Apoyando el desarrollo en la primera infancia : de la ciencia a la aplicación a gran escala

Mensajes clave de la serie: Las consecuencias de salud y económicas de no actuar son elevadas. Un alarmante 43% de los niños menores de cinco años que viven en países de ingresos bajos y medianos (en total, unos 250 millones de niños) están en riesgo de tener un desarrollo inadecuado a causa de la pobreza y el retraso del crecimiento.1,4 En realidad, este porcentaje es más elevado porque hay otros factores que representan riesgos para la salud y el bienestar. Un mal comienzo en la vida puede afectar negativamente la salud, la nutrición y el aprendizaje. Estos efectos negativos se extienden a la edad adulta, resultando en bajos ingresos económicos y generando tensiones sociales. Además, estas consecuencias negativas repercuten no solo en la generación actual, sino también en las futuras. Se calcula que los individuos afectados por un mal comienzo en la vida sufren una pérdida de aproximadamente una cuarta parte del promedio anual de ingresos en la edad adulta, mientras que los países pueden perder hasta el doble de su gasto actual del PIB en salud y educación; Los niños pequeños necesitan recibir, desde el principio, un cuidado cariñoso y sensible a sus necesidades. El desarrollo empieza en el momento de la concepción. Los estudios demuestran que la primera infancia no es solamente el período de mayor vulnerabilidad a los factores de riesgo, sino también una etapa crítica en la que los efectos positivos de las intervenciones tempranas son más marcados y en la que se pueden reducir los efectos de los factores que afectan negativamente al desarrollo. La experiencia que influye más en el desarrollo de los niños pequeños es el cuidado cariñoso y sensible que le procuran sus padres, otros familiares, sus cuidadores y los servicios comunitarios. El cuidado cariñoso y sensible a las necesidades del niño se caracteriza por la existencia de un ambiente estable que facilita la buena salud y la nutrición de los niños, que protege al niño de posibles peligros y le ofrece la posibilidad de empezar su aprendizaje a una edad temprana, a través de relaciones e interacciones cariñosas. Los beneficios del cuidado cariñoso y sensible se extienden a toda la vida y se expresan en una mejor salud, mayor bienestar y mayor capacidad de aprender y de ganarse la vida. Las familias necesitan apoyo para proveer el cuidado cariñoso y sensible, incluyendo recursos materiales y económicos, políticas nacionales, como licencias de paternidad remuneradas, y prestación de diversos servicios, incluyendo servicios de salud, nutrición, educación y la protección infantil y social; Debemos de entregar intervenciones multisectoriales comenzando con el sector salud como punto de partida para llegar a los niños más pequeños. El objetivo de estas intervenciones, entre ellas el apoyo a las familias para que puedan proporcionar un cuidado cariñoso y sensible y hagan frente a los problemas que se puedan presentar, es proteger al niño de diversos riesgos que pueden afectar a su desarrollo. Para ello, se pueden integrar las intervenciones en los servicios de salud materno-infantil existentes. Estos servicios deben satisfacer las necesidades tanto del niño como de su cuidador principal. Por tanto, deben apoyar el desarrollo del niño y la salud y el bienestar de la madre y la familia. Este enfoque viable es un punto de partida esencial para establecer colaboraciones multisectoriales de ayuda a las familias que permitan llegar a los niños más pequeños. Estas intervenciones deben satisfacer necesidades básicas como la nutrición, el apoyo al crecimiento y la salud; la protección de los niños; la prevención de la violencia doméstica, la protección social que asegure la estabilidad económica de la familia y la capacidad para acceder a servicios; y la educación que brinde acceso a oportunidades de aprendizaje de calidad a una edad temprana; Debemos reforzar la capacidad de las autoridades gubernamentales para ampliar los servicios que funcionan. Cuatro estudios de casos realizados en países de distintas regiones del mundo demuestran que se pueden llevar a gran escala programas nacionales que son efectivos y sostenibles. Sin embargo, para que esto suceda es un requisito indispensable el contar con liderazgo de las autoridades y dar prioridad a las políticas adecuadas. Los gobiernos disponen de distintas opciones para alcanzar las metas y los objetivos fijados en relación con el desarrollo en la primera infancia, desde iniciativas que promuevan cambios y abarquen a diversos sectores gubernamentales hasta la ampliación progresiva de servicios existentes. Los servicios y las intervenciones en favor del desarrollo de los niños pequeños son fundamentales para que todos ellos alcancen el máximo de su potencial en el transcurso de su vida y para extender estos efectos a la siguiente generación. Este propósito es un elemento central de los Objetivos de Desarrollo Sostenible

