwood BR. Association between probable postnatal depression and increased infant mortality and morbidity: findings from the DON population-based cohort study in rural Ghana. BMJ Open 2015; 5:e006509. [PMID: 26316646 PMCID: PMC4554911 DOI: 10.1136/bmjopen-2014-006509] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess the impact of probable depression in the immediate postnatal period on subsequent infant mortality and morbidity. DESIGN Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths. SETTING Rural/periurban communities within the Kintampo Health Research Centre study area of the Brong-Ahafo Region of Ghana. PARTICIPANTS 16,560 mothers who had a live singleton birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression (pPND) between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. PRIMARY/SECONDARY OUTCOME MEASURES All-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal assessment to 12 months of age. RESULTS 130 infant deaths were recorded and singletons were followed for 67,457.4 infant-months from the time of their mothers' postnatal depression assessment. pPND was associated with an almost threefold increased risk of mortality up to 6 months (adjusted rate ratio (RR), 2.86 (1.58 to 5.19); p=0.001). The RR up to 12 months was 1.88 (1.09 to 3.24; p=0.023). pPND was also associated with increased risk of infant morbidity. CONCLUSIONS There is new evidence for the association between maternal pPND and infant mortality in low-income and middle-income countries. Implementation of the WHO's Mental Health Gap Action Programme (mhGAP) to scale up packages of care integrated with maternal health is encouraged as an important adjunct to child survival efforts.
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Affiliation(s)
- Benedict Weobong
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Department of Public Health, Academic Medical Centre, Amsterdam, The Netherlands
| | - Augustinus H A ten Asbroek
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Public Health, Academic Medical Centre, Amsterdam, The Netherlands
| | - Seyi Soremekun
- Department of Public Health, Academic Medical Centre, Amsterdam, The Netherlands
| | - Lu Gram
- Department of Public Health, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Samuel Danso
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Prince
- Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - Betty R Kirkwood
- Department of Public Health, Academic Medical Centre, Amsterdam, The Netherlands
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Abstract
This article reviews the central role of nutrition in advancing the maternal, newborn, and child health agenda with a focus on evidence for effective interventions generated using randomized controlled trials in low- and middle-income countries (LMIC). The 1000 days spanning from conception to 2 years of life are a critical period of time when nutritional needs must be ensured; failure to do so can lead to adverse impacts on short-term survival as well as long-term health and development [corrected]. The burden of maternal mortality continues to be high in many under-resourced settings; prenatal calcium supplementation in populations with low intakes can reduce the risk of pre-eclampsia and eclampsia morbidity and mortality and is recommended, and antenatal iron-folic acid use in many countries may reduce anemia, a condition that may be an underlying factor in postpartum hemorrhage. Sufficient evidence exists to promote multiple micronutrient supplementation during pregnancy to reduce fetal growth restriction and low birth weight. Early initiation of breastfeeding (within an hour), exclusive breastfeeding in the first 6 months of life, and vitamin A supplementation in the first few days of life in Asia (but not in Africa) reduce infant mortality. Biannual large-dose vitamin A supplements to children 6-59 months of age and zinc for treatment of diarrhea continue to be important strategies for improving child health and survival. Early nutrition and micronutrient status can influence child development but should be integrated with early responsive learning interventions. Future research is needed that goes beyond the 1000 days to ensure adequate preconceptional nutrition and health, with special emphasis on adolescents who contribute to a large proportion of first births in many LMIC. Thus, we make the case for integrating proven nutrition interventions with those for health in pregnant women, and with those for health and child development in neonates, infants, and young children to help advance the global MNCH agenda.
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Affiliation(s)
- Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E2541, Baltimore, MD 21205.
| | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E2541, Baltimore, MD 21205
| | - Kristen M Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E2541, Baltimore, MD 21205
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E2541, Baltimore, MD 21205
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E2541, Baltimore, MD 21205
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Angwenyi V, Asante KP, Traoré A, Febir LG, Tawiah C, Kwarteng A, Ouédraogo A, Sirima SB, Owusu-Agyei S, Imoukhuede EB, Webster J, Chandramohan D, Molyneux S, Jones C. Health providers' perceptions of clinical trials: lessons from Ghana, Kenya and Burkina Faso. PLoS One 2015; 10:e0124554. [PMID: 25933429 PMCID: PMC4416706 DOI: 10.1371/journal.pone.0124554] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/15/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Clinical trials conducted in Africa often require substantial investments to support trial centres and public health facilities. Trial resources could potentially generate benefits for routine health service delivery but may have unintended consequences. Strengthening ethical practice requires understanding the potential effects of trial inputs on the perceptions and practices of routine health care providers. This study explores the influence of malaria vaccine trials on health service delivery in Ghana, Kenya and Burkina Faso. METHODS We conducted: audits of trial inputs in 10 trial facilities and among 144 health workers; individual interviews with frontline providers (n=99) and health managers (n=14); and group discussions with fieldworkers (n=9 discussions). Descriptive summaries were generated from audit data. Qualitative data were analysed using a framework approach. RESULTS Facilities involved in trials benefited from infrastructure and equipment upgrades, support with essential drugs, access to trial vehicles, and placement of additional qualified trial staff. Qualified trial staff in facilities were often seen as role models by their colleagues; assisting with supportive supervision and reducing facility workload. Some facility staff in place before the trial also received formal training and salary top-ups from the trials. However, differential access to support caused dissatisfaction, and some interviewees expressed concerns about what would happen at the end of the trial once financial and supervisory support was removed. CONCLUSION Clinical trials function as short-term complex health service delivery interventions in the facilities in which they are based. They have the potential to both benefit facilities, staff and communities through providing the supportive environment required for improvements in routine care, but they can also generate dissatisfaction, relationship challenges and demoralisation among staff. Minimising trial related harm and maximising benefits requires careful planning and engagement of key actors at the outset of trials, throughout the trial and on its' completion.
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Affiliation(s)
- Vibian Angwenyi
- Department of Public Health Research, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box, 230–80108, Kilifi, Kenya
- * E-mail:
| | - Kwaku-Poku Asante
- Kintampo Health Research Centre (KHRC), P.O. Box 200, Kintampo, Ghana
| | - Abdoulaye Traoré
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), 01 BP 2208, Ouagadougou 01, Burkina Faso
| | | | - Charlotte Tawiah
- Kintampo Health Research Centre (KHRC), P.O. Box 200, Kintampo, Ghana
| | - Anthony Kwarteng
- Kintampo Health Research Centre (KHRC), P.O. Box 200, Kintampo, Ghana
| | - Alphonse Ouédraogo
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), 01 BP 2208, Ouagadougou 01, Burkina Faso
| | - Sodiomon Bienvenue Sirima
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), 01 BP 2208, Ouagadougou 01, Burkina Faso
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre (KHRC), P.O. Box 200, Kintampo, Ghana
| | - Egeruan Babatunde Imoukhuede
- European Vaccine Initiative (EVI),Universitäts Klinikum Heidelberg, Im Neuenheimer Feld 326, 69120, Heidelberg, Germany
| | - Jayne Webster
- Disease Control Department, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, WC1E 7HT, London, United Kingdom
| | - Daniel Chandramohan
- Disease Control Department, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, WC1E 7HT, London, United Kingdom
| | - Sassy Molyneux
- Department of Public Health Research, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box, 230–80108, Kilifi, Kenya
- The Ethox Centre, Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom
- The Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom
| | - Caroline Jones
- Department of Public Health Research, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box, 230–80108, Kilifi, Kenya
- Disease Control Department, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, WC1E 7HT, London, United Kingdom
- The Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom
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Affiliation(s)
- Batool A Haider
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Zulfiqar A Bhutta
- Robert Harding Chair in Global Child Health and Policy, Centre for Global Child Health, The Hospital for Sick Children, Toronto M5G 0A4, ON, Canada; Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan.
