How Mistimed and Unwanted Pregnancies Affect Timing of Antenatal Care Initiation in three Districts in Tanzania

Early antenatal care (ANC) initiation is a doorway to early detection and management of potential complications associated with pregnancy. Although the literature reports various factors associated with ANC initiation such as parity and age, pregnancy intentions is yet to be recognized as a possible predictor of timing of ANC initiation. Data originate from a cross-sectional household survey on health behaviour and service utilization patterns. The survey was conducted in 2011 in Rufiji, Kilombero and Ulanga districts in Tanzania on 910 women of reproductive age who had given birth in the past two years. ANC initiation was considered to be early only if it occurred in the first trimester of pregnancy gestation. A recently completed pregnancy was defined as mistimed if a woman wanted it later, and if she did not want it at all the pregnancy was termed as unwanted. Chisquare was used to test for associations and multinomial logistic regression was conducted to examine how mistimed and unwanted pregnancies affect timing of ANC initiation. Although 49.3% of the women intended to become pregnant, 50.7% (34.9% mistimed and 15.8% unwanted) became pregnant unintentionally. While ANC initiation in the 1st trimester was 18.5%, so was 71.7% and 9.9% in the 2nd and 3rd trimesters respectively. Multivariate analysis revealed that ANC initiation in the 2nd trimester was 1.68 (95% CI 1.10‒2.58) and 2.00 (95% CI 1.05‒3.82) times more likely for mistimed and unwanted pregnancies respectively compared to intended pregnancies. These estimates rose to 2.81 (95% CI 1.41‒5.59) and 4.10 (95% CI 1.68‒10.00) respectively in the 3rd trimester. We controlled for gravidity, age, education, household wealth, marital status, religion, district of residence and travel time to a health facility. Late ANC initiation is a significant maternal and child health consequence of mistimed and unwanted pregnancies in Tanzania. Women should be empowered to delay or avoid pregnancies whenever they need to do so. Appropriate counseling to women, especially those who happen to conceive unintentionally is needed to minimize the possibility of delaying ANC initiation.\u

A Good Samaritan inspired foundation for a fair health care system

Distributive justice on the income and on the service aspects is the most vexing modern day problem for the creation and maintenance of an all inclusive health care system. A pervasive problem of all current schemes is the lack of effective cost control, which continues to result in increasing burdens for all public and private stakeholders. This proposal posits that the responsibility and financial obligation to achieve an ideal outcome of equal and affordable access and benefits for all citizens is misplaced. The Good Samaritan demonstrated basic ethical principles, which are revisited, elaborated and integrated into a new approach to health care. The participants are limited to individual contributors and beneficiaries and organized as a citizen carried, closed, independent, and self-sufficient self-governing cooperative for their own and the benefit of a minority of disadvantaged health care consumers. The government assumes oversight, provides arbitration, enforces democratic decision making, a scheme of progressive taxation, a separate and transparent accounting system, and a balance between income and reinvestment in health care. The results are a fair distribution of cost, its effective control, and increased individual motivation to take on responsibility for personal health as a private good and a sharpened focus towards community health. At the sociopolitical level the government as well as employers are released from the inappropriate burden of catering to individual health

What are the living conditions and health status of those who don't report their migration status? a population-based study in Chile

