Violent conflict and breastfeeding: the case of Iraq

Background: This study explores the relationship between armed conflict and breastfeeding practices of Iraqi mothers. To date, the relationship between violent conflict and breastfeeding is surprisingly understudied. Especially in the Middle East, which is conflict-prone and has a young population, research on war and household behavior is critical for promoting recovery and sustainable development. Methods: This study employs a unique pairing of the Iraq Body Count Database and the 2006 and 2011 Multiple Indicator Cluster Surveys for Iraq. We use probit models to explore the association between armed conflict and several breastfeeding outcomes – whether a child was ever breastfed, whether a child was breastfed within 1 h after birth, whether a child is currently breastfed, and whether an infant under 6 months of age is exclusively breastfed. Our proxies for conflict intensity are the average rate of conflict-related casualties across the 3 years prior to survey administration and the rate of casualties averaged across the 2 years prior to the birth of the child, in the governorate in which the family resides. We employ a number of other independent variables important for breastfeeding status, including health controls and characteristics of the household, child and mother. We also use a Cox proportional hazards model to study the association between conflict and breastfeeding duration. We complement this analysis with various robustness checks, including disaggregation by year, controls for household wealth and an analysis of breastmilk substitutes and their potential for an interaction with household wealth. Results: We find in our main results that increases in conflict-related casualties are associated with a significant decline in the probability that a child was ever breastfed and a decline in the probability that a child is currently breastfeeding. There is no significant association with exclusive breastfeeding or with initiation of breastfeeding within 1 h after birth. This result is robust to alternative measures of conflict, although some coefficients from estimation based on the 2006 subsample are positive and not significant, and reverse causation is a potential source of bias in interpreting cross-sectional feeding patterns. Results on breastfeeding duration are mixed. Our results also suggest an increase in the use of breastfeeding substitutes like formula concurrent to higher levels of conflict among wealthier households. Conclusion: The results are informative in the context of designing policy aimed at stabilizing the long-term health and productivity of populations in conflict areas. Infant formula provided with the objective of offering temporary relief creates risks, including reducing the probability and duration of breastfeeding. Attention to the supply of health care and to support systems for women, especially skilled breastfeeding support and targeted support to infants dependent on formula, are matters of the utmost urgency during and after conflict periods

Empowered Worldviews: Assessing the Persistence of Psychosocial Intervention Effects in Zambia

Evidence on the persistence of psychosocial outcomes of interventions over the medium and long term, and in the face of shocks and stressors, is limited. We examined the extent to which empowerment associated with a psychosocial, faith-based approach, Empowered Worldview (EWV) persisted 3–5 years post-delivery of the intervention in Zambia among smallholder farmers. The EWV intervention in Zambia was delivered as part of THRIVE, an integrated livelihoods programme. We followed a previous study to disaggregate individual-level empowerment associated with EWV into three domains: internal (which relates to ‘power within’), localised (typically participation and access), and structural (e.g. institutional, environmental, and social structures). To explore the persistence of EWV effects on empowerment, we used mixed methods and longitudinal data collected in 2020 and 2023, which were the midline and endline points of the THRIVE programme. Empirically, we used descriptive and regression analysis to compare internal and localised empowerment levels between the survey rounds (2020 and 2023) across study groups – including groups that received EWV before and after 2020 – and to the control group. We also re- interviewed a subset of EWV participants interviewed in 2020 to understand how empowerment has changed at the individual level over time . The results show levels of internal empowerment associated with the EWV intervention persisted between the midline and endline surveys, especially when combined with THRIVE livelihood interventions. At the midline, 80.0 per cent of THRIVE with EWV participants were empowered, compared to 82.3 per cent at the endline. In contrast, 72.6 per cent and 73.07 per cent of the control sample participants were empowered at the midline and the endline, respectively. Quantitative results further show that localised empowerment significantly improved between survey rounds among participants who received EWV training and is positively associated with internal empowerment, consistent with literature that suggests localised enablers (supporting social environments) are crucial to sustaining internal empowerment. The qualitative data shows that persistent internal and localised empowerment was observed mostly among households in the non- poor wellbeing category, suggesting that additional interventions are needed to reach the poorest participants. Results also show internal and localised empowerment are positively associated with indicators of household resilience. We conclude the paper with recommendations for programming

Social Protection Experiences of and Attitudes Towards New Urban Poor After Covid-19 in Bangladesh

The Covid-19 pandemic led to a large increase in poverty in Bangladesh, especially in urban areas. Rising food prices and high inflation rates further compounded already high levels of socioeconomic uncertainty. Social protection is vital to help mitigate the effects of crisis and make households more resilient to uncertainty. This paper provides insights into urban residents’ experiences of poverty and the support they received since the Covid-19 pandemic, and derives implications for social protection programming in urban Bangladesh. Using secondary longitudinal data collected since the start of the pandemic with new quantitative surveys and qualitative data collected in Kallyanpur, Dhaka and Shantinagar, Chittagong in March 2023, the study points to high levels of precarity; poverty’s toll on mental health; widespread stigmatisation and discrimination of residents of low-income neighbourhoods, and inadequate social protection support. It argues for the need to expand social protection in urban areas; counter area-based discrimination; ensure dignified delivery of assistance, and provide an integrated policy response

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries