The high burden of infant deaths in rural Burkina Faso: a prospective community-based cohort study

Does oral iron and folate supplementation during pregnancy protect against adverse birth outcomes and reduced neonatal and infant mortality in Africa: A protocol for a systematic review and meta-analysis?

BACKGROUND

Globally, one-third of pregnant women are at risk of iron deficiency, particularly in the African region. While recent findings show that iron and folate supplementation can lower the risk of adverse birth outcomes and childhood mortality, our understanding of its impact in Africa remains incomplete due to insufficient evidence. This protocol outlines the systematic review steps to investigate the impact of oral iron and folate supplementation during pregnancy on adverse birth outcomes, neonatal mortality and infant mortality in Africa.

METHODS AND ANALYSIS

MEDLINE, PsycINFO, Embase, Scopus, CINAHL, Web of Science, and Cochrane databases were searched for published articles. Google Scholar and Advanced Google Search were used for gray literature and nonindexed articles. Oral iron and/or folate supplementation during pregnancy is the primary exposure. The review will focus on adverse birth outcomes, neonatal mortality and infant mortality. Both Cochrane Effective Practice and Organization of Care and Newcastle-Ottawa Scale risk of bias assessment tools will be used. Meta-analysis will be conducted if design and data analysis methodologies permit. This systematic review and meta-analysis will provide up-to-date evidence about iron and folate supplementation's role in adverse birth outcomes, neonatal mortality and infant mortality in the African region.

ETHICS AND DISSEMINATION

This review will provide insights that help policymakers, program planners, researchers, and public health practitioners interested in working in the region.

PROSPERO REGISTRATION NUMBER

CRD42023452588.

Optimizing primary health care in Burkina Faso: an approach informed by EQUIST

Introduction

Burkina Faso has made access to primary health care a national priority by including it in the 2021-2030 national health development plan.

Purpose of research

Our study aimed to analyze the causes of inequalities in access to primary health care, priority interventions and strategies for strengthening primary health care, and their potential impact on reducing maternal and infant mortality.

Results

Diarrheal diseases, malaria, and pneumonia are the main causes of inequalities in infant and child deaths in rural areas. As for maternal deaths, abortion and its complications are the main causes of inequalities in deaths associated with hypertensive disorders. The Sahel, Boucle du Mouhoun, Center-North, East, and Cascades regions are the geographical areas where interventions are essential to reduce inequalities in maternal, neonatal, infant and child deaths and malnutrition.

Conclusions

The national priorities have included all the high-impact interventions for strengthening primary health care identified in our study. Interventions must prioritize the populations in rural areas, the most affected and high-impact geographical regions. This requires the involvement and empowerment of beneficiary communities and the consideration of the fragile safety context.

Challenges and recommendations for addressing under-five pneumonia morbidity and mortality in Nigeria

Background

Pneumonia is a severe infection and one of the most common causes of mortality among children under five years of age, when not appropriately managed. Infection of the lungs by bacteria, viruses, or fungi and consequent inflammation may lead to cough and difficult breathing. Some of the key predisposing factors are malnutrition and air pollution. WHO reports that Africa has the highest burden of global child mortality, and 16% of all deaths in pneumonia, were children under five years of age in 2016.

Objectives

This study aimed to explore how health providers perceive pneumonia as a cause of under-five mortality in Nigeria.

Methods

A qualitative study design with in-depth interviews and focus group discussions was used to explore and understand nurses and pediatricians' views regarding the pneumonia situation, vaccinations, and preventive suggestions to reduce under five pneumonia deaths in Nigeria.

Results

Two themes and four categories emerged: participant's anxiety over the situation, their views on impediments, current policies and strategies, and suggestions on addressing severe pneumonia.

Conclusions

The results from this study highlight contextual issues playing major roles in pneumonia mortality among children in Nigeria, which will need approaches on several levels to address them.

Prevalence and risk factors associated with under-five mortality in the Solomon Islands: an investigation from the 2015 Solomon Islands demographic and health survey data

Background

Annually, over five million children die before their fifth birthday worldwide, with 98% of these deaths occurring in low-and middle-income countries. The prevalence and risks for under-five mortality are not well-established for the Solomon Islands.

