Child wasting and concurrent stunting in low- and middle-income countries.

Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.

Early-childhood linear growth faltering in low- and middle-income countries.

Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards)1,2. Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age.

Causes and consequences of child growth faltering in low-resource settings.

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

Mosaic embryo transfer versus additional IVF with PGT-A Cycle: a decision model comparing live birth rate and cost.

PURPOSE: To evaluate the relative live birth rate and net cost difference between mosaic embryo transfer and an additional cycle of IVF with PGT-A for patients whose only remaining embryos are non-euploid. METHODS: A decision analytic model was designed with model parameters varying based on discrete age cutoffs (<35, 35-37, 38-39, 40-42, 43-44, >44). Model inputs included probabilities of successful IVF, clinical pregnancy, and live birth as well as costs of IVF with PGT-A, embryo transfer, live birth, amniocentesis, and dilation and curettage. All costs were modeled from the healthcare system perspective and adjusted for inflation to 2023 $USD. Model outcomes were sub-stratified by degree and type of mosaicism. RESULTS: For patients younger than 43, an additional cycle of IVF with PGT-A resulted in a higher relative live birth rate (<35, +20%; 35-37, +15%; 38-39, +17%; 40-42, +6%; average, +14.5%) compared to mosaic embryo transfer with an average additional cost of $16,633. For patients older than 42, mosaic embryo transfer resulted in a higher live birth rate (43-44, +5%; >44, +3%; average, +4%) while on average costing $9572 less than an additional cycle of IVF with PGT-A. CONCLUSION: Mosaic embryo transfers are a superior alternative to an additional cycle of IVF with PGT-A for patients older than 42 whose only remaining embryos are non-euploid. Mosaic embryo transfers also should be considered for patients younger than 42 who are unable to pursue additional autologous IVF cycles. Counseling and care should be personalized to individual patients and embryos.

Fertility issues in hypopituitarism.

Women with hypopituitarism have lower fertility rates and worse pregnancy outcomes than women with normal pituitary function. These disparities exist despite the use of assisted reproductive technologies and hormone replacement. In women with hypogonadotropic hypogonadism, administration of exogenous gonadotropins can be used to successfully induce ovulation. Growth hormone replacement in the setting of growth hormone deficiency has been suggested to potentiate reproductive function, but its routine use in hypopituitary women remains unclear and warrants further study. In this review, we will discuss the clinical approach to fertility in a woman with hypopituitarism.

Non-linear associations between HPA axis activity during infancy and mental health difficulties during early childhood among children in rural Pakistan.

Hypothalamic pituitary adrenal (HPA) axis activity may be a mechanism linking early adversity to child mental health difficulties. However, there is a dearth of longitudinal evidence for the association between HPA axis activity and mental health among children in low-resource contexts. The goal of this study is to examine linear and curvilinear associations between HPA axis activity during infancy and mental health difficulties in early childhood among children in rural Pakistan. Participants included 104 children (46% male) from the Bachpan study, a longitudinal cohort embedded within a maternal depression trial in Pakistan. We examined the associations between hair-derived cortisol and dehydroepiandosterone (DHEA) at 12 months old and mental health difficulties, measured with the Strengths and Difficulties Questionnaire (SDQ), at 36 months old. There was a significant quadratic association between hair cortisol and SDQ scores, with results showing a U-shaped relationship (i.e., having relatively high or low cortisol predicted increased mental health difficulties). DHEA showed a quadratic association with SDQ scores with an inverted U-shaped relationship (i.e., high and low DHEA was associated with decreased mental health difficulties). Results provide evidence of longitudinal and curvilinear effects of cortisol and DHEA during infancy on mental health difficulties in early childhood.

Generativity and Engagement in Grandparenting Activities Among Older Adults in Northern Sri Lanka.

Generativity refers to the desire to pass on one's skills, knowledge, and wisdom to future generations; this may be a clear indicator of the likelihood of older adults investing time and effort in engagement with their grandchildren. This cross-sectional study examines the relationship between generative beliefs and an index of multiple potential grandparenting activities. The data come from a convenience sample of 79 grandparents (aged 55+) living in Sri Lanka, a society experiencing rapid growth in its population of older adults. Regression analyses demonstrate that more endorsement of generative beliefs among older adults is associated with increased engagement in various grandparenting activities, with the strongest associations with reading, singing songs, and helping grandchildren with schoolwork or teaching them. Our findings suggest that generativity may be important for understanding the relationship between grandparenting and improved well-being for older adults.

Mental health status of internally displaced persons in the Garmian region of Kurdistan, Iraq: a cross-sectional survey.

There are an estimated 4 million internally displaced persons (IDPs) in Iraq, mainly settled in the Kurdistan Region of Iraq, and yet few studies have documented the mental health of IDPs in the region. The aims of this study were (1) to assess the prevalence of mental health disorders and trauma experiences amongst IDPs and (2) to explore associations between prior displacement and years living in the camp and mental health disorders. A cross-sectional survey was conducted with adults (N = 100) from March - July 2018. Structured surveys were used to collect sociodemographic information, and adapted measures included the Harvard Trauma Questionnaire (HTQ), Post-traumatic Stress Disorder Inventory (PTSD-8), Hopkins Symptoms Checklist-25 (HSCL-25) and the Post-Migration Living Difficulties Checklist (PMLD). The average number of traumatic events experienced was 4.43 (SD = 2.63). The most commonly reported traumatic events included oppression due to ethnicity, religion or sect (92%) and exposure to combat situations (83%). Nearly half of the participants had experienced ill health without access to medical care, 44% lack of shelter and 43% lack of food or clean water. Thirty-two percent of respondents witnessed someone being murdered. There is a critical need for quality mental health services for IDPs in KR.

