Population modifiable risk factors associated with neonatal mortality in 35 sub-Saharan Africa countries: analysis of data from demographic and health surveys.

Background: Sub-Saharan Africa (SSA) has the highest burden of neonatal mortality in the world. Identifying the most critical modifiable risk factors is imperative for reducing neonatal mortality rates. This study is the first to calculate population-attributable fractions (PAFs) for modifiable risk factors of neonatal mortality in SSA. Methods: We analysed the most recent Demographic and Health Surveys data sets from 35 SSA countries conducted between 2010 and 2022. Generalized linear latent and mixed models were used to estimate odds ratios (ORs) along with 95% confidence intervals (CIs). PAFs adjusted for communality were calculated using ORs and prevalence estimates for key modifiable risk factors. Subregional analyses were conducted to examine variations in modifiable risk factors for neonatal mortality across Central, Eastern, Southern, and Western SSA regions. Findings: In this study, we included 255,891 live births in the five years before the survey. The highest PAFs of neonatal mortality among singleton children were attributed to delayed initiation of breastfeeding (>1 h after birth: PAF = 23.88%; 95% CI: 15.91, 24.86), uncleaned cooking fuel (PAF = 5.27%; 95% CI: 1.41, 8.73), mother's lacking formal education (PAF = 4.34%; 95% CI: 1.15, 6.31), mother's lacking tetanus vaccination (PAF = 3.54%; 95% CI: 1.55, 4.92), and infrequent antenatal care (ANC) visits (PAF = 2.45; 95% CI: 0.76, 3.63). Together, these five modifiable risk factors were associated with 39.49% (95% CI: 21.13, 48.44) of neonatal deaths among singleton children in SSA. Our subregional analyses revealed some variations in modifiable risk factors for neonatal mortality. Notably, delayed initiation of breastfeeding consistently contributed to the highest PAFs of neonatal mortality across all four regions of SSA: Central, Eastern, Southern, and Western SSA. Interpretation: The PAF estimates in the present study indicate that a considerable proportion of neonatal deaths in SSA are preventable. We identified five modifiable risk factors that accounted for approximately 40% of neonatal deaths in SSA. The findings have policy implications. Funding: None.

Effectiveness of nirmatrelvir/ritonavir and molnupiravir in non-hospitalized adults with COVID-19: systematic review and meta-analysis of observational studies.

OBJECTIVE: To determine the effectiveness of nirmatrelvir/ritonavir and molnupiravir among vaccinated and unvaccinated non-hospitalized adults with COVID-19. METHODS: Observational studies of nirmatrelvir/ritonavir or molnupiravir compared to no antiviral drug treatment for COVID-19 in non-hospitalized adults with data on vaccination status were included. We searched MEDLINE, EMBASE, Scopus, Web of Science, WHO COVID-19 Research Database and medRxiv for reports published between 1 January 2022 and 8 November 2023. The primary outcome was a composite of hospitalization or mortality up to 35 days after COVID-19 diagnosis. Risk of bias was assessed with ROBINS-I. Risk ratios (RR), hazard ratios (HR) and risk differences (RD) were separately estimated using random-effects models. RESULTS: We included 30 cohort studies on adults treated with nirmatrelvir/ritonavir (n = 462 279) and molnupiravir (n = 48 008). Nirmatrelvir/ritonavir probably reduced the composite outcome (RR 0.62, 95%CI 0.55-0.70; I2 = 0%; moderate certainty) with no evidence of effect modification by vaccination status (RR Psubgroup = 0.47). In five studies, RD estimates against the composite outcome for nirmatrelvir/ritonavir were 1.21% (95%CI 0.57% to 1.84%) in vaccinated and 1.72% (95%CI 0.59% to 2.85%) in unvaccinated subgroups.Molnupiravir may slightly reduce the composite outcome (RR 0.75, 95%CI 0.67-0.85; I2 = 32%; low certainty). Evidence of effect modification by vaccination status was inconsistent among studies reporting different effect measures (RR Psubgroup = 0.78; HR Psubgroup = 0.08). In two studies, RD against the composite outcome for molnupiravir were -0.01% (95%CI -1.13% to 1.10%) in vaccinated and 1.73% (95%CI -2.08% to 5.53%) in unvaccinated subgroups. CONCLUSIONS: Among cohort studies of non-hospitalized adults with COVID-19, nirmatrelvir/ritonavir is effective against the composite outcome of severe COVID-19 independent of vaccination status. Further research and a reassessment of molnupiravir use among vaccinated adults are warranted. REGISTRATION: PROSPERO CRD42023429232.