Methods

We used the Solomon Islands Demographic and Health Survey 2015 data (SIDHS 2015) to estimate the prevalence and risk factors associated with under-five mortality.

Findings

Neonatal, infant, child and under-five mortality prevalence were 8/1000, 17/1000, 12/1000 and 21/1000 live births, respectively. After adjustment for potential confounders, neonatal mortality was associated with no breastfeeding [aRR 34.80 (13.60, 89.03)], no postnatal check [aRR 11.36 (1.22, 106.16)], and Roman Catholic [aRR 3.99 (1.34, 11.88)] and Anglican [aRR 2.78 (0.89, 8.65); infant mortality to no breastfeeding [aRR 11.85 (6.15, 22.83)], Micronesian [aRR 5.54 (1.67, 18.35)], and higher birth order [aRR 2.00 (1.03, 3.88)]; child mortality to multiple gestation [aRR 6.15 (2.08, 18.18)], Polynesian [aRR 5.80 (2.48, 13.53)], and Micronesian [aRR 3.65 (1.46, 9.10)], cigarette and tobacco [aRR 1.77 (0.79, 3.96)] and marijuana use [aRR 1.94 (0.43, 8.73)] and rural residence [aRR 1.85 (0.88, 3.92)]; under-five mortality to no breastfeeding [aRR 8.65 (4.97, 15.05)], Polynesian [aRR 3.23 (1.09, 9.54)], Micronesian [aRR 5.60 (2.52, 12.46)], and multiple gestation [aRR 3.34 (1.26, 8.88)]. Proportions of 9% for neonatal and 8% of under-five mortality were attributable to no maternal tetanus vaccination.

Interpretation

Under-five mortality in the Solomon Islands from the SIDHS 2015 data was attributable to maternal health, behavioural, and sociodemographic risk factors. We recommended future studies to confirm these associations.

Funding

No funding was declared to support this study directly.

Influence of maternal age on birth and infant outcomes at 6 months: a cohort study with quantitative bias analysis

BACKGROUND

Maternal age is increasingly recognized as a predictor of birth outcomes. Given the importance of birth and growth outcomes for children's development, wellbeing and survival, this study examined the effect of maternal age on infant birth and growth outcomes at 6 months and mortality. Additionally, we conducted quantitative bias analysis (QBA) to estimate the role of selection bias and unmeasured confounding on the effect of maternal age on infant mortality.

METHODS

We used data from randomized-controlled trials (RCTs) of 21 555 neonates in Burkina Faso conducted in 2019-2020. Newborns of mothers aged 13-19 years (adolescents) and 20-40 years (adults) were enrolled in the study 8-27 days after birth and followed for 6 months. Measurements of child's anthropometric measures were collected at baseline and 6 months. We used multivariable linear regression to compare child anthropometric measures at birth and 6 months, and logistic regression models to obtain the odds ratio (OR) of all-cause mortality. Using multidimensional deterministic analysis, we assessed scenarios in which the difference in selection probability of adolescent and adult mothers with infant mortality at 6 months increased from 0% to 5%, 10%, 15% and 20% if babies born to adolescent mothers more often died during the first week or were of lower weight and hence were not eligible to be included in the original RCT. Using probabilistic bias analysis, we assessed the role of unmeasured confounding by socio-economic status (SES).

RESULTS

Babies born to adolescent mothers on average had lower weight at birth, lower anthropometric measures at baseline, similar growth outcomes from enrolment to 6 months and higher odds of all-cause mortality by 6 months (adjusted OR = 2.17, 95% CI 1.35 to 3.47) compared with those born to adult mothers. In QBA, we found that differential selection of adolescent and adult mothers could bias the observed effect (OR = 2.24, 95% CI 1.41 to 3.57) towards the null [bias-corrected OR range: 2.37 (95% CI 1.49 to 3.77) to 2.84 (95% CI 1.79 to 4.52)], whereas unmeasured confounding by SES could bias the observed effect away from the null (bias-corrected OR: 2.06, 95% CI 1.31 to 2.64).

