Breastfeeding in low-resource settings: Not a "small matter".

Despite its clear biological benefits, many infants globally do not receive exclusive breastfeeding. In a Guest Editorial, Lars Åke Persson discusses what is needed to make breastfeeding the social norm

Early life arsenic exposure, infant and child growth, and morbidity: a systematic review.

Epidemiological studies have suggested a negative association between early life arsenic exposure and fetal size at birth, and subsequently with child morbidity and growth. However, our understanding of the relationship between arsenic exposure and morbidity and growth is limited. This paper aims to systematically review original human studies with an analytical epidemiological study design that have assessed arsenic exposure in fetal life or early childhood and evaluated the association with one or several of the following outcomes: fetal growth, birth weight or other birth anthropometry, infant and child growth, infectious disease morbidity in infancy and early childhood. A literature search was conducted in PubMed, TOXLINE, Web of Science, SciFinder and Scopus databases filtered for human studies. Based on the predefined eligibility criteria, two authors independently evaluated the studies. A total of 707 studies with morbidity outcomes were identified, of which six studies were eligible and included in this review. For the growth outcomes, a total of 2959 studies were found and nine fulfilled the criteria and were included in the review. A majority of the papers (10/15) emanated from Bangladesh, three from the USA, one from Romania and one from Canada. All included studies on arsenic exposure and morbidity showed an increased risk of respiratory tract infections and diarrhea. The findings in the studies of arsenic exposure and fetal, infant, and child growth were heterogeneous. Arsenic exposure was not associated with fetal growth. There was limited evidence of negative associations between arsenic exposures and birth weight and growth during early childhood. More studies from arsenic-affected low- and middle-income countries are needed to support the generalizability of study findings

Nutrition for women and children-Are we doing the right things in the right way?

The Guest Editors for the PLOS Medicine Special Issue on Maternal and Child Health & Nutrition discuss the published research in the context of global priorities for women's and children's health

Free formula milk in the prevention of mother-to-child transmission programme: voices of a peri-urban community in South Africa on policy change.

BACKGROUND: In 2001, South Africa began implementing the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme. This programme included distribution of free formula milk for infants up to 6 months of age at all public health facilities. Effective from 1 January 2011, KwaZulu-Natal became the first province to phase out free formula milk from its PMTCT programme. On 23 August 2011, the South African National Department of Health adopted promotion of exclusive breastfeeding as the national infant feeding strategy and made a decision to withdraw free formula milk from the PMTCT programme. OBJECTIVE: To explore the perceptions and understanding of households at community level on the policy decision to phase out free formula milk from the PMTCT programme in South Africa. METHODS: An exploratory qualitative study was conducted amongst women enrolled in a community randomized trial known as Good Start III. Focus group discussions were held with grandmothers, fathers and teenage mothers; and in-depth interviews were performed with HIV-positive and HIV-negative mothers. Data were analysed using thematic analysis. RESULTS: Identified themes included: (1) variations in awareness and lack of understanding of the basis for the policy change, (2) abuse of and dysfunctional policy as perceived reasons for policy change and (3) proposed strategies for communicating the policy change. CONCLUSION: There is an urgent need to develop a multifaceted communication strategy clearly articulating the reasons for the infant feeding policy change and promoting the new breastfeeding strategy. The communication strategy should take into account inputs from the community. With a supportive environment and one national infant feeding strategy, South Africa has an opportunity to reverse years of poor infant feeding practices and to improve the health of all children in the country

Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis.

BACKGROUND: Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals. METHODS: Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model. RESULTS: Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths. CONCLUSIONS: Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival

Prevention and treatment of suspected pneumonia in Ethiopian children less than five years from household to primary care.

