Burden of severe maternal morbidity and association with adverse birth outcomes in sub–Saharan Africa and south Asia: protocol for a prospective cohort study.

OBJECTIVES: The AMANHI morbidity study aims to quantify and describe severe maternal morbidities and assess their associations with adverse maternal, fetal and newborn outcomes in predominantly rural areas of nine sites in eight South Asian and sub-Saharan African countries. METHODS: AMANHI takes advantage of on-going population-based cohort studies covering approximately 2 million women of reproductive age with 1- to 3-monthly pregnancy surveillance to enrol pregnant women. Morbidity information is collected at five follow-up home visits - three during the antenatal period at 24-28 weeks, 32-36 weeks and 37+ weeks of pregnancy and two during the postpartum period at 1-6 days and after 42-60 days after birth. Structured-questionnaires are used to collect self-reported maternal morbidities including hemorrhage, hypertensive disorders, infections, difficulty in labor and obstetric fistula, as well as care-seeking for these morbidities and outcomes for mothers and babies. Additionally, structured questionnaires are used to interview birth attendants who attended women's deliveries. All protocols were harmonised across the sites including training, implementation and operationalising definitions for maternal morbidities. IMPORTANCE OF THE AMANHI MORBIDITY STUDY: Availability of reliable data to synthesize evidence for policy direction, interventions and programmes, remains a crucial step for prioritization and ensuring equitable delivery of maternal health interventions especially in high burden areas. AMANHI is one of the first large harmonized population-based cohort studies being conducted in several rural centres in South Asia and sub-Saharan Africa, and is expected to make substantial contributions to global knowledge on maternal morbidity burden and its implications

Peer Support and Exclusive Breastfeeding Duration in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

Objective: To examine the effect of peer support on duration of exclusive breastfeeding (EBF) in low and middle-income countries (LMICs). Data Sources Medline, EMBASE, and Cochrane Central Register for Controlled Trials were searched from inception to April 2012. Methods: Two authors independently searched, reviewed, and assessed the quality of randomized controlled trials utilizing peer support in LMICs. Meta-analysis and metaregression techniques were used to produce pooled relative risks and investigate sources of heterogeneity in the estimates. Results: Eleven randomized controlled trials conducted at 13 study sites met the inclusion criteria for systematic review. We noted significant differences in study populations, peer counselor training methods, peer visit schedule, and outcome ascertainment methods. Peer support significantly decreased the risk of discontinuing EBF as compared to control (RR: 0.71; 95% CI: 0.61–0.82; I2 = 92%). The effect of peer support was significantly reduced in settings with >10% community prevalence of formula feeding as compared to settings with <10% prevalence (p = 0.048). There was no evidence of effect modification by inclusion of low birth weight infants (p = 0.367) and no difference in the effect of peer support on EBF at 4 versus 6 months postpartum (p = 0.398). Conclusions: Peer support increases the duration of EBF in LMICs; however, the effect appears to be reduced in formula feeding cultures. Future studies are needed to determine the optimal timing of peer visits, how to best integrate peer support into packaged intervention strategies, and the effectiveness of supplemental interventions to peer support in formula feeding cultures

Changing patterns of social inequalities in anaemia among women in India: cross-sectional study using nationally representative data