CONCLUSIONS

Our findings suggest that delaying the first birth from adolescence to adulthood may improve birth outcomes and reduce mortality of neonates. Babies born to younger mothers, who are smaller at birth, may experience catch-up growth, reducing some of the anthropometric disparities by 6 months of age.

Predictors of infant-survival practices among mothers attending paediatric clinics in Ijebu-Ode, Ogun State, Nigeria

Background

Despite concerted global efforts towards achieving infant-survival, infant mortality lingers as a problem in developing countries. Environmental and personal-level factors are assumed to account for this situation. This study was undertaken to provide better understanding of the dynamics of predictors of infant-survival practices among mothers with infants attending paediatric clinics.

Methods

A cross-sectional survey design was adopted. Data was collected from 386 nursing mothers selected by convenience sampling. Interviewer-administered questionnaires were used for data collection. The questionnaire consisted of 38-items including demographic information of respondents, health-literacy counsels received during antenatal care, social-support from significant others, and self-efficacy to carry-out infant-survival instructions. Responses were transformed into rating scales for each variable and data analysis was conducted by linear regression analysis with test of hypotheses at 5% level of significance.

Results

The mean age of respondents was 29.8 ± 5.8 years. Majority (81.6%) were married. Yorubas (83.90%) were predominant. Participants had mean scores of 10.50 ± 3.83, 10.56 ± 3.70 and 16.61 ± 4.56 respectively computed for levels of health-literacy, social-support, and self-efficacy. The dependent variable measured level of infant-survival practices and respondents scored 16.53 ± 4.71. The study found a significant association among variables. Self-efficacy was the major predictor variable of self-reported infant-survival practices (R = 0.466; R² = 0.217; P<0.05).

Conclusion

We conclude that participants had average levels of health-literacy, social-support, self-efficacy, and infant-survival practices. Healthcare providers should make efforts to empower pregnant women on activities essential for infant-survival. Family members of nursing mothers should as well be knowledgeable about the advantages of supporting them.

A multi-year analysis of kangaroo mother care outcomes in low birth weight babies at a Nyakahanga Hospital in rural Tanzania

BACKGROUND

Kangaroo Mother Care (KMC) requires few specialized resources, reduces mortality, and can be implemented in low resource environments. It is now recommended for implementation around the globe.

OBJECTIVES

This paper discusses KMC use with low birth weight newborns at a Tanzania hospital providing valuable outcomes assessment of KMC use in rural areas of sub-Saharan Africa.

METHODS

The research used retrospective records (136 Low Birth Weight (LBW) and 33 Very Low Birth Weight (VLBW) neonates) supplemented by observations. Data included weights (longitudinal), survival period, and cause of death if it occurred. This hospital's KMC use and study data began when the mother-baby dyad was referred, usually birth day.

RESULTS

This KMC group demonstrated 70% survival, but 77% of deaths occur within 24 hours. After the first 24 hours, KMC survival rate was 92%. Even VLBW neonates (<1000 g) had 37.5% survival among the KMC program. Prematurity and respiratory distress caused nearly half of the deaths, but hypothermia (19% of deaths) and infection were factors also.

CONCLUSION

Our study indicates the value of KMC in rural low resource environments. Results are comparable to KMC programs in urban areas where newborns begin KMC after stabilization and better than outcomes reported for comparable populations not practicing KMC in rural sub-Saharan Africa.

Effects of schooling on aspects of attention in rural Burkina Faso, West Africa

Background

We aimed to study the effects of schooling on aspects of attention using the Test of Variables of Attention (TOVA) among children in rural Burkina Faso.

Methods

We re-enrolled children of a previously community-based cluster randomized exclusive breastfeeding trial in rural Burkina Faso. A total of 534 children (280 boys and 254 girls) aged 6 to 8 years were assessed using the TOVA. We examined the effect size difference using Cohen’s d, ANOVA and conducted regression analyses.

Results

Forty nine percent of the children were in school. Children not in school performed poorly with a small effect size difference for ‘Response Time’, ‘Errors of omission’, and ‘Errors of commission’ compared to children in school. The effect size difference was moderate for ‘Response Time Variability’, and ‘D prime score’.