BACKGROUND: Undocumented immigrants are likely to be missing from population databases, making it impossible to identify an accurate sampling frame in migration research. No population-based data has been collected in Chile regarding the living conditions and health status of undocumented immigrants. However, the CASEN survey (Caracterizacion Socio- Economica Nacional) asked about migration status in Chile for the first time in 2006 and provides an opportunity to set the base for future analysis of available migration data. We explored the living conditions and health of self-reported immigrants and respondents who preferred not to report their migration status in this survey. METHODS: Cross-sectional secondary analysis of CASEN survey in Chile in 2006. Outcomes: any disability, illness/accident, hospitalization/surgery, cancer/chronic condition (all binary variables); and the number of medical/emergency attentions received (count variables). Covariates: Demographics (age, sex, marital status, urban/rural, ethnicity), socioeconomic status (education level, employment status and household income), and material standard of living (overcrowding, sanitation, housing quality). Weighted regression models were estimated for each health outcome, crude and adjusted by sets of covariates, in STATA 10.0. RESULTS: About 1% of the total sample reported being immigrants and 0.7% preferred not to report their migration status (Migration Status - Missing Values; MS-MV). The MS-MV lived in more deprived conditions and reported a higher rate of health problems than immigrants. Some gender differences were observed by health status among immigrants and the MS-MV but they were not statistically significant. Regressions indicated that age, sex, SES and material factors consistently affected MS-MVs’ chance of presenting poor health and these patterns were different to those found among immigrants. Great heterogeneity in both the MS-MV and the immigrants, as indicated by wide confidence intervals, prevented the identification of other significantly associated covariates. CONCLUSION: This is the first study to look at the living conditions and health of those that preferred not to respond their migration status in Chile. Respondents that do not report their migration status are vulnerable to poor health and may represent undocumented immigrants. Surveys that fail to identify these people are likely to misrepresent the experiences of immigrants and further quantitative and qualitative research is urgently required

Does the timing of parental migration matter for child growth? A life course study on left-behind children in rural China

BACKGROUND: China’s unprecedented internal migration has left 61 million rural children living apart from parents. This study investigates how being left behind is associated with children’s growth, by examining children’s height and weight trajectories by age, testing the accumulation and critical period life course hypotheses. METHODS: Data were drawn from five waves of the China Health and Nutrition Survey (CHNS). Multiple cohorts of children under 6 years old from 1997–2009 were examined (N = 2,555). Growth curve models investigated whether height and weight trajectories differ for children who were left behind at different stages of the life course: in early childhood (from ages 0–5 but not afterwards), in later childhood (from ages 6 to 17 only), and in both early and later childhood (from ages 0–5 and from ages 6–17), compared to their peers from intact households. RESULTS: Boys who were left behind at different life stages of childhood differed in height and weight growth compared with boys from intact families. No significant associations were found for girls. As young boys turned into adolescents, those left behind in early childhood tended to have slower height growth and weight gain than their peers from intact households. There was a 2.8 cm difference in the predicted heights of boys who were left behind in early childhood compared to boys from intact households, by the age of 14. Similarly, the difference in weight between the two groups of boys was 5.3 kg by the age of 14. CONCLUSIONS: Being left behind during early childhood, as compared to not being left behind, could lead to slower growth rates of height and weight for boys. The life course approach adopted in this study suggests that early childhood is a critical period of children’s growth in later life, especially for boys who are left behind. The gender paradox in China, where sons are preferred, but being left behind appears to affect boys more than girls, needs further exploration

Associations of vitamin D pathway genes with circulating 25-hydroxyvitamin-D, 1,25-dihydroxyvitamin-D, and prostate cancer:a nested case-control study

Vitamin D pathway single nucleotide polymorphisms (SNPs) are potentially useful proxies for investigating whether circulating vitamin D metabolites [total 25-hydroxyvitamin-D, 25(OH)D; 1,25-dihydroxyvitamin, 1,25(OH)2D] are causally related to prostate cancer. We investigated associations of sixteen SNPs across seven genes with prostate-specific antigen-detected prostate cancer

Tracking progress towards equitable child survival in a Nicaraguan community: neonatal mortality challenges to meet the MDG 4