Daily Activity Lifelogs of People With Heart Failure: Observational Study.

BACKGROUND: Globally, heart failure (HF) affects more than 64 million people, and attempts to reduce its social and economic burden are a public health priority. Interventions to support people with HF to self-manage have been shown to reduce hospitalizations, improve quality of life, and reduce mortality rates. Understanding how people self-manage is imperative to improve future interventions; however, most approaches to date, have used self-report methods to achieve this. Wearable cameras provide a unique tool to understand the lived experiences of people with HF and the daily activities they undertake, which could lead to more effective interventions. However, their potential for understanding chronic conditions such as HF is unclear. OBJECTIVE: This study aimed to determine the potential utility of wearable cameras to better understand the activities of daily living in people living with HF. METHODS: The "Seeing is Believing (SIB)" study involved 30 patients with HF who wore wearable cameras for a maximum of 30 days. We used the E-Myscéal web-based lifelog retrieval system to process and analyze the wearable camera image data set. Search terms for 7 daily activities (physical activity, gardening, shopping, screen time, drinking, eating, and medication intake) were developed and used for image retrieval. Sensitivity analysis was conducted to compare the number of images retrieved using different search terms. Temporal patterns in daily activities were examined, and differences before and after hospitalization were assessed. RESULTS: E-Myscéal exhibited sensitivity to specific search terms, leading to significant variations in the number of images retrieved for each activity. The highest number of images returned were related to eating and drinking, with fewer images for physical activity, screen time, and taking medication. The majority of captured activities occurred before midday. Notably, temporal differences in daily activity patterns were observed for participants hospitalized during this study. The number of medication images increased after hospital discharge, while screen time images decreased. CONCLUSIONS: Wearable cameras offer valuable insights into daily activities and self-management in people living with HF. E-Myscéal efficiently retrieves relevant images, but search term sensitivity underscores the need for careful selection.

Life-course trajectories of body mass index and cardiovascular disease risks and health outcomes in adulthood: Systematic review and meta-analysis.

OBJECTIVE: This systematic review aimed to assess the effect of life course body mass index (BMI) trajectories (childhood to adulthood) on cardiovascular disease (CVD) risk factors and outcomes. METHODS: Prospective or retrospective cohort studies were identified that assessed the association of BMI trajectories with CVD risks and outcomes from databases published in English. The pooled effect sizes were estimated using a random-effects model. FINDINGS: Seventeen eligible studies were included in this systematic review. The results revealed that a persistently overweight trajectory from childhood to adulthood was associated with a higher risk of hypertension (RR: 2.49; 95% CI: 1.9, 3.28) and type 2 diabetes (RR: 4.62; 95% CI: 2.36, 9.04) compared with a trajectory characterized by a normal BMI throughout both childhood and adulthood. Similarly, the risk of hypertension (RR: 2.38; 95% CI: 1.70, 3.33) and type 2 diabetes (RR: 3.66; 95% CI: 2.57, 5.19) was higher in those with normal-to-overweight trajectory compared with participants with a stable normal weight trajectory. CONCLUSION: The findings suggest that lifetime BMI trajectories may be influential on health outcomes, and preventive strategies should be designed accordingly. Implementing appropriate preventive strategies at all life stages may reduce CVD risks and adverse outcomes later in life.

Interventions to improve the nutritional status of children under 5 years in Ethiopia: a systematic review.