Conclusion

Schooling affects different aspects of attention in rural Burkina Faso. In settings where literacy and schooling rate is low, public sensitizations of the benefits of schooling need to be reinforced and advice on sending children to school need to be provided continuously.

Association between stunting and neuro-psychological outcomes among children in Burkina Faso, West Africa

BACKGROUND

In Burkina Faso, stunting affects children and is a public health problem. We studied the association between stunting and child's neuro-psychological outcomes at 6-8 years of age in rural Burkina Faso using the Kaufman Assessment Battery for Children, 2nd edition (KABC-II), the Children's Category Test 1 (CCT-1) and the Test of Variable of Attention (TOVA).

METHODS

We re-enrolled children of a previously community-based Exclusive breastfeeding trial in Burkina Faso. We assessed a total of 532 children aged 6-8 years using KABC-II for memory (Atlantis and Number Recall subtests), spatial abilities (Conceptual Thinking, Face Recognition and Triangle subtests), reasoning (Block Counting subtest), general cognition and CCT-1 for cognitive flexibility. A total 513 children were assessed using the TOVA to measure attention and inhibition. We calculated the Cohen's d to examine the effect size and conducted a linear regression to examine the association.

RESULTS

The proportion of stunting was 15.6% (83/532). Stunted children performed significantly poorer for memory (Atlantis and Number Recall), spatial abilities (Conceptual Thinking, Face Recognition and Triangle), general cognition and attention with a small effect size compared to non-stunted children. Children who were exposed scored significantly higher errors for cognitive flexibility and inhibition with a small effect size compared to unexposed children. At standardized and unstandardized multivariable regression analysis, stunted children performed significantly poorer for Atlantis (p = 0.001), Number Recall (p = 0.02), Conceptual Thinking (p = 0.01), Triangle (p = 0.001), general cognition (p ≤ 0.0001) and attention (p = 0.04) compared to non-stunted children. Children who were exposed scored significantly higher errors for cognitive flexibility (p = 0.02) and for inhibition (p = 0.02) compared to unexposed children. We adjusted all the results for age, schooling, sex, playing, father education, mother employment and promotion of previous exclusive breastfeeding.

CONCLUSION

Stunting is associated with poorer neuro-psychological outcomes among children in rural Burkina Faso. Initiatives related to prevention need to be established and advice on nutrition need to be provided.

Maternal alcohol consumption during pregnancy and child's cognitive performance at 6-8 years of age in rural Burkina Faso: an observational study

Background

In Burkina Faso, it is not uncommon for mothers to drink alcohol, even during pregnancy. We aimed to study the association between maternal alcohol consumption during pregnancy and the child’s cognitive performance using the Kaufman Assessment Battery for Children, 2nd edition (KABC-II) and the Children’s Category Test Level 1 (CCT-1) in rural Burkina Faso.

Methods

We conducted a follow-up study of a community cluster-randomised Exclusive breastfeeding trial, and re-enrolled the children in rural Burkina Faso. A total of 518 children (268 boys and 250 girls) aged 6–8 years were assessed using the KABC-II and the CCT-1. We examined the effect size difference using Cohen’s d and conducted a linear regression analysis to examine the association.

Results

Self-reported alcohol consumption during pregnancy was 18.5% (96/518). Children whose mothers reported alcohol consumption during pregnancy performed significantly poorly for memory and spatial abilities tests from small effect size difference for ‘Atlantis’ (0.27) and ‘Triangle’ (0.29) to moderate effect size difference for ‘Number recall’ (0.72) compared to children whose mothers did not consume alcohol during pregnancy; the exposed children scored significantly higher errors with a small effect size (0.37) at problem solving (CCT-1) test compared to unexposed children.

At unstandardized and standardized multivariable analysis, children whose mothers reported alcohol consumption during pregnancy performed significantly poorer for memory-‘Atlantis’ (p = 0.03) and ‘Number recall’ (p = 0.0001), and spatial ability tests-‘Triangle’ (p = 0.03); they scored significantly higher errors at problem solving CCT-1 test (p = 0.002); all the results were adjusted for age, sex, schooling, stunting, father’s education, mother’s employment and the promotion of exclusive breastfeeding. No statistical association was found for visual abilities-‘Conceptual Thinking’, ‘Face recognition’, ‘Story completion’, and reasoning tests-‘Rover’, ‘Block counting’, and ‘Pattern Reasoning’.