Objectives: To examine the patterns of social inequalities in anaemia over time among women of reproductive age in India. Design: Repeated cross-sectional study using nationally representative data from the 1998/1999 and 2005/2006 National Family Health Surveys of India. Multivariate modified Poisson regression models were used to assess trends and social inequalities in anaemia. Setting: India. Population 164 600 ever-married women aged 15–49 years (n=79 197 in 1998/1999 and n=85 403 in 2005/2006) from 25 Indian states. Main outcome measure Anaemia status defined by haemoglobin level (<12 g/dl in non-pregnant women, haemoglobin<11 g/dl for pregnant women). Results: Over the 7-year period, anaemia prevalence increased significantly from 51.3% (95% CI 50.6% to 52%) to 56.1% (95% CI 55.4% to 56.8%) among Indian women. This corresponded to a 1.11-fold increase in anaemia prevalence (95% CI 1.09 to 1.13) after adjustment for age and parity, and 1.08-fold increase (95% CI 1.06 to 1.10) after further adjustment for wealth, education and caste. There was marked state variation in anaemia prevalence; in only 4 of the 25 states did anaemia prevalence significantly decline. In both periods, anaemia was socially patterned, being positively associated with lower wealth status, lower education and belonging to scheduled tribes and scheduled castes. In this context of overall increasing anaemia prevalence, adjusted relative and absolute socioeconomic inequalities in anaemia by wealth, education and caste have narrowed significantly over time. Conclusions: The significant increase in anaemia among India's women during this recent period is a matter of concern, and in contrast to secular improvements in other markers of women's health and nutritional status. While socioeconomic inequalities in anaemia persist, the relative and absolute inequalities in anaemia have decreased over time. Future research should explore the causes for these changing patterns, and inform the policy and programmatic response to address anaemia and its inequalities in this vulnerable population

Towards Comprehensive Women's Healthcare in Sub-Saharan Africa: Addressing Intersections Between HIV, Reproductive and Maternal Health

Abstract: This themed supplement to JAIDS: Journal of Acquired Immune Deficiency Syndromes focuses on the critical intersections between HIV, reproductive, and maternal health services in the health systems of sub-Saharan Africa. The epidemiology of HIV among women of reproductive age on the sub-continent demands a holistic conceptualization and comprehensive approaches to ensure that HIV, reproductive, and maternal health are optimally addressed. Yet, in many instances, the national and global responses to these health issues remain siloed. Women's health needs and new global and national guidelines for HIV treatment raise important policy, programmatic, and operational questions regarding service integration, scale-up, and health systems functioning. In June 2013, the Maternal Health Task Force at the Harvard School of Public Health, the United States Agency for International Development, and the United States Centers for Disease Control and Prevention convened an international technical meeting of researchers, policymakers, and practitioners to discuss the existing evidence base about the interconnections between HIV, reproductive, and maternal health and identify the most important knowledge gaps and research priorities. The articles in this special issue deepen and expand on those discussions by (1) providing empirical evidence about challenges, (2) identifying how improving clinical care and models of service delivery, strengthening health systems, and addressing social dynamics can contribute to better outcomes, and (3) mapping future research directions. Together, these articles underscore that new policy frameworks and integrated approaches are necessary but not sufficient to address health system challenges. Addressing the multiple needs of women of reproductive age who are living with HIV or are at risk of acquiring HIV is a complex undertaking that requires improved access to, utilization and quality of comprehensive women's healthcare. Continued evaluation and knowledge generation are needed to ensure that potential health gains are actualized

Pattern and Predictors of Weight Gain During Pregnancy Among HIV-1-Infected Women from Tanzania

Progression of HIV disease is often accompanied by weight loss and wasting. Gestational weight gain is a strong determinant of maternal and neonatal outcomes; however, the pattern and predictors of weight gain during pregnancy among HIV-positive women are unknown. We obtained monthly anthropometric measurements in a cohort of 957 pregnant women from Tanzania who were HIV infected. We estimated the weekly rate of weight gain at various points during the second and third trimesters of pregnancy and computed rate differences between levels of sociodemographic, nutritional, immunologic, and parasitic variables at the first prenatal visit. The change in mid-upper arm circumference (MUAC) from baseline to delivery was also examined. The rate of weight gain decreased progressively during pregnancy. There was an average decline of 1 cm in MUAC between weeks 12 and 38. Lower level of education and helminthic infections at first visit were associated with decreased adjusted rates of weight gain during the third trimester. High baseline MUAC, not contributing to household income, lower serum retinol and selenium concentrations, advanced clinical stage of HIV disease, and malaria infection were related to decreased rates of weight gain during the second trimester. Low baseline CD4 T-cell counts were related to a poorer pattern of weight gain throughout pregnancy. Prevention and treatment of parasitic infections and improvement of nutritional status are likely to enhance the pattern of gestational weight gain among HIV-infected women