OBJECTIVE: To conduct a systematic review of experimental or quasi-experimental studies that aimed to improve the nutritional status of children under 5 years of age in Ethiopia. DESIGN: Embase, MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, and Academic Search Database were used to locate peer-reviewed studies, and Google Scholar and Open Dissertation were used to locate grey literatures. All searches were conducted between 2000 and November 2022. SETTING: Ethiopia. PARTICIPANTS: Pregnant women and mothers with children aged 0-59 months. RESULTS: Ten cluster randomised controlled trials (RCT), six quasi-experimental studies and two individual RCT were included. Out of the identified eighteen studies, three studies targeted pregnant mothers. Our findings showed that almost two-thirds of published interventions had no impact on childhood stunting and wasting, and more than half had no impact on underweight. Some behaviour change communication (BCC) interventions, food vouchers, micronutrient supplementation and quality protein maize improved stunting. Similarly, BCC and fish oil supplementation showed promise in reducing wasting, while BCC and the provision of quality protein maize reduced underweight. Additionally, water, sanitation and hygiene (WaSH) interventions provided to pregnant mothers and children under 2 years of age were shown to significantly reduce childhood stunting. CONCLUSION: Future childhood nutritional interventions in Ethiopia should consider adopting an integrated approach that combines the positive effects of interdependent systems such as BCC, food supplemental programmes (e.g. boosting protein and micronutrients), health interventions (e.g. strengthening maternal and childcare), WaSH and financial initiatives (e.g. monetary support and income schemes).

Longitudinal patterns of lifestyle risk behaviours among UK adults with established cardiovascular disease: a latent transition analysis.

Background: People with cardiovascular disease (CVD) need to engage in healthy lifestyle behaviours. However, there is a gap in identifying longitudinal patterns of change in lifestyle behaviours among people with CVD. This study aimed to identify clustering of lifestyle risk behaviours and their 4 ± year changes among UK adults with CVD, and to determine the associated factors. Methods: We used the UK Biobank data collected at two time points (2006-2010/baseline data = T0 and 2014+/third visit data = T4). Six key lifestyle risk behaviours were assessed: smoking, high alcohol intake, poor fruit and vegetable consumption, physical inactivity, poor sleep balance (<7 or >8 h/night) and prolonged sitting. A random intercept latent transition analysis was performed to identify patterns of lifestyle risk behaviours at T0 and their changes from T0 to T4. Results: We included 5,304 participants with CVD whose data on lifestyle risk behaviours were collected at two-time points. Alcohol intake and current smoking were 75.7% and 5.4% at baseline, respectively, and 67.4% and 3.0% at follow-up. Three latent classes emerged: Latent class (LC) 1-"high alcohol intake, poor sleep balance and poor fruit and vegetable intake", LC2-"high alcohol intake and poor fruit and vegetable intake", and LC3-"high alcohol intake". Most adults remained in the same LC over the 4 + years (range: 83.9%-100.0%). After 4 + years, 3.5% from LC3 and 10.4% from LC2 at baseline moved into LC1. The odds of transitioning to LC2 relative to staying in LC1 and LC3 were 2.22 and 4.13 times higher for males than for females, respectively. A single-year increase in participants' age was associated with a 1.16 times increase in the odds of moving to LC1 relative to staying in LC2. Conclusion: People with CVD did not show improvement in lifestyle risk behaviours, and interventions targeting multiple lifestyle risk behaviours are needed to improve CVD.

The burden of type 2 diabetes in Australia during the period 1990-2019: Findings from the global burden of disease study.

AIMS: To describe morbidity and mortality trends of type 2 diabetes in Australia, from 1990 to 2019, compared with similar sociodemographic index (SDI) countries. METHODS: Australia-specific Global Burden of Diseases data were used to estimate age-standardised, age-specific, and sex-specific rates for prevalence, years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life years (DALYs), and deaths due to type 2 diabetes between 1990 and 2019. Australian data were compared with 14 similar SDI countries. RESULTS: Type 2 diabetes increased in Australia between 1990 and 2019. The age-standardised prevalence increased from 1,985 [95% Confidence Interval (CI): 1,786.7-2195.3] per 100,000 population, to 3,429 [95% CI 3,053.3-3,853.7]. Cases tripled, from 379,532 [342,465-419,475] to 1,307,261 [1,165,522-1,461,180]. The age-standardised death rates doubled, from 2,098 [1,953-2,203] per 100,000, to 4,122 [3,617-4,512]. DALYs doubled, from 70,348 [59,187-83,500] to 169,763 [129,792-216,150], with increases seen in YLDs and YLLs. Men displayed higher rates. Compared to similar SDI countries, Australia ranked 4th in terms of burden for type 2 diabetes. CONCLUSIONS: The burden of type 2 diabetes in Australia has increased considerably over three decades. There is an urgent need to prioritise resource allocation for prevention programs, screening initiatives to facilitate early detection, and effective and accessible management strategies for the large proportion of the population impacted by type 2 diabetes.