Conclusion

Maternal alcohol consumption during pregnancy is associated with poorer cognitive performance for memory, spatial ability, and problem solving tests in the offspring in rural Burkina Faso. Futures studies needs to assess in more detail the maternal alcohol consumption patterns in Burkina Faso and possible preventive strategies.

Seasonal variation in child mortality in rural Guinea-Bissau

Objectives

In many African countries, child mortality is higher in the rainy season than in the dry season. We investigated the effect of season on child mortality by time periods, sex and age in rural Guinea‐Bissau.

Methods

Bandim health project follows children under‐five in a health and demographic surveillance system in rural Guinea‐Bissau. We compared the mortality in the rainy season (June to November) between 1990 and 2013 with the mortality in the dry season (December to May) in Cox proportional hazards models providing rainy vs. dry season mortality rate ratios (r/d‐mrr). Seasonal effects were estimated in strata defined by time periods with different frequency of vaccination campaigns, sex and age (<1 month, 1–11 months, 12–59 months). Verbal autopsies were interpreted using InterVa‐4 software.

Results

From 1990 to 2013, overall mortality was declined by almost two‐thirds among 81 292 children (10 588 deaths). Mortality was 51% (95% ci: 45–58%) higher in the rainy season than in the dry season throughout the study period. The seasonal difference increased significantly with age, the r/d‐mrr being 0.94 (0.86–1.03) among neonates, 1.57 (1.46–1.69) in post‐neonatal infants and 1.83 (1.72–1.95) in under‐five children (P for same effect <0.001). According to the InterVa, malaria deaths were the main reason for the seasonal mortality difference, causing 50% of all deaths in the rainy season, but only if the InterVa included season of death, making the argument self‐confirmatory.

Conclusion

The mortality declined throughout the study, yet rainy season continued to be associated with 51% higher overall mortality.

A cohort study of low birth weight and health outcomes in the first year of life, Ghana

Objective

To investigate the effect of birth weight on infant mortality, illness and care seeking in rural Ghana.

Methods

Using randomized controlled trial data, we compared infants weighing 2.00–2.49, 1.50–1.99 and < 1.50 kg with non-low-birth-weight infants. We generated adjusted mortality hazard ratios (aHR), adjusted illness rate ratios (aRR) and adjusted odds ratios (aOR) for health-facility admissions and absence of care seeking for four time periods: infancy, the neonatal period, early infancy and late infancy – represented by ages of 0–364, 0–27, 28–182 and 183–364 days, respectively.

Findings

Among 22 906 infants, compared with non-low-birth-weight infants: (i) infants weighing 2.00–2.49, 1.50–1.99 and < 1.50 kg were about two (aHR: 2.13; 95% confidence interval, CI: 1.76–2.59), eight (aHR: 8.21; 95% CI: 6.26–10.76) and 25 (aHR: 25.38; 95% CI: 18.36–35.10) times more likely to die in infancy, respectively; (ii) those born weighing < 1.50 kg were about 48 (aHR: 48.45; 95% CI: 32.81–71.55) and eight (aHR: 8.42; 95% CI: 3.09–22.92) times more likely to die in the neonatal period and late infancy, respectively; (iii) those born weighing 1.50–1.99 kg (aRR: 1.57; 95% CI: 1.27–1.95) or < 1.50 kg (aRR: 1.58; 95% CI: 1.13–2.21) had higher neonatal illness rates; and (iv) for those born weighing 1.50–1.99 kg, care was less likely to be sought in the neonatal period (aOR: 3.30; 95% CI: 1.98–5.48) and early infancy (aOR : 1.74; 95% CI: 1.26–2.39).

Conclusion

For low-birth-weight infants in Ghana, strategies to minimize mortality and improve care seeking are needed.