<p>Abstract</p> <p>Background</p> <p>Nicaragua has made progress in the reduction of the under-five mortality since 1980s. Data for the national trends indicate that this poor Central American country is on track to reach the Millennium Development Goal-4 by 2015. Despite this progress, neonatal mortality has not showed same progress. The aim of this study is to analyse trends and social differentials in neonatal and under-five mortality in a Nicaraguan community from 1970 to 2005.</p> <p>Methods</p> <p>Two linked community-based reproductive surveys in 1993 and 2002 followed by a health and demographic surveillance system providing information on all births and child deaths in urban and rural areas of León municipality, Nicaragua. A total of 49 972 live births were registered.</p> <p>Results</p> <p>A rapid reduction in under-five mortality was observed during the late 1970s (from 103 deaths/1000 live births) and the 1980s, followed by a gradual decline to the level of 23 deaths/1000 live births in 2005. This community is on track for the Millennium Development Goal 4 for improved child survival. However, neonatal mortality increased lately in spite of a good coverage of skilled assistance at delivery. After some years in the 1990s with a very small gap in neonatal survival between children of mothers of different educational levels this divide is increasing.</p> <p>Conclusions</p> <p>After the reduction of high under-five mortality that coincided with improved equity in survival in this Nicaraguan community, the current challenge is the neonatal mortality where questions of an equitable perinatal care of good quality must be addressed.</p

Impact of a Citywide Sanitation Program in Northeast Brazil on Intestinal Parasites Infection in Young Children

BACKGROUND: Sanitation affects health, especially that of young children. Residents of Salvador, in Northeast Brazil, have had a high prevalence of intestinal parasites. A citywide sanitation intervention started in 1996 aimed to raise the level of sewer coverage from 26% to 80% of households. OBJECTIVES: We evaluated the impact of this intervention on the prevalence of Ascaris lumbricoides, Trichuris trichuria, and Giardia duodenalis infections in preschool children. METHODS: The evaluation was composed of two cross-sectional studies (1998 and 2003-2004), each of a sample of 681 and 976 children 1-4 years of age, respectively. Children were sampled from 24 sentinel areas chosen to represent the range of environmental conditions in the study site. Data were collected using an individual/household questionnaire, and an environmental survey was conducted in each area before and after the intervention to assess basic household and neighborhood sanitation conditions. Stool samples were examined for the presence of intestinal parasites. The effect of the intervention was estimated by hierarchical modeling, fitting a sequence of multivariate regression models. FINDINGS: The prevalence ofA. lumbricoides infection was reduced from 24.4% to 12.0%, T. trichuria from 18.0% to 5.0%, and G. duodenalis from 14.1% to 5.3%. Most of this reduction appeared to be explained by the increased coverage in each neighborhood by the sewage system constructed during the intervention. The key explanatory variable was thus an ecological measure of exposure and not household-based, suggesting that the parasite transmission prevented by the program was mainly in the public (vs. the domestic) domain. CONCLUSION: This study, using advanced statistical modeling to control for individual and ecological potential confounders, demonstrates the impact on intestinal parasites of sanitation improvements implemented at the scale of a large population

Comparative field performance and adherence to test results of four malaria rapid diagnostic tests among febrile patients more than five years of age in Blantyre, Malawi

<p>Abstract</p> <p>Background</p> <p>Malaria rapid diagnostics tests (RDTs) can increase availability of laboratory-based diagnosis and improve the overall management of febrile patients in malaria endemic areas. In preparation to scale-up RDTs in health facilities in Malawi, an evaluation of four RDTs to help guide national-level decision-making was conducted.</p> <p>Methods</p> <p>A cross sectional study of four histidine rich-protein-type-2- (HRP2) based RDTs at four health centres in Blantyre, Malawi, was undertaken to evaluate the sensitivity and specificity of RDTs, assess prescriber adherence to RDT test results and explore operational issues regarding RDT implementation. Three RDTs were evaluated in only one health centre each and one RDT was evaluated in two health centres. Light microscopy in a reference laboratory was used as the gold standard.</p> <p>Results</p> <p>A total of 2,576 patients were included in the analysis. All of the RDTs tested had relatively high sensitivity for detecting any parasitaemia [Bioline SD (97%), First response malaria (92%), Paracheck (91%), ICT diagnostics (90%)], but low specificity [Bioline SD (39%), First response malaria (42%), Paracheck (68%), ICT diagnostics (54%)]. Specificity was significantly lower in patients who self-treated with an anti-malarial in the previous two weeks (odds ratio (OR) 0.5; p-value < 0.001), patients 5-15 years old versus patients > 15 years old (OR 0.4, p-value < 0.001) and when the RDT was performed by a community health worker versus a laboratory technician (OR 0.4; p-value < 0.001). Health workers correctly prescribed anti-malarials for patients with positive RDT results, but ignored negative RDT results with 58% of patients with a negative RDT result treated with an anti-malarial.</p> <p>Conclusions</p> <p>The results of this evaluation, combined with other published data and global recommendations, have been used to select RDTs for national scale-up. In addition, the study identified some key issues that need to be further delineated: the low field specificity of RDTs, variable RDT performance by different cadres of health workers and the need for a robust quality assurance system. Close monitoring of RDT scale-up will be needed to ensure that RDTs truly improve malaria case management.</p