Spatial and hierarchical Bayesian analysis to identify factors associated with caesarean delivery use in Ethiopia: Evidence from national population and health facility data.

BACKGROUND: Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia. METHOD: Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure. RESULTS: Women's age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had ≥4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women's age at first childbirth and ≥4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia. CONCLUSION: Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.

Effects of lifestyle risk behaviour clustering on cardiovascular disease among UK adults: latent class analysis with distal outcomes.

Lifestyle risk behaviours such as smoking, physical inactivity, and unhealthy diet account for a considerable disease burden globally. These risk behaviours tend to cluster within an individual, which could have detrimental health effects. In this study, we aimed to examine the clustering effect of lifestyle risk behaviours on cardiovascular disease (CVD) and CVD risk among adults in the United Kingdom (UK). We performed a latent class (LC) analysis with distal outcomes using the UK Biobank baseline (2006-2010) data. First, we estimated LC measurement models, followed by an auxiliary model conditional on LC variables. We reported continuous (mean difference-MD) and binary (odds ratio-OR) outcomes with 95% confidence intervals. We included 283,172 and 174,030 UK adults who had data on CVD and CVD risk, respectively. Multiple lifestyle risk behaviour clustering (physically inactive, poor fruit & vegetable intake, high alcohol intake, and prolonged sitting) had a 3.29 mean increase in CVD risk compared to high alcohol intake. In addition, adults with three risk behaviours (physically inactive, poor fruit & vegetable intake, and high alcohol intake) had 25.18 higher odds of having CVD than those with two risk behaviours (physically inactive, and poor fruit and vegetable intake). Social deprivation, gender and age were also associated with CVD. Individuals' LC membership with two or more lifestyle risk behaviours negatively affects CVD. Interventions targeting multiple lifestyle behaviours and social circumstances should be prioritized to reduce the CVD burden.

Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis.

BACKGROUND: This review aimed to compare the relative effectiveness of different exercise-based cardiac rehabilitation (ExCR) delivery modes (centre-based, home-based, hybrid and technology-enabled ExCR) on key heart failure (HF) outcomes: exercise capacity, health-related quality of life (HRQoL), HF-related hospitalisation and HF-related mortality. METHODS AND RESULTS: Randomised controlled trials (RCTs) published through 20 June 2021 were identified from six databases, and reference lists of included studies. Risk of bias and certainty of evidence were evaluated using the Cochrane tool and Grading of Recommendations Assessment, Development and Evaluation, respectively. Bayesian network meta-analysis was performed using R. Continuous and binary outcomes are reported as mean differences (MD) and ORs, respectively, with 95% credible intervals (95% CrI). One-hundred and thirty-nine RCTs (n=18 670) were included in the analysis. Network meta-analysis demonstrated improvements in VO2peak following centre-based (MD (95% CrI)=3.10 (2.56 to 3.65) mL/kg/min), home-based (MD=2.69 (1.67 to 3.70) mL/kg/min) and technology-enabled ExCR (MD=1.76 (0.27 to 3.26) mL/kg/min). Similarly, 6 min walk distance was improved following hybrid (MD=84.78 (31.64 to 138.32) m), centre-based (MD=50.35 (30.15 to 70.56) m) and home-based ExCR (MD=36.77 (12.47 to 61.29) m). Incremental shuttle walk distance did not improve following any ExCR delivery modes. Minnesota living with HF questionnaire improved after centre-based (MD=-10.38 (-14.15 to -6.46)) and home-based ExCR (MD=-8.80 (-13.62 to -4.07)). Kansas City Cardiomyopathy Questionnaire was improved following home-based ExCR (MD=20.61 (4.61 to 36.47)), and Short Form Survey 36 mental component after centre-based ExCR (MD=3.64 (0.30 to 6.14)). HF-related hospitalisation and mortality risks reduced only after centre-based ExCR (OR=0.41 (0.17 to 0.76) and OR=0.42 (0.16 to 0.90), respectively). Mean age of study participants was only associated with changes in VO2peak. CONCLUSION: ExCR programmes have broader benefits for people with HF and since different delivery modes were comparably effective for improving exercise capacity and HRQoL, the selection of delivery modes should be tailored to individuals' preferences.