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Weobong B, Ten Asbroek AH, Soremekun S, Danso S, Owusu-Agyei S, Prince M, Kirkwood BR. Determinants of postnatal depression in rural ghana: findings from the don population based cohort study. Depress Anxiety 2015; 32:108-19. [PMID: 24272979 DOI: 10.1002/da.22218] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 10/27/2013] [Accepted: 10/28/2013] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Risk factors for postnatal depression (PND), one of the most pervasive complications of child bearing, are poorly understood in Africa. A recent systematic review of 31 studies found that the strongest predictors are social and economic disadvantage and gender-based factors; only six of these studies were community based, and almost all were in South Asia. METHODS Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy and after birth using the Patient Health Questionnaire to ascertain DSM-IV major or minor depression. Information was collected on determinants relating to the mother, birth, and baby, which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. RESULTS Thirteen thousand nine hundred and twenty nine women were screened both during pregnancy and after birth, of whom 13,360 (95.9%) had complete data on potential determinants. Two hundred and fifty five (3.8%, 95% CI: 3.5%, 4.1%) had PND. Antenatal depression (AND) was the strongest determinant accounting for 34.4% of PND cases. Other determinants were season of delivery, peripartum/postpartum complications, newborn ill health, still birth, or neonatal death. Common determinants were observed for onset and persistent depression. CONCLUSIONS Although most AND resolves in this setting, more than a third of women with PND also had AND. Adverse birth- and baby-related outcomes are the other main determinants. We recommend that programs detect and treat depression during pregnancy and provide support to women with adverse birth outcomes.
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Weobong B, ten Asbroek AHA, Soremekun S, Manu AA, Owusu-Agyei S, Prince M, Kirkwood BR. Association of antenatal depression with adverse consequences for the mother and newborn in rural Ghana: findings from the DON population-based cohort study. PLoS One 2014; 9:e116333. [PMID: 25549334 PMCID: PMC4280205 DOI: 10.1371/journal.pone.0116333] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 12/05/2014] [Indexed: 12/31/2022] Open
Abstract
Background Whilst there is compelling evidence of an almost 2-fold increased risk of still births, and suggestive evidence of increased mortality among offspring of mothers with psychotic disorders, only three studies have addressed the role of antenatal depression (AND) on survival of the baby. We examined these associations in a large cohort of pregnant women in Ghana. Methods A Cohort study nested within 4-weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for AND using the Patient Health Questionnaire (PHQ-9) to ascertain DSM-IV major or minor depression. Outcomes were adverse birth outcomes, maternal/infant morbidity, and uptake of key newborn care practices, examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. Results 20679 (89.6%) pregnant women completed the PHQ-9. The prevalence of AND was 9.9% (n = 2032) (95% confidence interval 9.4%–10.2%). AND was associated with: prolonged labour (RR 1.25, 95% CI 1.02–1.53); peripartum complications (RR 1.11, 95% CI 1.07–1.15);postpartum complications (RR 1.27, 96% CI 1.21–1.34); non-vaginal delivery (RR 1.19, 95% CI 1.02–1.40); newborn illness (RR 1.52, 95% CI 1.16–1.99); and bed net use during pregnancy (RR 0.93, 95% CI 0.89–0.98), but not neonatal deaths, still births, low birth weight, immediate breast feeding initiation, or exclusive breastfeeding. AND was marginally associated with preterm births (RR 1.32, 95% CI 0.98–1.76). Conclusion This paper has contributed important evidence on the role of antenatal depression as a potential contributor to maternal and infant morbidity. Non-pharmacological treatments anchored on primary care delivery structures are recommended as an immediate step. We further recommend that trials are designed to assess if treating antenatal depression in conjunction with improving the quality of obstetric care results in improved maternal and newborn outcomes.
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Affiliation(s)
- Benedict Weobong
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | | | - Seyi Soremekun
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alexander A. Manu
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Martin Prince
- Health Services and Population Research Department, Institute of Psychiatry, King’s College London, London, United Kingdom
| | - Betty R. Kirkwood
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mason J, Greiner T, Shrimpton R, Sanders D, Yukich J. Vitamin A policies need rethinking. Int J Epidemiol 2014; 44:283-92. [DOI: 10.1093/ije/dyu194] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Weobong B, Soremekun S, Ten Asbroek AH, Amenga-Etego S, Danso S, Owusu-Agyei S, Prince M, Kirkwood BR. Prevalence and determinants of antenatal depression among pregnant women in a predominantly rural population in Ghana: the DON population-based study. J Affect Disord 2014; 165:1-7. [PMID: 24882170 DOI: 10.1016/j.jad.2014.04.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/11/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND While depression during pregnancy is one of the strongest risk factors for postnatal depression, it has been comparatively little studied, particularly in sub-Saharan Africa. METHODS Cohort study nested within 4-weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy using the Patient Health Questionnaire to ascertain DSM-IV major or minor depression. Information on demographic factors, indicators of social and economic disadvantage, and previous obstetric history were also collected which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. RESULTS 21,135 pregnant women were screened of whom 20,920 (98.9%) had complete data on potential determinants. 2086 (9.9%, 95% CI: 9.5%-10.3%) had AND. Determinants of AND were: maternal age 30+ years (relative risk [RR], 1.16 (1.06-1.27); never married ([RR] 1.34, (1.14-1.58); lower wealth quintile ([RR], 1.30 (1.13-1.50); unplanned pregnancy ([RR], 1.55 (1.43-1.69); previous pregnancy loss ([RR], 1.30 (1.18-1.43). LIMITATIONS We did not assess women for physical health during pregnancy, and lacked information on some potentially relevant psychosocial factors. CONCLUSION Prevalence of antenatal depression, applying clinical criteria, is similar to that seen in high income countries. Factors related to chronic social and economic disadvantage are among the most important co-determinants. Population-level interventions that address these problems among women of reproductive age may be the most effective strategy for reducing the prevalence and impact of depression in pregnancy.