Analysis of risk factors for infant mortality in the 1992-3 and 2002-3 birth cohorts in rural Guinea-Bissau

Introduction

Though still high, the infant mortality rate in Guinea-Bissau has declined. We aimed to identify risk factors including vaccination coverage, for infant mortality in the rural population of Guinea-Bissau and assess whether these risk factors changed from 1992–3 to 2002–3.

Methods

The Bandim Health Project (BHP) continuously surveys children in rural Guinea-Bissau. We investigated the association between maternal and infant factors (especially DTP and measles coverage) and infant mortality. Hazard ratios (HR) were calculated using Cox regression. We tested for interactions with sex, age groups (defined by current vaccination schedule) and cohort to assess whether the risk factors were the same for boys and girls, in different age groups in 1992–3 and in 2002–3.

Results

The infant mortality rate declined from 148/1000 person years (PYRS) in 1992–3 to 124/1000 PYRS in 2002–3 (HR = 0.88;95%CI:0.77–0.99); this decline was significant for girls (0.77;0.64–0.94) but not for boys (0.97;0.82–1.15) (p = 0.10 for interaction). Risk factors did not differ significantly by cohort in either distribution or effect. Mortality decline was most marked among girls aged 9–11 months (0.56;0.37–0.83). There was no significant mortality decline for girls 1.5–8 months of age (0.93;0.68–1.28) (p = 0.05 for interaction). DTP and measles coverage increased from 1992–3 to 2002–3.

Conclusions

Risk factors did not change with the decline in mortality. Due to beneficial non-specific effects for girls, the increased coverage of measles vaccination may have contributed to the disproportional decline in mortality by sex and age group.

Classification systems for causes of stillbirth and neonatal death, 2009-2014: an assessment of alignment with characteristics for an effective global system

Background

To reduce the burden of 5.3 million stillbirths and neonatal deaths annually, an understanding of causes of deaths is critical. A systematic review identified 81 systems for classification of causes of stillbirth (SB) and neonatal death (NND) between 2009 and 2014. The large number of systems hampers efforts to understand and prevent these deaths. This study aimed to assess the alignment of current classification systems with expert-identified characteristics for a globally effective classification system.

Methods

Eighty-one classification systems were assessed for alignment with 17 characteristics previously identified through expert consensus as necessary for an effective global system. Data were extracted independently by two authors. Systems were assessed against each characteristic and weighted and unweighted scores assigned to each. Subgroup analyses were undertaken by system use, setting, type of death included and type of characteristic.

Results

None of the 81 systems were aligned with more than 9 of the 17 characteristics; most (82 %) were aligned with four or fewer. On average, systems were aligned with 19 % of characteristics. The most aligned system (Frøen 2009-Codac) still had an unweighted score of only 9/17. Alignment with individual characteristics ranged from 0 to 49 %. Alignment was somewhat higher for widely used as compared to less used systems (22 % v 17 %), systems used only in high income countries as compared to only in low and middle income countries (20 % vs 16 %), and systems including both SB and NND (23 %) as compared to NND-only (15 %) and SB-only systems (13 %). Alignment was higher with characteristics assessing structure (23 %) than function (15 %).

Conclusions

There is an unmet need for a system exhibiting all the characteristics of a globally effective system as defined by experts in the use of systems, as none of the 81 contemporary classification systems assessed was highly aligned with these characteristics. A particular concern in terms of global effectiveness is the lack of alignment with “ease of use” among all systems, including even the most-aligned. A system which meets the needs of users would have the potential to become the first truly globally effective classification system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1040-7) contains supplementary material, which is available to authorized users.

Infant mortality and causes of infant deaths in rural Ethiopia: a population-based cohort of 3684 births

Background

Ethiopia has made large-scale healthcare investments to improve child health and survival. However, there is insufficient population level data on the current estimates of infant mortality rate (IMR) in the country. The aim of this study was to measure infant mortality rate, investigate risk factors for infant deaths and identify causes of death in a rural population of northern Ethiopia.

Methods

Live births to a cohort of mothers under the Kilite Awlaelo Health and Demographic Surveillance System were followed up to their first birthday or death, between September 11, 2009 and September 10, 2013. Maternal and infant characteristics were collected at baseline and during the regular follow-up visit. Multiple-Cox regression was used to investigate risk factors for infant death. Causes of infant death were identified using physician review verbal autopsy method.

Results

Of the total 3684 infants followed, 174 of them died before their first birthday, yielding an IMR of 47 per 1000 live births (95 % CI: 41, 54) over the four years of follow-up. About 96 % of infants survived up to their first birthday, and 56 % of infant deaths occurred during the neonatal period. Infants born to mothers aged 15–19 years old had higher risk of death (HR = 2.68, 95 % CI: 1. 74, 4.87) than those born to 25–29 years old. Infants of mothers who attained a secondary school and above had 56 % lower risk of death (HR = 0.44, 95 % CI: 0.24, 0.81) compared to those whose mothers did not attend formal education. Sepsis, prematurity and asphyxia and acute lower respiratory tract infections were the commonest causes of death.

Conclusion

The IMR for the four-year period was lower than the national and regional estimates. Our findings suggest the need to improve the newborn care, and empower teenagers to delay teenage pregnancy and attain higher levels of education.

A case-control study of correlates of severe acute maternal morbidity in Kabul, Afghanistan

OBJECTIVE

To identify correlates of severe acute maternal morbidity (SAMM) in Kabul, Afghanistan.

METHODS

The present case-control study enrolled postpartum couples at four public maternity hospitals between September 2007 and December 2009. Eligibility was determined by: spousal consent; SAMM criteria from chart review for cases; and matching by age, parity, and time since previous delivery for controls (uncomplicated deliveries). Staff administered questionnaires to women and their husbands separately. SAMM correlates were analyzed with conditional logistic regression in models including (proximate) and excluding (distal) care factors.

RESULTS

Among 285 case and 285 control couples, the most frequent SAMM diagnoses were obstructed labor (104 [36.5%]) and hemorrhage requiring transfusion (102 [35.8%]). In both models, SAMM was associated with the husband having more than one wife (distal: adjusted odds ratio [aOR] 48.6, 95% CI 5.4-436.5; proximate: 141.8, 3.5-5819.0), prior stillbirth(s) (distal: 16.2, 6.1-42.9; proximate: 8.0, 2.9-22.4), and complications in a prior pregnancy (distal: 5.4, 95% CI 2.5-12.1; proximate: 7.1, 2.5-20.4). In the proximate model, SAMM was associated with visiting another facility before hospitalization (aOR 7.5, 95% CI 3.1-17.9), male-reported planned home delivery (5.5, 1.5-20.0), and provider-determined care-seeking (4.8, 1.6-14.9).

CONCLUSION

Planned home delivery and referral to multiple facilities or by providers are factors associated with SAMM that are potentially amenable to intervention in Afghanistan.

Socioeconomic inequality and its determinants regarding infant mortality in iran

BACKGROUND

Infant mortality rate is a useful indicator of health conditions in the society, the racial and socioeconomic inequality of which is from the most important measures of social inequality.

OBJECTIVES

The aim of this study was to determine the socioeconomic inequality and its determinants regarding infant mortality in an Iranian population.

PATIENTS AND METHODS

This cross-sectional study was performed on 3794 children born during 2010-2011 in Shahroud, Iran. Based on children's addresses and phone numbers, 3412 were available and finally 3297 participated in the study. A data collection form was filled out through interviewing the mothers as well as using health records. Using principal component analysis, the study population was divided to high and low socioeconomic groups based on the case's home asset, education and job of the household's head, marital status, and composition of the household members. Inequality between the groups with regard to infant mortality was investigated by Blinder-Oaxaca decomposition method.

RESULTS

The mortality rate was 15.1 per 1000 live births in the high socioeconomic group and 42.3 per 1000 in the low socioeconomic group. Mother's education, consanguinity of parents, and infant's nutrition type and birth weight constituted 44% of the gap contributing factors. Child's gender, high-risk pregnancy, and living area had no impact on the gap.

CONCLUSIONS

There was considerable socioeconomic inequality regarding infant mortality in Shahroud. Mother's education was the most contributing factor in this inequality.