Now you see it! Using wearable cameras to gain insights into the lived experience of cardiovascular conditions.

Wearable cameras offer an innovative way to discover new insights into the lived experience of people with cardiovascular conditions. Wearable cameras can be used alone or supplement more traditional research methods, such as interviews and participant observations. This paper provides an overview of the benefits of using wearable cameras for data collection and outlines some key considerations for researchers and clinicians interested in this method. We provide a case study describing a study design using wearable cameras and how the data were used.

Wearable cuffless blood pressure monitoring devices: a systematic review and meta-analysis.

Aims: High blood pressure (BP) is the commonest modifiable cardiovascular risk factor, yet its monitoring remains problematic. Wearable cuffless BP devices offer potential solutions; however, little is known about their validity and utility. We aimed to systematically review the validity, features and clinical use of wearable cuffless BP devices. Methods and results: We searched MEDLINE, Embase, IEEE Xplore and the Cochrane Database till December 2019 for studies that reported validating cuffless BP devices. We extracted information about study characteristics, device features, validation processes, and clinical applications. Devices were classified according to their functions and features. We defined devices with a mean systolic BP (SBP) and diastolic BP (DBP) biases of <5 mmHg as valid as a consensus. Our definition of validity did not include assessment of device measurement precision, which is assessed by standard deviation of the mean difference-a critical component of ISO protocol validation criteria. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. A random-effects model meta-analysis was performed to summarise the mean biases for SBP and DBP across studies. Of the 430 studies identified, 16 studies (15 devices, 974 participants) were selected. The majority of devices (81.3%) used photoplethysmography to estimate BP against a reference device; other technologies included tonometry, auscultation and electrocardiogram. In addition to BP and heart rate, some devices also measured night-time BP (n = 5), sleep monitoring (n = 3), oxygen saturation (n = 3), temperature (n = 2) and electrocardiogram (n = 3). Eight devices showed mean biases of <5 mmHg for SBP and DBP compared with a reference device and three devices were commercially available. The meta-analysis showed no statistically significant differences between the wearable and reference devices for SBP (pooled mean difference = 3.42 mmHg, 95% CI: -2.17, 9.01, I2 95.4%) and DBP (pooled mean = 1.16 mmHg, 95% CI: -1.26, 3.58, I2 87.1%). Conclusion: Several cuffless BP devices are currently available using different technologies, offering the potential for continuous BP monitoring. The variation in standards and validation protocols limited the comparability of findings across studies and the identification of the most accurate device. Challenges such as validation using standard protocols and in real-life settings must be overcome before they can be recommended for uptake into clinical practice.

Risk factors for COVID-19 infection, disease severity and related deaths in Africa: a systematic review.

OBJECTIVE: The aim of this study was to provide a comprehensive evidence on risk factors for transmission, disease severity and COVID-19 related deaths in Africa. DESIGN: A systematic review has been conducted to synthesise existing evidence on risk factors affecting COVID-19 outcomes across Africa. DATA SOURCES: Data were systematically searched from MEDLINE, Scopus, MedRxiv and BioRxiv. ELIGIBILITY CRITERIA: Studies for review were included if they were published in English and reported at least one risk factor and/or one health outcome. We included all relevant literature published up until 11 August 2020. DATA EXTRACTION AND SYNTHESIS: We performed a systematic narrative synthesis to describe the available studies for each outcome. Data were extracted using a standardised Joanna Briggs Institute data extraction form. RESULTS: Fifteen articles met the inclusion criteria of which four were exclusively on Africa and the remaining 11 papers had a global focus with some data from Africa. Higher rates of infection in Africa are associated with high population density, urbanisation, transport connectivity, high volume of tourism and international trade, and high level of economic and political openness. Limited or poor access to healthcare are also associated with higher COVID-19 infection rates. Older people and individuals with chronic conditions such as HIV, tuberculosis and anaemia experience severe forms COVID-19 leading to hospitalisation and death. Similarly, high burden of chronic obstructive pulmonary disease, high prevalence of tobacco consumption and low levels of expenditure on health and low levels of global health security score contribute to COVID-19 related deaths. CONCLUSIONS: Demographic, institutional, ecological, health system and politico-economic factors influenced the spectrum of COVID-19 infection, severity and death. We recommend multidisciplinary and integrated approaches to mitigate the identified factors and strengthen effective prevention strategies.

Spatial variations and associated factors of modern contraceptive use in Ethiopia: a spatial and multilevel analysis.

OBJECTIVE: To assess spatial variations in modern contraceptive use and to identify factors associated with it among married women in Ethiopia. DESIGN: Cross-sectional analysis of population-based and health facility data. SETTING: Ethiopia Demographic and Health Survey data linked to Service Provision Assessment data. POPULATION: 8473 married women and 1020 facilities that reported providing family planning services. METHODS: A linked secondary data analysis of population and health facility data was carried out. Both multilevel and spatial analyses were conducted to identify key determinants of women's use of modern contraceptive and spatial clustering of modern contraceptive use. MAIN OUTCOME MEASURE: Modern contraceptive use. RESULTS: About 24% of the variation in the use of modern contraception was accounted for by location. A one-unit increase in the mean score of health facilities' readiness to provide short-term modern contraceptives in a typical region was associated with a 20-fold increase in the odds of modern contraceptive use (adjusted OR (AOR) 20.49, 95% CI 1.44 to 29.54). In the spatial analysis, it was found that Addis Ababa and the Amhara region had high clusters of modern contraceptive use rates. On the other hand, low rates of contraceptive use were clustered in the Afar and Somali regions. CONCLUSION: There were significant variations in the use of modern contraceptives across the different regions of Ethiopia. Therefore, regions with low contraceptive rates and high fertility rates should be targeted for scaling up and tailoring of services to the culture and lifestyles of the population of those regions.

Antenatal care use in Ethiopia: a spatial and multilevel analysis.

BACKGROUND: Accessibility and utilization of antenatal care (ANC) service varies depending on different geographical locations, sociodemographic characteristics, political and other factors. A geographically linked data analysis using population and health facility data is valuable to map ANC use, and identify inequalities in service access and provision. Thus, this study aimed to assess the spatial patterns of ANC use, and to identify associated factors among pregnant women in Ethiopia. METHOD: A secondary data analysis of the 2016 Ethiopia Demographic and Health Survey linked with the 2014 Ethiopian Service Provision Assessment was conducted. A multilevel analysis was carried out using the SAS GLIMMIX procedure. Furthermore, hot spot analysis and spatial regressions were carried out to identify the hot spot areas of and factors associated with the spatial variations in ANC use using ArcGIS and R softwares. RESULTS: A one-unit increase in the mean score of ANC service availability in a typical region was associated with a five-fold increase in the odds of having more ANC visits. Moreover, every one-kilometre increase in distance to the nearest ANC facility in a typical region was negatively associated with having at least four ANC visits. Twenty-five percent of the variability in having at least four ANC visits was accounted for by region of living. The spatial analysis found that the Southern Nations, Nationalities and Peoples region had high clusters of at least four ANC visits. Furthermore, the coefficients of having the first ANC visit during the first trimester were estimated to have spatial variations in the use of at least four ANC visits. CONCLUSION: There were significant variations in the use of ANC services across the different regions of Ethiopia. Region of living and distance were key drivers of ANC use underscoring the need for increased ANC availability, particularly in the cold spot regions.

Service environment link and false discovery rate correction: Methodological considerations in population and health facility surveys.