Patterns of postnatal growth in HIV-infected and HIV-exposed children

HIV infection can contribute to disturbances in both linear growth and weight gain in early childhood, with disturbances often apparent as early as 3 mo of age. There is little evidence for a difference in the early growth of HIV-exposed but uninfected children compared to healthy controls. Owing to the close association of growth with immune function and clinical progression, an understanding of growth patterns may be an important tool to ensure the provision of appropriate care to HIV-infected and exposed children. Timely growth monitoring may be used to improve the clinical course and quality of life of these children

Vitamin D Status and TB Treatment Outcomes in Adult Patients in Tanzania: A Cohort Study.

Vitamin D is an immunomodulator and can alter response to tuberculosis (TB) treatment, though randomised trials have been inconclusive to date. We present one of the first comprehensive analysis of the associations between vitamin D status and TB treatment, T-cell counts and nutritional outcomes by HIV status. Cohort study. Outpatient clinics in Tanzania. 25-hydroxyvitamin D levels were assessed in a cohort of 677 patients with TB (344 HIV infected) initiating anti-TB treatment at enrolment in a multivitamin supplementation (excluding vitamin D) trial (Clinicaltrials.gov identifier: NCT00197704). Information on treatment outcomes such as failure and relapse, HIV disease progression, T-cell counts and anthropometry was collected routinely, with a median follow-up of 52 and 30 months for HIV-uninfected and HIV-infected patients, respectively. Cox and binomial regression, and generalised estimating equations were used to assess the association of vitamin D status with these outcomes. Mean 25-hydroxyvitamin D concentrations at enrolment were 69.8 (±21.5) nmol/L (27.9 (±8.6) ng/mL). Vitamin D insufficiency (<75 nmol/L) was associated with a 66% higher risk of relapse (95% CI 4% to 164%; 133% higher risk in HIV-uninfected patients). Each unit higher 25-hydroxyvitamin D levels at baseline were associated with a decrease of 3 (p=0.004) CD8 and 3 (p=0.01) CD3 T-cells/µL during follow-up in patients with HIV infection. Vitamin D insufficiency was also associated with a greater decrease of body mass index (BMI; -0.21 kg/m(2); 95% CI -0.39 to -0.02), during the first 8 months of follow-up. No association was observed for vitamin D status with mortality or HIV disease progression. Adequate vitamin D status is associated with a lower risk of relapse and with improved nutritional indicators such as BMI in patients with TB, with or without HIV infection. Further research is needed to determine the optimal dose of vitamin D and effectiveness of daily vitamin D supplementation among patients with TB

The influence of depressive symptoms and school-going status on risky behaviors: a pooled analysis among adolescents in six sub-Saharan African countries

BackgroundEvidence from sub-Saharan Africa (SSA) regarding risky behaviors among adolescents remains scarce, despite the large population (approximately 249 million out of 1.2 billion globally in 2019) of adolescents in the region. We aimed to examine the potential influence of depressive symptoms and school-going status on risky behaviors among adolescents in six SSA countries.MethodsWe used individual cross-sectional data from adolescents aged 10–19 based in eight communities across six SSA countries, participating in the ARISE Network Adolescent Health Study (N = 7,661). Outcomes of interest were cigarette or tobacco use, alcohol use, other substance use, getting into a physical fight, no condom use during last sexual intercourse, and suicidal behavior. We examined the proportion of adolescents reporting these behaviors, and examined potential effects of depressive symptoms [tertiles of 6-item Kutcher Adolescent Depression Scale (KADS-6) score] and school-going status on these behaviors using mixed-effects Poisson regression models. We also assessed effect modification of associations by sex, age, and school-going status.ResultsThe proportion of adolescents reporting risky behaviors was varied, from 2.2% for suicidal behaviors to 26.2% for getting into a physical fight. Being in the higher tertiles of KADS-6 score was associated with increased risk of almost all risky behaviors [adjusted risk ratio (RR) for highest KADS-6 tertile for alcohol use: 1.70, 95% confidence interval (95% CI): 1.48–1.95, p &lt; 0.001; for physical fight: 1.52, 95% CI: 1.36–1.70, p &lt; 0.001; for suicidal behavior: 7.07, 95% CI: 2.69–18.57, p &lt; 0.001]. Being in school was associated with reduced risk of substance use (RR for alcohol use: 0.73, 95% CI: 0.53–1.00, p = 0.047), and not using a condom (RR: 0.81, 95% CI: 0.66–0.99, p = 0.040). There was evidence of modification of the effect of school-going status on risky behaviors by age and sex.ConclusionOur findings reinforce the need for a greater focus on risky behaviors among adolescents in SSA. Addressing depressive symptoms among adolescents, facilitating school attendance and using schools as platforms to improve health may help reduce risky behaviors in this population. Further research is also required to better assess the potential bidirectionality of associations