Feeding practices of pre-school children and associated factors in Kathmandu, Nepal

Background: In developing countries such as Nepal, many children aged below 3 years do not grow at a sufficiently high rate and are vulnerable to micronutrient deficiencies (e.g. vitamin A). Challenges to child nutrition can result from poverty, unhealthy traditional practices, inadequate caring and feeding practices. The present study aimed to assess the feeding prac- tices of pre-school children and their associated factors. Methods: A cross-sectional study was carried out in pre-schools located in Kathmandu district between February and March 2018. Three levels in terms of price range (lower, medium and higher level) of pre-schools were selected to reach the mothers of children aged ≤3 years. A structured ques- tionnaire was administered to 145 mothers. Descriptive analyses were con- ducted to observe the characteristics of the population. Multinomial logistic regression analyses were performed to identify the association for the factors of mothers’ perception of their current feeding practices. Results: We found that dal-bhat/jaulo was a common complementary food irrespective of socio-economic background. Interestingly, mothers who had received a higher education were significantly less likely to change their feeding practices (odds ratio = 0.118, confidence interval = 0.01–0.94). The mothers that fed a higher quantity porridge to their children showed a high willingness to change the feeding practices. Conclusions: Poor feeding practices are still an important public health problem in Nepal and were observed to be associated with low socio-eco- nomic status, unawareness and a lack of knowledge towards dietary diversity combined with strong beliefs related to social forces and cultures

Analysing success in the fight against malnutrition in Peru

The prevalence of underweight children worldwide fell from 31per cent in 1990 to 26 per cent in 2008 (UNICEF 2009). However, progress is still slow and very uneven. Half of the countries have made progress on hunger, but levels of malnutrition did not improve in 28 countries and got worse in 24. The case of Peru appears to be an encouraging exception to the rule. With the support of CARE and others organisations from civil society and the donor community, the Peruvian Government has generated the political momentum to overcome obstacles and create national coordination structures and mechanisms, increase public (and private) spending on programs to tackle malnutrition and align social programs with the national nutrition strategy (known as CRECER). This included adding conditionalities on taking children to regular growth monitoring in the Conditional Cash Transfer programme, JUNTOS. The international aid system has also aligned itself around CRECER. After ten years of almost no change in child chronic malnutrition (stunting) rates (25.8 per cent in 1996, and 22.9 per cent in 2005 – with rural rates moving from 40.4 per cent to 40.1 per cent), this change in strategy has started to lead to results: malnutrition rates fell to 17.9 per cent between 2005 and 2010, with reductions mainly occurring in rural areas where malnutrition rates are highest (from 40.1per cent in 2005 to 31.3 per cent in 2010) according to the Peruvian National Statistical Office (INEI). Over 130,000 children under five are now not chronically malnourished who would have been had rates not fallen. Indeed, there is a strong case to be made that these changes would not have occurred without the formation in early 2006 of the Child Nutrition Initiative, and its advocacy success in getting ten Presidential candidates to sign a commitment to reduce chronic malnutrition in children under five by 5 per cent in five years (‘5 by 5 by 5’), followed by the support provided subsequently to the new government to meet that commitment. This paper documents and systematises Peru’s recent experience in tackling malnutrition. Through an intensive review of quantitative and qualitative evidence, it argues that success is not explained by the presence of favourable socioeconomic changes in Peru, and it explores the political determinants of success in three dimensions. Horizontally, it looks at government efforts to form policy coalitions across representatives of different government and non-government agencies; it looks at the vertical integration of agencies and programmes between national, regional and municipal governments, and it analyses the allocation of government resources used to fund the government’s nutrition effort. In closing, the paper identifies some salient challenges to ensure long term sustainability of the initiative and draws policy recommendations and knowledge sharing lessons that could be of use for Southern Governments, donor agencies and civil society organisations. Keywords: Peru; political economy; malnutrition; sub national politics; poverty reduction; political parties

