The association between household socio-economic status, maternal socio-demographic characteristics and adverse birth and infant growth outcomes in sub-Saharan Africa: A systematic review

Adverse birth outcomes and infant undernutrition remain the leading causes of morbidity and mortality in sub-Saharan Africa (SSA). Impaired infant growth and development, which often begins during foetal development, may persist during the first 2 years of life and has been associated with higher risks of cardiometabolic diseases. This systematic review assessed the associations between maternal demographic characteristics and household socio-economic status (SES), and preterm birth (PTB), small for gestational age, low birth weight (LBW), stunting, wasting and underweight in children under 2 years of age in SSA countries. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched for publications in three electronic databases (PubMed, Scopus and ScienceDirect). Eleven studies on children under 2 years of age, in four SSA regions, published in English between 1990 and 2018, were included

Demande du travail agricole et bien-être des ménages agricoles sous non-séparabilité au Sud-Kivu (RD Congo)

This study aimed to analyze the welfare impact of labor demand within the Farm Household Model. The study analyzed 350 farm households divided into two distinct rural groupings of South Kivu, Lurhala and Katana in 2017. The data show that the separability hypothesis of decisions is rejected, suggesting a evidence of the imperfection of the rural labor market. Thus, the demand for agricultural labor depends on the shadow wage and the shadow income, among others. In addition, the analysis of labor demand on welfare (Total Annual Agricultural Production as proxy) shows that the demand for family labor for households using hired labor is likely to improve intensively the household welfare than be the demand for family labor or hired labor. This suggests that it is more the combination of the demand for family and hired labor that is likely to maximize the welfare of farm households. Anti-poverty policies should allow farm households to access both family and hired labor work. 1 Est Doctorant à la FASE-UPC,Ce travail visait à analyser l'impact sur le bien-être de la demande du travail dans le cadre du modèle de ménage agricole. L'étude a analysé 350 ménages agricoles répartis en deux groupements ruraux distincts du Sud-Kivu, Lurhala et Katana en 2017. Les données montrent que l'hypothèse de séparabilité des décisions est rejetée, suggérant une étroite évidence de l'imperfection du marché du travail rural. Ainsi, la demande de travail agricole dépend du salaire implicite (shadow wage) et du revenu implicite (shadow income) entre autres. Par ailleurs, l'analyse de la demande de travail sur le bien-être (proxy total production agricole annuelle) montre que la demande du travail familial pour les ménages utilisant la main-d'oeuvre salariée est susceptible d'améliorer plus intensément le bien-être que la demande du travail familial ou du travail salarié. Ce qui suggère que c'est plus la combinaison de la demande de travail familial et salarié qui est susceptible d'optimiser le bien-être des ménages agricoles. Les politiques anti-pauvreté devraient permettre aux ménages agricoles d'accéder à la fois au travail familial comme au travail salarié

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review

Abstract Background In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016. Objectives The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods. Methods We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980–2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework. Results From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce. Conclusions From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed

Starting well: infant feeding in the first six months, Soweto, South Africa

Abstract Background The health and development benefits of exclusive breastfeeding (EBF) for the first six months of life are well documented. However, breastfeeding has also been associated with HIV transmission. With around 30% of pregnant mothers testing HIV-positive during antenatal visits nationally, the potential HIV risks of breastfeeding have been weighed against the benefits. This has resulted in numerous different infant feeding guidelines over the past 20 years, changing with the evidence base for this risk-benefit equation. The latest guidelines were passed in South Africa in 2011, with the South African government deciding to support EBF only for all mothers and to end the programme that, from 2000, had provided free formula to HIV-exposed infants. However, infant feeding decisions are not influenced by health advice alone. Such decisions are made within a context that also includes family, friends, colleagues and social norms; in this context knowledge does not always reign supreme. Interventions to promote breastfeeding need to address existing barriers and amplify facilitators if South Africa hopes to continue increasing EBF beyond the current rate of 32%. In order to invest in the right mix of interventions, insight is needed into the levers of decision-making. Methods A mixed methods study design was applied to respond to the question, “What influences infant feeding decisions during the first six months?” To gain a national and historical perspective, a mixed methods systematic review of 71 articles was conducted for the period 1980-2018 on EBF influences specific to South Africa. Primary cross-sectional data were also collected from 2015-2016 in Soweto, a large urban township outside of Johannesburg. Data collection included a survey of 298 mothers of infants below six months, who were accessing care at community health clinics, and of whom two thirds were HIV positive. Qualitative in-depth interviews with mothers (46), frontline health workers (11) and vi key informants (3) were also conducted. For the systematic review, articles were analysed by method and the findings were then synthesized. Descriptive and inferential statistics were used to analyse the quantitative findings from the survey and thematic analysis was used for qualitative data. Findings Collectively, the findings highlighted longstanding challenges, such as mixed feeding norms and beliefs in milk insufficiency, as well as context-specific barriers to EBF, such as the government’s free formula programme. Evolving definitions of “optimal” feeding were not developed in consultation with communities and thus reflected strong biomedical biases. Health worker counselling content and approaches were identified as highly influential for breastfeeding initiation, with waning influence during the postnatal period except in community health worker programmes. Mothers’ HIV status was very influential in terms of following exclusive feeding practices out of fears of transmission, which was also reflected health workers’ focus on EBF as an HIV-specific issue. Family influences were cited as reasons for abandoning breastfeeding, along with the need for the mother to return to school or work. Honouring traditions and culture were other reasons to mix feed. Specific factors were identified and discussed at all levels of the socio-ecological model. Blind spots in research were also found in terms of who is researched (mostly Black Africans), where (provinces with large research universities) and how (minimal participatory designs). Conclusion A multi-sectoral and multi-level initiative is needed to bring about continued improvements in EBF. Mothers will not be able to act on knowledge without supportive environments, whether they are in health facilities, at home, work, school or in public spaces. Messages about breastfeeding need to emphasize the benefits for all infants, rather than HIVexposed infants only. Similarly, the health risks of mixed feeding need to be explained in a clear, but culturally sensitive manner. Mothers and frontline health workers have abundant insights that can be drawn upon in the creation of supportive interventions. The postpartum period is particularly important, which means more needs to be done to engage directly with families and communities. For those mothers who will not or cannot opt for EBF, there are still mechanisms within public health responses to support the nutrition and growth of their infants. Rather than blaming mothers, collective efforts are needed to support a healthy start for all infants in South Africa

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review.

BackgroundIn 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.ObjectivesThe aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.MethodsWe applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980-2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.ResultsFrom an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.ConclusionsFrom a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed

Body size preferences for women and adolescent girls living in Africa: a mixed-methods systematic review

International audienceObjective: To synthesise evidence on body size preferences for females living in Africa and the factors influencing these. Design: Mixed-methods systematic review including searches on Medline, CINHAL, ASSIA, Web of Science and PsycINFO (PROSPERO CRD42015020509). A sequential-explanatory approach was used to integrate quantitative and qualitative findings. Setting: Urban and rural Africa. Participants: Studies of both sexes providing data on body size preferences for adolescent girls and women aged ≥10 years. Results: Seventy-three articles from twenty-one countries were included: fifty quantitative, fifteen qualitative and eight mixed methods. Most studies reported a preference for normal or overweight body sizes. Some studies of adolescent girls/young women indicated a preference for underweight. Factors influencing preferences for large(r) body sizes included: socio-demographic (e.g. education, rural residency), health-related (e.g. current BMI, pubertal status), psycho-social (e.g. avoiding HIV stigma) and socio-cultural factors (e.g. spouse’s preference, social standing, cultural norms). Factors influencing preferences for slim(mer) body sizes included: socio-demographic (e.g. higher socioeconomic status, urban residency, younger age), health-related (e.g. health knowledge, being nulliparous), psycho-social (e.g. appearance, body size perception as overweight/obese) and socio-cultural factors (e.g. peer pressure, media). Conclusions: Preference for overweight (not obese) body sizes among some African females means that interventions need to account for the array of factors that maintain these preferences. The widespread preference for normal weight is positive in public health terms, but the valorisation of underweight in adolescent girls/young women may lead to an increase in body dissatisfaction. Emphasis needs to be placed on education to prevent all forms of malnutrition

Infection, nutritional status, and body composition: Associations at birth and 6 months postnatally in Soweto, South Africa.

INTRODUCTION: The impact of infection on infant nutritional status, body size, and growth is well documented. However, research into the impact of infection on infant body composition is limited. Greater understanding is, therefore, needed on the effects of infection in early life. METHODS: Associations between a composite morbidity index consisting of the sum of the cumulative tallies for a range of symptoms representing infection and morbidity in the infants and nutritional status (height-for-age (HAZ), and weight-for-height (WHZ)), and body composition (fat-free mass (FFM), fat mass (FM), fat-free mass index (FFMI), and fat mass index (FMI)) at 6 months of age were investigated using hierarchical regression analysis. RESULTS: The sample comprised data between birth and 6 months postnatally, of 156 infants who were a priori born healthy in Soweto, South Africa. Morbidity, over the cumulative period of birth to 6 months, was associated with lower FMI (β = -1.77) and lower FM (β = -0.61), and conversely with higher FFM (β = 0.94), in infants at 6 months. No associations were found between the morbidity index and FFMI, HAZ, and WHZ. Increased birthweight was associated with a higher FFM (β = 0.66), HAZ (β = 1.14), and WHZ (β = 0.87). Finally, safely managed sanitation facilities, representative of reduced environmental exposure to fecal-oral transmission pathways were associated with a higher HAZ (β = 1.21). DISCUSSION: Reduction in FMI and FM and exposure to inflammatory cytokines associated with mounting an immune response could alter phenotypic trajectories during to this period of plasticity. From a public health perspective, these results imply that it is important to intensify efforts to prevent infection in infants in the first 6 months postnatally, and that these efforts should concentrate on access to safely managed sanitation facilities

Body size preferences for women and adolescent girls living in Africa: a mixed-methods systematic review

Objective: To synthesise evidence on body size preferences for females living in Africa and the factors influencing these. Design: Mixed-methods systematic review including searches on Medline, CINHAL, ASSIA, Web of Science and PsycINFO (PROSPERO CRD42015020509). A sequential-explanatory approach was used to integrate quantitative and qualitative findings. Setting: Urban and rural Africa. Participants: Studies of both sexes providing data on body size preferences for adolescent girls and women aged ≥10 years. Results: 73 articles from 21 countries were included: 50 quantitative, 15 qualitative and eight mixed methods. Most studies reported a preference for normal or overweight body sizes. Some studies of adolescent girls/young women indicated a preference for underweight. Factors influencing preferences for large(r) body sizes included: socio-demographic (e.g. education, rural residency), health-related (e.g. current Body Mass Index, pubertal status), psycho-social (e.g. avoiding HIV stigma) and socio-cultural factors (e.g. spouse's preference, social standing, cultural norms). Factors influencing preferences for slim(mer) body sizes included: socio-demographic (e.g. higher socioeconomic status, urban residency, younger age), health-related (e.g. health knowledge, being nulliparous), psycho-social (e.g. appearance, body size perception as overweight/obese), and socio-cultural factors (e.g. peer pressure, media). Conclusions: A preference for overweight (not obese) body sizes among some African females means that interventions need to account for the array of factors that maintain these preferences. The widespread preference for normal weight is positive in public health terms, but the valorisation of underweight in adolescent girls/young women may lead to an increase in body dissatisfaction. Emphasis needs to be placed on education to prevent all forms of malnutrition

Supplementary Information Files for Body size preferences for women and adolescent girls living in Africa: a mixed-methods systematic review

Supplementary Information Files for Body size preferences for women and adolescent girls living in Africa: a mixed-methods systematic reviewObjective: To synthesise evidence on body size preferences for females living in Africa and the factors influencing these. Design: Mixed-methods systematic review including searches on Medline, CINHAL, ASSIA, Web of Science and PsycINFO (PROSPERO CRD42015020509). A sequential-explanatory approach was used to integrate quantitative and qualitative findings. Setting: Urban and rural Africa. Participants: Studies of both sexes providing data on body size preferences for adolescent girls and women aged ≥10 years. Results: 73 articles from 21 countries were included: 50 quantitative, 15 qualitative and eight mixed methods. Most studies reported a preference for normal or overweight body sizes. Some studies of adolescent girls/young women indicated a preference for underweight. Factors influencing preferences for large(r) body sizes included: socio-demographic (e.g. education, rural residency), health-related (e.g. current Body Mass Index, pubertal status), psycho-social (e.g. avoiding HIV stigma) and socio-cultural factors (e.g. spouse's preference, social standing, cultural norms). Factors influencing preferences for slim(mer) body sizes included: socio-demographic (e.g. higher socioeconomic status, urban residency, younger age), health-related (e.g. health knowledge, being nulliparous), psycho-social (e.g. appearance, body size perception as overweight/obese), and socio-cultural factors (e.g. peer pressure, media). Conclusions: A preference for overweight (not obese) body sizes among some African females means that interventions need to account for the array of factors that maintain these preferences. The widespread preference for normal weight is positive in public health terms, but the valorisation of underweight in adolescent girls/young women may lead to an increase in body dissatisfaction. Emphasis needs to be placed on education to prevent all forms of malnutrition.<br