Relationship between child survival and malaria transmission: an analysis of the malaria transmission intensity and mortality burden across Africa (MTIMBA) project data in Rufiji demographic surveillance system, Tanzania

BACKGROUND

The precise nature of the relationship between malaria mortality and levels of transmission is unclear. Due to methodological limitations, earlier efforts to assess the linkage have lead to inconclusive results. The malaria transmission intensity and mortality burden across Africa (MTIMBA) project initiated by the INDEPTH Network collected longitudinally entomological data within a number of sites in sub-Saharan Africa to study this relationship. This work linked the MTIMBA entomology database with the routinely collected vital events within the Rufiji Demographic Surveillance System to analyse the transmission-mortality relation in the region.

METHODS

Bayesian Bernoulli spatio-temporal Cox proportional hazards models with village clustering, adjusted for age and insecticide-treated nets (ITNs), were fitted to assess the relation between mortality and malaria transmission measured by entomology inoculation rate (EIR). EIR was predicted at household locations using transmission models and it was incorporated in the model as a covariate with measure of uncertainty. Effects of covariates estimated by the model are reported as hazard ratios (HR) with 95% Bayesian confidence interval (BCI) and spatial and temporal parameters are presented.

RESULTS

Separate analysis was carried out for neonates, infants and children 1-4 years of age. No significant relation between all-cause mortality and intensity of malaria transmission was indicated at any age in childhood. However, a strong age effect was shown. Comparing effects of ITN and EIR on mortality at different age categories, a decrease in protective efficacy of ITN was observed (i.e. neonates: HR = 0.65; 95% BCI:0.39-1.05; infants: HR = 0.72; 95% BCI:0.48-1.07; children 1-4 years: HR = 0.88; 95% BCI:0.62-1.23) and reduction on the effect of malaria transmission exposure was detected (i.e. neonates: HR = 1.15; 95% BCI:0.95-1.36; infants: HR = 1.13; 95% BCI:0.98-1.25; children 1-4 years: HR = 1.04; 95% BCI:0.89-1.18). A very strong spatial correlation was also observed.

CONCLUSION

These results imply that assessing the malaria transmission-mortality relation involves more than the knowledge on the performance of interventions and control measures. This relation depends on the levels of malaria endemicity and transmission intensity, which varies significantly between different settings. Thus, sub-regions analyses are necessary to validate and assess reproducibility of findings.

Relationship between household socio-economic status and under-five mortality in Rufiji DSS, Tanzania

Background

Disparities in health outcomes between the poor and the better off are increasingly attracting attention from researchers and policy makers. However, policies aimed at reducing inequity need to be based on evidence of their nature, magnitude, and determinants.

Objectives

The study aims to investigate the relationship between household socio-economic status (SES) and under-five mortality, and to measure health inequality by comparing poorest/least poor quintile mortality rate ratio and the use of a mortality concentration index. It also aims to describe the risk factors associated with under-five mortality at Rufiji Demographic Surveillance Site (RDSS), Tanzania.

Methods

This analytical cross sectional study included 11,189 children under-five residing in 7,298 households in RDSS in 2005. Principal component analysis was used to construct household SES. Kaplan–Meier survival incidence estimates were used for mortality rates. Health inequality was measured by calculating and comparing mortality rates between the poorest and least poor wealth quintile. We also computed a mortality concentration index. Risk factors of child mortality were assessed using Poisson regression taking into account potential confounders.

Results

Under-five mortality was 26.9 per 1,000 person-years [95% confidence interval (CI) (23.7–30.4)]. The poorest were 2.4 times more likely to die compared to the least poor. Our mortality concentration index [−0.16; 95% CI (−0.24, −0.08)] indicated considerable health inequality. Least poor households had a 52% reduced mortality risk [incidence rate ratio (IRR) = 0.48; 95% CI 0.30–0.80]. Furthermore, children with mothers who had attained secondary education had a 70% reduced risk of dying compared to mothers with no education [IRR = 0.30; 95% CI (0.22–0.88)].

Conclusion

Household socio-economic inequality and maternal education were associated with under-five mortality in the RDSS. Targeted interventions to address these factors may contribute towards accelerating the reduction of child mortality in rural Tanzania.