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Affiliation(s)
- Benedict Weobong
- Kintampo Health Research Centre, Ghana Health Service, P.O. Box 200, Kintampo, Brong-Ahafo Region, Ghana; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK.
| | - Seyi Soremekun
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK
| | | | - Seeba Amenga-Etego
- Kintampo Health Research Centre, Ghana Health Service, P.O. Box 200, Kintampo, Brong-Ahafo Region, Ghana
| | - Samuel Danso
- Kintampo Health Research Centre, Ghana Health Service, P.O. Box 200, Kintampo, Brong-Ahafo Region, Ghana
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, P.O. Box 200, Kintampo, Brong-Ahafo Region, Ghana; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK
| | - Martin Prince
- Health Services and Population Research Department, Institute of Psychiatry, King׳s College, London
| | - Betty R Kirkwood
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK
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Gram L, Soremekun S, ten Asbroek A, Manu A, O'Leary M, Hill Z, Danso S, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Socio-economic determinants and inequities in coverage and timeliness of early childhood immunisation in rural Ghana. Trop Med Int Health 2014; 19:802-11. [PMID: 24766425 DOI: 10.1111/tmi.12324] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the extent of socio-economic inequity in coverage and timeliness of key childhood immunisations in Ghana. METHODS Secondary analysis of vaccination card data collected from babies born between January 2008 and January 2010 who were registered in the surveillance system supporting the ObaapaVita and Newhints Trials was carried out. 20 251 babies had 6 weeks' follow-up, 16 652 had 26 weeks' follow-up, and 5568 had 1 year's follow-up. We performed a descriptive analysis of coverage and timeliness of vaccinations by indicators for urban/rural status, wealth and educational attainment. The association of coverage with socio-economic indicators was tested using a chi-square-test and the association with timeliness using Cox regression. RESULTS Overall coverage at 1 year of age was high (>95%) for Bacillus Calmette-Guérin (BCG), all three pentavalent diphtheria-pertussis-tetanus-haemophilus influenzae B-hepatitis B (DPTHH) doses and all polio doses except polio at birth (63%). Coverage against measles and yellow fever was 85%. Median delay for BCG was 1.7 weeks. For polio at birth, the median delay was 5 days; all other vaccine doses had median delays of 2-4 weeks. We found substantial health inequity across all socio-economic indicators for all vaccines in terms of timeliness, but not coverage at 1 year. For example, for the last DPTHH dose, the proportion of children delayed more than 8 weeks were 27% for urban children and 31% for rural children (P < 0.001), 21% in the wealthiest quintile and 41% in the poorest quintile (P < 0.001), and 9% in the most educated group and 39% in the least educated group (P < 0.001). However, 1-year coverage of the same dose remained above 90% for all levels of all socio-economic indicators. CONCLUSIONS Ghana has substantial health inequity across urban/rural, socio-economic and educational divides. While overall coverage was high, most vaccines suffered from poor timeliness. We suggest that countries achieving high coverage should include timeliness indicators in their surveillance systems.