A Trial of the Effect of Micronutrient Supplementation on Treatment Outcome, T Cell Counts, Morbidity, and Mortality in Adults with Pulmonary Tuberculosis.

Tuberculosis (TB) often coincides with nutritional deficiencies. The effects of micronutrient supplementation on TB treatment outcomes, clinical complications, and mortality are uncertain. We conducted a randomized, double-blind, placebo-controlled trial of micronutrients (vitamins A, B complex, C, and E, as well as selenium) in Dar es Salaam, Tanzania. We enrolled 471 human immunodeficiency virus (HIV)-infected and 416 HIV-negative adults with pulmonary TB at the time of initiating chemotherapy and monitored them for a median of 43 months. Micronutrients decreased the risk ofTB recurrence by 45% overall (95% confidence interval [CI], 7% to 67%; P = .02) and by 63% in HIV-infected patients (95% CI, 8% to 85%; P = .02). There were no significant effects on mortality overall; however, we noted a marginally significant 64% reduction of deaths in HIV-negative subjects (95% CI, -14% to 88%; P = .08). Supplementation increased CD3+ and CD4+ cell counts and decreased the incidence of extrapulmonary TB and genital ulcers in HIV-negative patients. Micronutrients reduced the incidence of peripheral neuropathy by 57% (95% CI, 41% to 69%; P < .001), irrespective of HIV status. There were no significant effects on weight gain, body composition, anemia, or HIV load. Micronutrient supplementation could improve the outcome in patients undergoing TB chemotherapy in Tanzania

Scaling-Up Access to Family Planning May Improve Linear Growth and Child Development in Low and Middle Income Countries

Background: A large literature has indicated a robust association between birth spacing and child survival, but evidence on the association of birth timing with physical growth in low and middle income countries (LMICs) remains limited. Methods and Results: Data from 153 cross-sectional Demographic and Health Surveys (DHS) across 61 LMICs conducted between 1990 and 2011 were combined to assess the association of birth timing with child stunting (height-for-age z-score <−2). A total of 623,789 children of birth order 1–5 contributed to the maternal age analysis, while the birth spacing dataset consisted of 584,226 children of birth order 2 and higher. Compared to 27–34 year old mothers, maternal age under 18 years was associated with a relative stunting risk of 1.35 (95% CI: 1.29–1.40) for firstborn children, whereas the relative risk was 1.24 (95% CI: 1.19–1.29) for mothers aged 18–19 years. The association of young maternal age with stunting was significantly greater for urban residents and those in the top 50% of household wealth. Birth intervals less than 12 months and 12–23 months had relative risks for stunting of 1.09 (95% CI: 1.06–1.12) and 1.06 (95% CI: 1.05–1.06) as compared to a 24–35 month inter-pregnancy interval, respectively. The strength of both teenage pregnancy and short birth interval associations showed substantial variation across WHO region. We estimate that 8.6% (6.9–10.3%) of stunted cases in the South Asian DHS sample would have been averted by jointly eliminating teen pregnancies and birth intervals less than 24 months, while only 3.6% (1.5–5.7%) of stunting cases would have prevented in the Middle East and North Africa sample. Conclusions: Postponing the age of first birth and increasing inter-pregnancy intervals has the potential to significantly reduce the prevalence of stunting and improve child development in LMICs