Progressing Gender Equality Post?2015: Harnessing the Multiplier Effects of Existing Achievements

This article argues that international efforts to progress gender equality now and post?2015 need to build on the achievements of the MDGs and other international frameworks, but simultaneously address the gender dynamics that underpin the root causes of poverty. The first half of the article seeks to unpack the ways in which gender inequalities underpin five clusters of MDGs: poverty and sustainable development; service access; care and caregiving; voice and agency; international partnerships and accountability. The analysis then turns to highlight the importance of harnessing the momentum from other global initiatives such as CEDAW (Convention on the Elimination of All Forms of Discrimination against Women) and the Beijing Platform for Action to promote more fundamental change including: the establishment of a more powerful UN agency to champion gender equality; the institutionalisation of gender budgeting and gender?responsive aid effectiveness approaches; and the promotion of gender?sensitive social protection to tackle gender?specific experiences of poverty and vulnerability

Prevalence and factors associated with non-utilization of healthcare facility for childbirth in rural and urban Nigeria: Analysis of a national population-based survey

Aim: The aim of this study was to assess the rural–urban differences in the prevalence and factors associated with non-utilization of healthcare facility for childbirth (home delivery) in Nigeria. Methods: Dataset from the Nigeria demographic and health survey, 2013, disaggregated by rural–urban residence were analyzed with appropriate adjustment for the cluster sampling design of the survey. Factors associated with home delivery were identified using multivariable logistic regression analysis. Results: In rural and urban residence, the prevalence of home delivery were 78.3% and 38.1%, respectively (p < 0.001). The lowest prevalence of home delivery occurred in the South-East region for rural residence (18.6%) and the South-West region for urban residence (17.9%). The North-West region had the highest prevalence of home delivery, 93.6% and 70.5% in rural and urban residence, respectively. Low maternal as well as paternal education, low antenatal attendance, being less wealthy, the practice of Islam, and living in the North-East, North-West and the South-South regions increased the likelihood of home delivery in both rural and urban residences. Whether in rural or urban residence, birth order of one decreased the likelihood of home delivery. In rural residence only, living in the North-Central region increased the chances of home delivery. In urban residence only, maternal age ⩾ 36 years decreased the likelihood of home delivery, while ‘Traditionalist/other’ religion and maternal age < 20 years increased it. Conclusion: The prevalence of home delivery was much higher in rural than urban Nigeria and the associated factors differ to varying degrees in the two residences. Future intervention efforts would need to prioritize findings in this study

Global poverty and the new bottom billion: what if three-quarters of the world's poor live in middle-income countries?

This paper argues that the global poverty problem has changed because most of the world’s poor no longer live in low income countries (LICs). Previously, poverty was viewed as an LIC issue predominantly; nowadays such simplistic assumptions/ classifications are misleading because some large countries that graduated into the MIC category still have large numbers of poor people. In 1990, we estimate 93 per cent of the world’s poor lived in LICs; contrastingly in 2007–8 three quarters of the world’s poor approximately 1.3bn lived in middle-income countries (MICs) and about a quarter of the world’s poor, approximately 370mn people live in the remaining 39 low-income countries – largely in sub-Saharan Africa. This startling change over two decades implies a new ‘bottom billion’ who do not live in fragile and conflict-affected states, but in stable, middle-income countries. Such global patterns are evident across monetary, nutritional and multi-dimensional poverty measures. This paper argues the general pattern is robust enough to warrant further investigation and discussion

Percent Fat Mass Increases with Recovery, But Does Not Vary According to Dietary Therapy in Young Malian Children Treated for Moderate Acute Malnutrition.

BackgroundModerate acute malnutrition (MAM) affects 34.1 million children globally. Treatment effectiveness is generally determined by the amount and rate of weight gain. Body composition (BC) assessment provides more detailed information on nutritional stores and the type of tissue accrual than traditional weight measurements alone.ObjectiveThe aim of this study was to compare the change in percentage fat mass (%FM) and other BC parameters among young Malian children with MAM according to receipt of 1 of 4 dietary supplements, and recovery status at the end of the 12-wk intervention period.MethodsBC was assessed using the deuterium oxide dilution method in a subgroup of 286 children aged 6-35 mo who participated in a 12-wk community-based, cluster-randomized effectiveness trial of 4 dietary supplements for the treatment of MAM: 1) lipid-based, ready-to-use supplementary food (RUSF); 2) special corn-soy blend "plus plus" (CSB++); 3) locally processed, fortified flour (MI); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). Multivariate linear regression modeling was used to evaluate change in BC parameters by treatment group and recovery status.ResultsMean&nbsp;±&nbsp;SD %FM at baseline was 28.6%&nbsp;±&nbsp;5.32%. Change in %FM did not vary between groups. Children who received RUSF vs. MI gained more (mean; 95% CI) weight (1.43; 1.13, 1.74 kg compared with 0.84; 0.66, 1.03 kg; P&nbsp;=&nbsp;0.02), FM (0.70; 0.45, 0.96 kg compared with 0.20; 0.05, 0.36 kg; P&nbsp;=&nbsp;0.01), and weight-for-length z score (1.23; 0.79, 1.54 compared with 0.49; 0.34, 0.71; P&nbsp;=&nbsp;0.03). Children who recovered from MAM exhibited greater increases in all BC parameters, including %FM, than children who did not recover.ConclusionsIn this study population, children had higher than expected %FM at baseline. There were no differences in %FM change between groups. International BC reference data are needed to assess the utility of BC assessment in community-based management of acute malnutrition programs. This trial was registered at clinicaltrials.gov as NCT01015950

Progress towards the achievement of MDG4 in the Commonwealth of Independent States: uncertain data, clear priorities

Data on under five mortality in the twelve countries of the Commonwealth of Independent States show important fluctuations over time due to variations in quality of data, definitions of neonatal deaths and methods of mortality estimation. Despite the uncertainties regarding mortality trends, the analysis of health and social information from different sources offers clues to identify priority areas and key strategic directions for accelerating the achievement of the 4th Millennium Development Goal. Neonatal deaths represent from 40% to over 50% of under five deaths in all these countries. Maternal mortality was above 50 per 100,000 in 2005, despite the good coverage with antenatal care and births assisted by skilled birth attendants. The scanty information on quality of perinatal care indicates widespread substandard care at all levels. Stunting in children under five is above 10% in ten out of twelve countries and coexists with emerging overweight. Exclusivity and duration of breastfeeding fall short of what is recommended. There are important inequalities in child and maternal mortality, malnutrition and access and use of health services within countries. Taken as a whole, the available information clearly indicates that priority should be given to improvement of the health of women in reproductive age and of the quality of perinatal care, including the establishment of reliable data collection systems. To achieve this, action will need to focus on strengthening the capacity of the health system to improve the technical content of service provision, and on improving access and appropriate use of services by the most disadvantaged groups. The involvement of other sectors will be necessary to improve reproductive health and nutrition at community level and to tackle inequity. Comparisons between countries with similar socioeconomic background but different health policies seem to indicate that gradual progression towards universal coverage with essential health care through a national health insurance system is associated with larger reduction of child mortality than troubled transition towards a privatized and unregulated health system

The burden of child maltreatment in the East Asia and Pacific region

This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. Systematic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child maltreatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region’s per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US$151 billion, accounting for 1.88% of the region’s GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child maltreatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally

Indicators for Women's Health in Developing Countries: What They Reveal and Conceal

Summary The health of women has recently resurfaced in the health policy debate and has tended to become viewed as important primarily because of its contribution to infant health. Maternal deaths are characterised by a range of fairly typical causes, all of which can normally be prevented with good obstetric medical services and antenatal care. The most widely used indicator, the maternal mortality rare, is closely associated with a range of socioeconomic determinants; most notably poverty and access to obstetric services, which suggests that medicine alone cannot solve the whole problem. Factors such as urbanization, female secondary education, contraceptive prevalence and fertility all appear to be important intermediate determinants, which highlight the fact that the problem is really rooted in a much wider one of the status and role of women in development. The indicator of the maternal mortality rate itself actually underestimates the true impact of fertility on women's health. The indicator of lifetime risk (of dying in childbirth) is much more relevant and it provides an even starker picture of differentials in health risks, and the role fertility plays in these risks. It puts fertility back into women's health and the object of measurement is women's lives rather than the disembodied event of birth. Resumé Indicateurs de la santé des femmes dans les pays en voie de développement: ce qu'ils révèlent et ce qu'ils cachent Le sujet de la santé des femmes remonte à la surface dans le débat concernant les politiques de santé; ce sujet a été censé important, du moins récemment, en raison principalement de sa contribution à la santé infantile. Les décès maternels sont caractérisés par une gamme de causes relativement typiques et qu'il est normalement possible d'éviter moyennant une bonne obstétrique médicale et des soins adéquats en période prénatale. L'indicateur le plus fréquemment employé, le taux de mortalité maternel, est étroitement lié à une gamme de déterminants socio?économiques, notamment la pauvreté et l'accès aux services obstétriques, qui suggèrent que l'accès à la médecine seule ne peut entièrement résoudre le problème. Les facteurs tels que l'urbanisation, l'enseignement secondaire des femmes, la disponibilité de la contraception et la fécondité sembleraient tous être des indicateurs d'ordre intermédiaire, et ceci aurait tendance à souligner le fait que le problème véritable est effectivement encastré dans un problème encore plus grave, à savoir celui du rôle et de la situation des femmes dans le développement. L'indicateur de mortalité maternelle sous?estime en fait l'impact véritable de la fertilité sur la santé des femmes. L'indicateur de risque à longueur de vie (de mourir durant un accouchement) est beaucoup plus approprié et offre une image encore plus déprimante des différentiels dans les risques à la santé, et du rôle que la fertilité joue dans ces risques. Cet indicateur remet en cause la fertilité au sein de la santé des femmes et en fait une mesure de la vie des femmes, à la place du simple événement qu'est tel ou tel accouchement. Resumen Indicadores de salud femenina en los países en desarrollo: lo que revelan y lo que ocultan El tema de la salud de la mujer ha resurgido recientemente en el debate sobre directivas de salud, y la tendencia ha sido considerarlo importante primordialmente por su contribución a la salud infantil. Las muertes maternales tienen una serie de causas bastante típicas, todas las cuales pueden normalmente ser evitadas con buenos servicios obstétricos y cuidados prenatales. El indicator más usado, la tasa de mortalidad maternal, está asociado a los determinantes socioeconómicos, notablemente la pobreza y la falta de acceso a los servicios ginecológicos, lo que sugiere que la medicina no puede resolver todo el problema por sí sola. Factores como la urbanización, la educación secundaria femenina, la prevalencia anticonceptiva y la fertilidad parecen ser importantes determinantes intermedios, y eso destaca el hecho de que el problema está realmente enraizado en otro mucho mas amplio: la condición y el papel de la mujer en el desarrollo. El indicador de la tasa de mortalidad maternal en realidad subestima el verdadero impacto de la fertilidad en la salud femenina. El indicador de riesgo vital: muerte de parto es mucho más significativo y da una imagen aún más severa de los diferenciales en riesgos de salud y el papel jugado por la fertilidad en esos riesgos. Pone a la fertilidad dentro de la salud femenina nuevamente, y lo que se mide es la vida de la mujer en vez del evento aislado del parto