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Affiliation(s)
- Lu Gram
- London School of Hygiene and Tropical Medicine, London, UK; Institute Of Child Health, University College London, London, UK
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Montoya A, Calvert C, Filippi V. Explaining differences in maternal mortality levels in sub-Saharan African hospitals: a systematic review and meta-analysis. Int Health 2014; 6:12-22. [DOI: 10.1093/inthealth/iht037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Emmett SD, West KP. Gestational vitamin A deficiency: a novel cause of sensorineural hearing loss in the developing world? Med Hypotheses 2014; 82:6-10. [PMID: 24120698 PMCID: PMC4391953 DOI: 10.1016/j.mehy.2013.09.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/11/2013] [Accepted: 09/17/2013] [Indexed: 10/26/2022]
Abstract
Hearing loss is a substantial public health problem with profound social and economic consequences in the developing world. The World Health Organization (WHO) estimates that there are 360 million people living with disabling hearing loss globally, and 80% of these individuals are from low- and middle-income countries. The epidemiology of hearing impairment remains poorly defined in most impoverished societies. Middle ear infections in childhood are a key determinant; however, congenital anomalies may also comprise an important etiology and may arise from gestational malnutrition. While evidence exists that preventable vitamin A deficiency exacerbates the severity of ear infections and, consequently, hearing loss, antenatal vitamin A deficiency during sensitive periods of fetal development may represent an etiologically distinct and virtually unexplored causal pathway. Evidence from multiple animal systems clearly shows that fetal inner ear development requires adequate vitamin A nutriture to proceed normally. Inner ear malformations occur in experimentally imposed maternal vitamin A deficiency in multiple species in a dose-response manner. These anomalies are likely due to the loss of retinoic acid-dependent regulation of both hindbrain development and otic morphogenic processes. Based on in vivo evidence in experimental animals, we hypothesize that preventable gestational vitamin A deficiency, especially during early stages of fetal development, may predispose offspring to inner ear malformations and sensorineural hearing loss. As vitamin A deficiency affects an estimated 20 million pregnant women globally, we hypothesize that, in undernourished settings, routine provision of supplemental vitamin A at the recommended allowance throughout pregnancy may promote normal inner ear development and reduce risk of an as yet unknown fraction of sensorineural hearing loss. If our hypothesis proves correct, gestational vitamin A deficiency would represent a potentially preventable etiology of sensorineural hearing loss of substantial public health significance.
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Affiliation(s)
- Susan D Emmett
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 N Caroline Street, Baltimore, MD 21287, USA; Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, W2041, Baltimore, MD 21205, USA.
| | - Keith P West
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, W2041, Baltimore, MD 21205, USA
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Nesbitt RC, Lohela TJ, Manu A, Vesel L, Okyere E, Edmond K, Owusu-Agyei S, Kirkwood BR, Gabrysch S. Quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana. PLoS One 2013; 8:e81089. [PMID: 24312265 PMCID: PMC3842335 DOI: 10.1371/journal.pone.0081089] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 10/09/2013] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate “effective coverage” of skilled attendance in Brong Ahafo, Ghana. Methods We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated “effective coverage” of skilled attendance as the proportion of births in facilities of high quality. Findings Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as “low” or “substandard” for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was “low” or “substandard” in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with “high” or “highest” quality in all dimensions. Conclusion Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated “effective coverage” of skilled attendance at 18%, thus revealing a large “quality gap.” Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.
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Affiliation(s)
- Robin C. Nesbitt
- Epidemiology and Biostatistics Unit, Institute of Public Health, Heidelberg University, Heidelberg, Germany
- * E-mail:
| | - Terhi J. Lohela
- Department of Anaesthesiology and Intensive Care Medicine, Jorvi Hospital, Helsinki University Hospital, Espoo, Finland
| | - Alexander Manu
- Kintampo Health Research Center, Ghana Health Service, Kintampo, Ghana
- Maternal & Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Linda Vesel
- Maternal & Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eunice Okyere
- Kintampo Health Research Center, Ghana Health Service, Kintampo, Ghana
| | - Karen Edmond
- School of Paediatrics and Child Health, University of Western Australia, Subiaco, Australia
| | - Seth Owusu-Agyei
- Kintampo Health Research Center, Ghana Health Service, Kintampo, Ghana,
| | - Betty R. Kirkwood
- Maternal & Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sabine Gabrysch
- Epidemiology and Biostatistics Unit, Institute of Public Health, Heidelberg University, Heidelberg, Germany
