High Child Mortality and Interventions Coverage in the City of Dar es Salaam, Tanzania: Are the Poorest Paying an Urban Penalty?

The 'urban penalty' in health refers to the loss of a presumed survival advantage due to adverse consequences of urban life. This study investigated the levels and trends in neonatal, post-neonatal and under-5 mortality rate and key determinants of child survival using data from Tanzania Demographic and Health Surveys (TDHS) (2004/05, 2010 and 2015/16), AIDS Indicator Survey (AIS), Malaria Indicator survey (MIS) and health facility data in Tanzania mainland. We compared Dar es Salaam results with other urban and rural areas in Tanzania mainland, and between the poorest and richest wealth tertiles within Dar es Salaam. Under-5 mortality declined by 41% between TDHS 2004/05 and 2015/2016 from 132 to 78 deaths per 1000 live births, with a greater decline in rural areas compared to Dar es Salaam and other urban areas. Neonatal mortality rate was consistently higher in Dar es Salaam during the same period, with the widest gap (> 50%) between Dar es Salaam and rural areas in TDHS 2015/2016. Coverage of maternal, new-born and child health interventions as well as living conditions were generally better in Dar es Salaam than elsewhere. Within the city, neonatal mortality was 63 and 44 per 1000 live births in the poorest 33% and richest 33%, respectively. The poorest had higher rates of stunting, more overcrowding, inadequate sanitation and lower coverage of institutional deliveries and C-section rate, compared to richest tertile. Children in Dar es Salaam do not have improved survival chances compared to rural children, despite better living conditions and higher coverage of essential health interventions. This urban penalty is higher among children of the poorest households which could only partly be explained by the available indicators of coverage of services and living conditions. Further research is urgently needed to understand the reasons for the urban penalty, including quality of care, health behaviours and environmental conditions.

Quality of reporting and trends of emergency obstetric and neonatal care indicators: an analysis from Tanzania district health information system data between 2016 and 2020.

BACKGROUND: Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability and usefulness of emergency obstetric care data including temporal and regional variations over the past five years in Tanzania Mainland. METHODS: Data were compiled from the routine monthly district reports compiled as part of the health management information systems for 2016-2020. Key indicators for maternal and neonatal care coverage, emergency obstetric and neonatal complications, and interventions indicators were computed. Assessment on reliability and consistency of reports was conducted and compared with annual rates and proportions over time, across the 26 regions in of Tanzania Mainland and by institutional delivery coverage. RESULTS: Facility reporting was near complete with 98% in 2018-2020. Estimated population coverage of institutional births increased by 10% points from 71.2% to 2016 to 81.7% in 2020 in Tanzania Mainland, driven by increased use of dispensaries and health centres compared to hospitals. This trend was more pronounced in regions with lower institutional birth rates. The Caesarean section rate remained stable at around 10% of institutional births. Trends in the occurrence of complications such as antepartum haemorrhage, premature rupture of membranes, pre-eclampsia, eclampsia or post-partum bleeding were consistent over time but at low levels (1% of institutional births). Prophylactic uterotonics were provided to nearly all births while curative uterotonics were reported to be used in less than 10% of post-partum bleeding and retained placenta cases. CONCLUSION: Our results show a mixed picture in terms of usefulness of the District Health Information System(DHIS2) data. Key indicators of institutional delivery and Caesarean section rates were plausible and provide useful information on regional disparities and trends. However, obstetric complications and several interventions were underreported thus diminishing the usefulness of these data for monitoring. Further research is needed on why complications and interventions to address them are not documented reliably.

Agrin mediates chondrocyte homeostasis and requires both LRP4 and α-dystroglycan to enhance cartilage formation in vitro and in vivo.

OBJECTIVES: Osteoarthritis (OA) is a leading cause of disability for which there is no cure. The identification of molecules supporting cartilage homeostasis and regeneration is therefore a major pursuit in musculoskeletal medicine. Agrin is a heparan sulfate proteoglycan which, through binding to low-density lipoprotein receptor-related protein 4 (LRP4), is required for neuromuscular synapse formation. In other tissues, it connects the cytoskeleton to the basement membrane through binding to α-dystroglycan. Prompted by an unexpected expression pattern, we investigated the role and receptor usage of agrin in cartilage. METHODS: Agrin expression pattern was investigated in human osteoarthritic cartilage and following destabilisation of the medial meniscus in mice. Extracellular matrix (ECM) formation and chondrocyte differentiation was studied in gain and loss of function experiments in vitro in three-dimensional cultures and gain of function in vivo, using an ectopic cartilage formation assay in nude mice. Receptor usage was investigated by disrupting LRP4 and α-dystroglycan by siRNA and blocking antibodies respectively. RESULTS: Agrin was detected in normal cartilage but was progressively lost in OA. In vitro, agrin knockdown resulted in reduced glycosaminoglycan content, downregulation of the cartilage transcription factor SOX9 and other cartilage-specific ECM molecules. Conversely, exogenous agrin supported cartilage differentiation in vitro and ectopic cartilage formation in vivo. In the context of cartilage differentiation, agrin used an unusual receptor repertoire requiring both LRP4 and α-dystroglycan. CONCLUSIONS: We have discovered that agrin strongly promotes chondrocyte differentiation and cartilage formation in vivo. Our results identify agrin as a novel potent anabolic growth factor with strong therapeutic potential in cartilage regeneration.