Elucidating the source–sink relationships of zinc biofortification in wheat grains: a review

Zinc (Zn) concentration in wheat grains is generally low, with an average value of around 28–30 mg/kg. Therefore, increasing wheat grain Zn concentration for better human health is the focus of HarvestPlus global initiatives. Source–sink interactions have been intensively studied for decades to enhance crop yield potential, but less on grain nutritional quality. This review applies concepts of source, sink, and their interactions to the study of wheat grain Zn nutrition and biofortification. Increasing Zn sources to wheat (via soil and foliar application) could directly enlarge available Zn in vegetative tissues and grain Zn sink. Rational nitrogen (N) supply increases grain Zn accumulation (N‐Zn synergism), but phosphorus (P) input generally decreases (P‐Zn antagonism), and the potassium (K) effect is unclear. Conventional and genetic breeding have potential to stimulate Zn flow from source to sink (uptake from soil, root‐to‐shoot translocation, and remobilization). However, a rational manipulation to establish a well‐coordinated source–sink relationship is required to finally realize the grain Zn target (40–50 mg/kg) and increase on‐farm crop yield. Future studies should focus more on fertilization modes adopted by farmers (uses of compound, slow/controlled release, and organic and microbial fertilizers) and develop integrated agronomic and genetic strategies for Zn biofortification. A highly systematic and mechanistic model includes (a) migration paths of Zn (particularly from leaves to different grain parts) using isotopic labeling methods, (b) cross‐talks between Zn and carbon, N, P, K, or other divalent cations, (c) inherent physiological and biochemical processes of enzymes and signaling phytohormones, and (d) complex genetic systems governing Zn homeostasis and their relationships with other nutrients, signaling molecules, and increase or dilution/penalty of yield under different environmental conditions (soil, water, and future climatic changes) and managements (breeding and fertilization). These aspects require further elucidation to fully unravel the “black box” of Zn flow from source to sink

Drug-Resistant Tuberculosis Control in China: Progress and Challenge

Background: China has the second highest caseload of multidrug-resistant tuberculosis (MDR-TB) in the world. In 2009, the Chinese government agreed to draw up a plan for MDR-TB prevention and control in the context of a comprehensive health system reform launched in the same year. Discussion: China is facing high prevalence rates of drug-resistant TB and MDR-TB. MDR-TB disproportionally affects the poor rural population and the highest rates are in less developed regions largely due to interrupted and/or inappropriate TB treatment. Most households with an affected member suffer a heavy financial burden because of a combination of treatment and other related costs. The influential Global Fund programme for MDR-TB control in China provides technical and financial support for MDR-TB diagnosis and treatment. However, this programme has a fixed timeline and cannot provide a long term solution. In 2009, the Bill and Melinda Gates Foundation, in cooperation with the National Health and Family Planning Commission of China, started to develop innovative approaches to TB/MDR-TB management and case-based payment mechanisms for treatment, alongside increased health insurance benefits for patients, in order to contain medical costs and reduce financial barriers to treatment. Although these efforts appear to be in the right direction, they may not be sufficient unless (a) domestic sources are mobilized to raise funding for TB/MDR-TB prevention and control and (b) appropriate incentives are given to both health facilities and their care providers. Summary: Along with the on-going Chinese health system reform, sustained government financing and social health protection schemes will be critical to ensure universal access to appropriate TB treatment in order to reduce risk of developing MDR-TB and systematic MDR-TB treatment and management