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Asante KP, Agyemang CT, Zandoh C, Saah J, Febir LG, Donlebo CK, Owusu-Agyei S. Community engagement in biomedical research in an African setting: the Kintampo Health Research Centre experience. BMC Health Serv Res 2013; 13:383. [PMID: 24090148 PMCID: PMC4015992 DOI: 10.1186/1472-6963-13-383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 09/30/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Community engagement (CE) is becoming relevant in health research activities; however, models for CE in health research are limited in developing countries. The Kintampo Health Research Centre (KHRC) conducts research to influence health policy locally and also internationally. Since its establishment in 1994 with the mandate of conducting relevant public health studies in the middle part of Ghana, KHRC has embarked on a series of clinical and operational studies involving community members. In these studies, community members have been engaged through community durbars before, during and also after all study implementations. Lessons learnt from these activities suggested the need to embark on further CE processes that could serve as a model for emerging research institutions based in African communities. METHODS Interactive community durbars, workshops, in-depth discussions, focus group discussions and radio interactions were used as the main methods in the CE process. RESULTS Community members outlined areas of research that they perceived as being of interest to them. Though community members expressed continual interest in our traditional areas of research in communicable, maternal, neonatal and child health, they were interested in new areas such as non- communicable diseases such as diabetes and hypertension. Misconceptions about KHRC and its research activities were identified and clarified. This research provided KHRC the opportunity to improve communication guidelines with the community and these are being used in engaging the community at various stages of our research, thus improving on the design and implementation of research. CONCLUSION KHRC has developed a culturally appropriate CE model based on mutual understanding with community members. The experience obtained in the CE process has contributed to building CE capacity in KHRC. Other health research institutions in developing countries could consider the experiences gained.
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Affiliation(s)
- Kwaku Poku Asante
- Kintampo Health Research Centre, Ghana Health Service, P. O. Box 200, Kintampo, Brong Ahafo Region, Ghana
| | - Charlotte Tawiah Agyemang
- Kintampo Health Research Centre, Ghana Health Service, P. O. Box 200, Kintampo, Brong Ahafo Region, Ghana
| | - Charles Zandoh
- Kintampo Health Research Centre, Ghana Health Service, P. O. Box 200, Kintampo, Brong Ahafo Region, Ghana
| | - Jacob Saah
- Kintampo Health Research Centre, Ghana Health Service, P. O. Box 200, Kintampo, Brong Ahafo Region, Ghana
| | - Lawrence Gyabaa Febir
- Kintampo Health Research Centre, Ghana Health Service, P. O. Box 200, Kintampo, Brong Ahafo Region, Ghana
| | - Casimir Kabio Donlebo
- Kintampo Health Research Centre, Ghana Health Service, P. O. Box 200, Kintampo, Brong Ahafo Region, Ghana
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, P. O. Box 200, Kintampo, Brong Ahafo Region, Ghana
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Stanton CK, Newton S, Mullany LC, Cofie P, Tawiah Agyemang C, Adiibokah E, Amenga-Etego S, Darcy N, Khan S, Armbruster D, Gyapong J, Owusu-Agyei S. Effect on postpartum hemorrhage of prophylactic oxytocin (10 IU) by injection by community health officers in Ghana: a community-based, cluster-randomized trial. PLoS Med 2013; 10:e1001524. [PMID: 24130463 PMCID: PMC3794862 DOI: 10.1371/journal.pmed.1001524] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 08/21/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oxytocin (10 IU) is the drug of choice for prevention of postpartum hemorrhage (PPH). Its use has generally been restricted to medically trained staff in health facilities. We assessed the effectiveness, safety, and feasibility of PPH prevention using oxytocin injected by peripheral health care providers without midwifery skills at home births. METHODS AND FINDINGS This community-based, cluster-randomized trial was conducted in four rural districts in Ghana. We randomly allocated 54 community health officers (stratified on district and catchment area distance to a health facility: ≥10 km versus <10 km) to intervention (one injection of oxytocin [10 IU] one minute after birth) and control (no provision of prophylactic oxytocin) arms. Births attended by a community health officer constituted a cluster. Our primary outcome was PPH, using multiple definitions; (PPH-1) blood loss ≥500 mL; (PPH-2) PPH-1 plus women who received early treatment for PPH; and (PPH-3) PPH-2 plus any other women referred to hospital for postpartum bleeding. Unsafe practice is defined as oxytocin use before delivery of the baby. We enrolled 689 and 897 women, respectively, into oxytocin and control arms of the trial from April 2011 to November 2012. In oxytocin and control arms, respectively, PPH-1 rates were 2.6% versus 5.5% (RR: 0.49; 95% CI: 0.27-0.88); PPH-2 rates were 3.8% versus 10.8% (RR: 0.35; 95% CI: 0.18-0.63), and PPH-3 rates were similar to those of PPH-2. Compared to women in control clusters, those in the intervention clusters lost 45.1 mL (17.7-72.6) less blood. There were no cases of oxytocin use before delivery of the baby and no major adverse events requiring notification of the institutional review boards. Limitations include an unblinded trial and imbalanced numbers of participants, favoring controls. CONCLUSION Maternal health care planners can consider adapting this model to extend the use of oxytocin into peripheral settings including, in some contexts, home births. TRIAL REGISTRATION ClinicalTrials.gov NCT01108289 Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Cynthia K. Stanton