AIM: Ethiopia has implemented the integrated community case management to reduce mortality in childhood diseases. We analysed prevention, care seeking and treatment of suspected pneumonia from household to health facility in Ethiopia. METHODS: Analyses were based on a survey in four regions that included modules covering 5714 households, 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Caregivers of children aged 2-59 months responded to questions on awareness of services and care seeking for suspected pneumonia. Pneumonia-related knowledge of health workers was assessed. RESULTS: When a child had suspected pneumonia, 46% (95% CI: 25,68) sought care at health facilities, and 27% (95% CI: 12,51) received antibiotics. Forty-one per cent had received full immunisation. One-fifth (21%, 95%: 19,22) of the caregivers were aware of pneumonia treatment. Sixty-four per cent of the health extension workers correctly mentioned fast or difficult breathing as signs of suspected pneumonia, and 88% suggested antibiotics treatment. CONCLUSION: The caregivers' awareness of suspected pneumonia treatment and the utilisation of these services were low. Some of the health extension workers were not knowledgeable about suspected pneumonia. Strengthening primary health care, including immunisation, and enhancing the utilisation of services are critical for further reduction of pneumonia mortality

Women's autonomy and social support and their associations with infant and young child feeding and nutritional status: community-based survey in rural Nicaragua.

OBJECTIVE: To evaluate the associations of women's autonomy and social support with infant and young child feeding practices (including consumption of highly processed snacks and sugar-sweetened beverages) and nutritional status in rural Nicaragua. DESIGN: Cross-sectional study. Feeding practices and children's nutritional status were evaluated according to the WHO guidelines complemented with information on highly processed snacks and sugar-sweetened beverages. Women's autonomy was assessed by a seventeen-item questionnaire covering dimensions of financial independence, household-, child-, reproductive and health-related decision making and freedom of movement. Women's social support was determined using the Duke-UNC Functional Social Support Questionnaire. The scores attained were categorized into tertiles. SETTING: Los Cuatro Santos area, rural Nicaragua. SUBJECTS: A total of 1371 children 0-35 months of age. RESULTS: Children of women with the lowest autonomy were more likely to be exclusively breast-fed and continue to be breast-fed, while children of women with middle level of autonomy had better complementary feeding practices. Children of women with the lowest social support were more likely to consume highly processed snacks and/or sugar-sweetened beverages but also be taller. CONCLUSIONS: While lower levels of autonomy and social support were independently associated with some favourable feeding and nutrition outcomes, this may not indicate a causal relationship but rather that these factors reflect other matters of importance for child care

Unreported births and deaths, a severe obstacle for improved neonatal survival in low-income countries; a population based study

<p>Abstract</p> <p>Background</p> <p>In order to improve child survival there is a need to target neonatal mortality. In this pursuit, valid local and national statistics on child health are essential. We analyze to what extent births and neonatal deaths are unreported in a low-income country and discuss the consequences at local and international levels for efforts to save newborn lives.</p> <p>Methods</p> <p>Information on all births and neonatal deaths in Quang Ninh province in Northern Vietnam in 2005 was ascertained by systematic inventory through group interviews with key informants, questionnaires and examination of health facility records. Health care staff at 187 Community Health Centers (CHC) and 18 hospitals, in addition to 1372 Village Health Workers (VHW), were included in the study. Results were compared with the official reports of the Provincial Health Bureau.</p> <p>Results</p> <p>The neonatal mortality rate (NMR) was 16/1000 (284 neonatal deaths/17 519 births), as compared to the official rate of 4.2/1000. The NMR varied between 44/1000 and 10/1000 in the different districts of the province. The under-reporting was mainly attributable to a dysfunctional reporting system and the fact that families, not the health system, were made responsible to register births and deaths. This under-reporting has severe consequences at local, national and international levels. At a local level, it results in a lack of awareness of the magnitude and differentials in NMR, leading to an indifference towards the problem. At a national and international level the perceived low mortality rate is manifested in a lack of investments in perinatal health programs.</p> <p>Conclusion</p> <p>This example of a faulty health information system is reportedly not unique in low and middle income countries where needs for neonatal health reforms are greatest. Improving reporting systems on births and neonatal deaths is a matter of human rights and a prerequisite for reducing neonatal mortality in order to reach the fourth millennium goal.</p