BACKGROUND: Geospatial data are important in monitoring many aspects of healthcare development. Geographically linking health facility data with population data is an important area of public health research. Examining healthcare problems spatially and hierarchically assists with efficient resource allocation and the monitoring and evaluation of service efficacy at different levels. This paper explored methodological issues associated with geographic data linkage, and the spatial and multilevel analyses that could be considered in analysing maternal health service data. METHODS: The 2016 Ethiopia Demographic and Health Survey and the 2014 Ethiopia Service Provision Assessment data were used. Two geographic data linking methods were used to link these two datasets. Administrative boundary link was used to link a sample of health facilities data with population survey data for analysing three areas of maternal health service use. Euclidean buffer link was used for a census of hospitals to analyse caesarean delivery use in Ethiopia. The Global Moran's I and the Getis-Ord Gi* statistics need to be carried out for identifying hot spots of maternal health service use in ArcGIS software. In addition to this, since the two datasets contain hierarchical data, a multilevel analysis was carried out to identify key determinants of maternal health service use in Ethiopia. RESULTS: Administrative boundary link gave more types of health facilities and more maternal health services as compared to the Euclidean buffer link. Administrative boundary link is the method of choice in case of sampled health facilities. However, for a census of health facilities, the Euclidean buffer link is the appropriate choice as this provides cluster level service environment estimates, which the administrative boundary link does not. Applying a False Discovery Rate correction enables the identification of true spatial clusters of maternal health service use. CONCLUSIONS: A service environment link minimizes the methodological issues associated with geographic data linkage. A False Discovery Rate correction needs to be used to account for multiple and dependent testing while carrying out local spatial statistics. Examining maternal health service use both spatially and hierarchically has tremendous importance for identifying geographic areas that need special emphasis and for intervention purposes.

Maternal dietary patterns and risk of adverse pregnancy (hypertensive disorders of pregnancy and gestational diabetes mellitus) and birth (preterm birth and low birth weight) outcomes: a systematic review and meta-analysis.

OBJECTIVE: Epidemiological studies have indicated that dietary patterns during pregnancy are associated with adverse pregnancy and birth outcomes such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), preterm birth (PTB) and low birth weight (LBW). However, the results of these studies are varied and inconsistent. The present study aimed to assess the association between dietary patterns and the risk of adverse pregnancy and birth outcomes. DESIGN: Systematic review and meta-analysis. Seven databases were searched for articles. Two reviewers performed the study selection and data extraction. A random-effects model was used to estimate pooled effect sizes of eligible studies. SETTING: Studies conducted all over the world were incorporated. SUBJECTS: The review focused on pregnant women. RESULTS: A total of twenty-one studies were identified. Adherence to a healthy dietary pattern (intake of vegetables, fruits, legumes, whole grains) was significantly associated with lower odds (OR; 95 % CI) of pre-eclampsia (0·78; 0·70, 0·86; I2=39·0 %, P=0·178), GDM (0·78; 0·56, 0·99; I2=68·6 %, P=0·013) and PTB (0·75; 0·57, 0·93; I2=89·6 %, P=0·0001). CONCLUSIONS: Our review suggests that dietary patterns with a higher intake of fruits, vegetables, legumes, whole grains and fish are associated with a decreased likelihood of adverse pregnancy and birth outcomes. Further research should be conducted in low-income countries to understand the impact of limited resources on dietary intake and adverse pregnancy and birth outcomes.

The impact of geographic access on institutional delivery care use in low and middle-income countries: Systematic review and meta-analysis.

BACKGROUND: Geographic access to obstetric care facilities has a significant influence on women's uptake of institutional delivery care. However, this effect was not consistent across studies. Some studies reported that geographic access to obstetric care facilities had no influence on the use of facility delivery. Therefore, this systematic review and meta-analysis synthesized and pooled the influence of geographic access on institutional delivery service uptake in low and middle-income countries. METHODS: Multiple combinations of search terms were used to search articles from six databases and a hand search of reference lists performed. We included observational studies conducted in low and middle-income countries which reported the influence of geographic access on delivery care use. The pooled effects of geographic access on institutional delivery care use were calculated using a random-effects model with a 95% confidence interval. FINDINGS: In this study a total of 31 studies were included. Among these studies, 15 met criteria for inclusion in the meta-analyses, while the remaining 16 were summarized using qualitative synthesis. Studies included in the analysis where women had to walk 60 minutes or less to access a health facility delivery were significantly heterogeneous. Having access to obstetric care facilities within five kilometres was significantly associated with institutional deliveries (pooled OR = 2.27; 95% CI = 1.82, 2.82). Similarly, a travelling time of 60 minutes or less was significantly associated with higher odds of health facility delivery (pooled OR = 3.30; 95% CI = 1.97, 5.53). Every one-hour and one-kilometre increase in travel time and distance, respectively, was negatively associated with institutional delivery care use. INTERPRETATION: Geographic access measured in either physical distance and/or travel time was significantly associated with women's use of facility delivery. The greater the distance and/or travel time to obstetric care facilities, the greater the barrier and the lesser the service uptake.