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Samuel Newton
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Luke C. Mullany
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | - Edward Adiibokah
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | | | - Niamh Darcy
- Research Triangle Institute, North Carolina, United States of America
| | - Sadaf Khan
- PATH, Seattle, Washington, United States of America
| | - Deborah Armbruster
- United States Agency for International Development, Washington (DC), United States of America
| | - John Gyapong
- School of Public Health, University of Ghana, Accra, Ghana
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
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Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health 2013; 13 Suppl 3:S19. [PMID: 24564770 PMCID: PMC3847227 DOI: 10.1186/1471-2458-13-s3-s19] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Early breastfeeding is defined as the initiation of breastfeeding within twenty four hours of birth. While the benefits of breastfeeding have been known for decades, only recently has the role of time to initiation of breastfeeding in neonatal mortality and morbidity been assessed. OBJECTIVE To review the evidence for early breastfeeding initiation practices and to estimate the association between timing and neonatal outcomes. METHODS We systematically reviewed multiple databases from 1963 to 2011. Standardized abstraction tables were used and quality was assessed for each study utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Three meta-analyses were conducted for mortality among babies surviving to 48 hours. RESULTS We identified 18 studies reporting a direct association between early breastfeeding initiation and neonatal mortality and morbidity outcomes. The results of random effects analyses of data from 3 studies (from 5 publications) demonstrated lower risks of all-cause neonatal mortality among all live births (RR = 0.56 [95% CI: 0.40 - 0.79]) and among low birth weight babies (RR=0.58 [95% CI: 0.43 - 0.78]), and infection-related neonatal mortality (RR = 0.55 [95% CI: 0.36 - 0.84]). Among exclusively breastfed infants, all-cause mortality risk did not differ between early and late initiators (RR = 0.69 [95% CI: 0.27 - 1.75]). CONCLUSIONS This review demonstrates that early breastfeeding initiation is a simple intervention that has the potential to significantly improve neonatal outcomes and should be universally recommended. Significant gaps in knowledge are highlighted, revealing a need to prioritize additional high quality studies that further clarify the specific cause of death, as well as providing improved understanding of the independent or combined effects of early initiation and breastfeeding patterns.
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Affiliation(s)
- Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anjalee Kohli
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karen Edmond
- School of Pediatrics and Child Health, University of Western Australia, Crawley, WA, Australia
| | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Enos MK, Burton JP, Dols J, Buhulata S, Changalucha J, Reid G. Probiotics and nutrients for the first 1000 days of life in the developing world. Benef Microbes 2013; 4:3-16. [PMID: 23257014 DOI: 10.3920/bm2012.0020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Clinically proven probiotics are, for the most part, not available in the developing world and certainly not affordable for the majority of people. This is unconscionable considering these products can alleviate diarrhoea and various infections, which are by far the major cause of death in children and in adults who are HIV positive. Indeed, some of these products have been proven in developing world settings. Distribution networks exist along with pharmacies and clinics that dispense drugs and products that require refrigeration. So, are lack of profit or company resources the problem? Our university has shown that alternative community based kitchen models that produce probiotics can be established. These empower local people, are socially responsible, produce affordable products and deliver benefits to over 3,000 children and adults daily. Surely, other institutions and corporations can multiply this effect and develop social business models across the developing world that are supported by clinical and basic science studies? In this review, we will discuss the application of probiotics and selected nutrients in the first 1000 days of life, a critical timepoint which is particularly challenging in resource disadvantaged countries.
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Affiliation(s)
- M K Enos
- Canadian Research and Development Centre for Probiotics, F2-116, The Lawson Health Research Institute, 268 Grosvenor Street, London, ON N6A 4V2, Canada
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