Level of partograph utilization and its associated factors among obstetric caregivers at public health facilities in East Gojam Zone, Northwest Ethiopia.

INTRODUCTION: The discrepancy regarding maternal mortality continues to be a health concern between developing and developed countries. The majority of global maternal deaths occur in developing countries, specifically, in the sub-Sahara African region which alone accounts for more than half of these deaths. It has been indicated that utilization of the partograph was significantly associated with improved maternal and neonatal outcomes of labour and that is why the World Health Organization recommends the universal use of the tool during labour. Therefore, this study has assessed the level of partograph use and its associated factors among obstetric caregivers in East Gojam Zone, Northwest Ethiopia. METHODS: A health facility based cross-sectional study was conducted among randomly selected obstetric caregivers in Northwest Ethiopia. The data were collected using a self-administered questionnaire and a clinical observation checklist. The data were entered into Epidata version 3.1, and cleaned and analyzed using SPSS version 24.0 statistical software. RESULT: About three quarters, or 198 (72.53%), of the obstetric caregivers, had attained diploma level of education. However, 153 (56.04%) of the obstetric caregivers had what was considered to be good knowledge about the partograph, but utilization of the tool was slightly lower than their level of knowledge, 147 (53.85%). Utilization of the partograph was significantly higher among obstetric caregivers holding a Bachelor of Science degree and above, than Diploma holders (AOR (95% C.I) 2.07 (1.15-3.75)) and the use was higher among those who were regularly working in the delivery ward compared to those regularly working in the Adult Outpatient Department (AOR (95% C.I): 2.25 (1.07-4.72)). Moreover, caregivers who had a good knowledge about the partograph and who had received on the job training in obstetric care were also more likely to use the partograph during labour and delivery (AOR (95% C.I): 1.79 (1.05-3.06) and 4.85 (2.63-8.96)) respectively. CONCLUSION: The results of this study revealed that although more than half of obstetric caregivers had a good knowledge of the partograph, the actual utilization of the tool was slightly lower than the knowledge they had. Therefore, in this study, we suggest that providing on the job obstetric care training for obstetric caregivers, about the partograph in particular, would improve partograph utilization.

The Use and Perceived Barriers of the Partograph at Public Health Institutions in East Gojjam Zone, Northwest Ethiopia.

INTRODUCTION: The partograph is a vital tool used to reduce maternal and fetal mortality and morbidity and to prevent prolonged and obstructed labor, as well as postpartum hemorrhage and fistula formation. This study explored the use and barriers of the partograph among obstetric caregivers in East Gojam Zone, Northwest Ethiopia. METHODS AND MATERIALS: A cross-sectional study design consisting of both quantitative and qualitative methods was utilized. Data was collected through a structured clinical observation checklist and semistructured questions. The content of the checklists was developed according to modified WHO partograph. Thematic analysis was employed using open code software version 3.6. Coding was done immediately after the data was collected. The coded data was defined and categorized into groups. Once the categories were identified and the names given, the data was related to the objectives of the study. Data was crosschecked to ensure consistency between the themes and the categories. Then we summarized the themes and drew conclusions that gave answers to the research questions. RESULTS AND CONCLUSION: This study showed that participants believed partograph is an essential tool used to reduce maternal and fetal mortality and morbidity and to prevent prolonged and obstructed labor, as well as postpartum hemorrhage. They explained that work overload, lack of skill and competency, negligence, lack of motivation and a shortage of infrastructure and resources hindered utilization of the partograph.