Evaluation of at-home serum anti-Müllerian hormone testing: a head-to-head comparison study.

BACKGROUND: For optimal fertility testing, serum anti-Müllerian hormone levels are used in combination with other testing to provide reliable ovarian reserve evaluations. The use of the ADx 100 card is widely commercially available for at-home reproductive hormone testing, but data demonstrating that its results are reproducible outside of a clinical setting are limited, as well as comparisons of its performance with other newer blood collection techniques. This study aimed to evaluate the concordance of serum AMH levels found via standard venipuncture and self-administered blood collection using the TAP II device (TAP) and ADx card in women of reproductive age. METHODS: This was a prospective, head-to-head-to-head within-person crossover comparison trial that included 41 women of reproductive age (20-39 years). It was hypothesized that the TAP device would be superior to the ADx card both in terms of agreement with venipuncture reference standard and patient experience. Each subject had their blood drawn using the three modalities (TAP, ADx, and venipuncture). We evaluated the concordance of AMH assays from samples obtained via the TAP device and ADx card with the gold standard being venipuncture. Two-sided 95% CIs were generated for each method to compare relative performance across all three modes. Patient preference for the TAP device versus the ADx card was based on self-reported pain and Net Promoter Score (NPS). RESULTS: The TAP device was superior to the ADx card on all outcome measures. TAP R-squared with venipuncture was 0.99 (95% CI 0.99, > 0.99), significantly higher than the ADx card, which had an R-squared of 0.87 (95% CI 0.80, 0.94) under most favorable treatment. TAP sensitivity and specificity were both 100% (no clinical disagreement with venipuncture), versus 100 and 88%, respectively, for the ADx card. Average pain reported by users of the TAP device was significantly lower than the ADx card (0.75 versus 2.73, p < 0.01) and the NPS was significantly higher than the ADx card (+ 72 versus - 48, p < 0.01). CONCLUSIONS: The TAP was non-inferior to venipuncture and superior to the ADx card with respect to correlation and false positives. Moreover, the TAP was superior to both alternatives on patient experience. TRIAL REGISTRATION: NCT04784325 (Mar 5, 2021).

Impact of comprehensive state insurance mandates on in vitro fertilization utilization, embryo transfer practices, and outcomes in the United States.

BACKGROUND: Previous studies have demonstrated that state mandated coverage of in vitro fertilization may be associated with increased utilization, fewer embryos per transfer, and lower multiple birth rates, but also lower overall live birth rates. Given new legislation and the delay between enactment and effect, a revisit of this analysis is warranted. OBJECTIVE: This study aimed to characterize the current impact of comprehensive state in vitro fertilization insurance mandates on in vitro fertilization utilization, live birth rates, multiple birth rates, and embryo transfer practices. STUDY DESIGN: We conducted a retrospective cohort study of in vitro fertilization cycles reported by the 2018 Centers for Disease Control and Prevention Assisted Reproductive Technology Fertility Clinic Success Rates Report in the United States. In vitro fertilization cycles were stratified according to state mandate as follows: comprehensive (providing coverage for in vitro fertilization with minimal restrictions) and noncomprehensive. The United States census estimates for 2018 were used to calculate the number of reproductive-aged women in each state. Outcomes of interest (stratified by state mandate status) included utilization rate of in vitro fertilization per 1000 women aged 25 to 44 years, live birth rate, multiple birth rate, number of embryo transfer procedures (overall and subdivided by fresh vs frozen cycles), and percentage of transfers performed with frozen embryos. Additional subanalyzes were performed with stratification of outcomes by patient age group. RESULTS: In 2018, 134,997 in vitro fertilization cycles from 456 clinics were reported. Six states had comprehensive mandates; 32,029 and 102,968 cycles were performed in states with and without comprehensive in vitro fertilization mandates, respectively. In vitro fertilization utilization in states with comprehensive mandates was 132% higher than in noncomprehensive states after age adjustment; increased utilization was observed regardless of age stratification. Live birth rate per cycle was significantly higher in states with comprehensive mandates (35.4% vs 33.4%; P<.001), especially among older age groups. Multiple birth rate as a percentage of all births was significantly lower in states with comprehensive mandates (10.2% vs 13.8%; P<.001), especially among younger patients. Mean number of embryos per transfer was significantly lower in states with comprehensive mandates (1.30 vs 1.36; P<.001). Significantly fewer frozen transfers were performed as a percentage of all embryo transfers in states with comprehensive mandates (66.1% vs 76.3%; P<.001). Among fresh embryo transfers, significantly fewer embryos were transferred in comprehensive states among all patients (1.55 vs 1.67; P<.001). CONCLUSION: Comprehensive state mandated insurance coverage for in vitro fertilization services is associated with greater utilization of these services, fewer embryos per transfer, fewer frozen embryo transfers, lower multiple birth rates, and higher live birth rates. These findings have important public health implications for reproductive-aged individuals in the United States and present notable opportunities for research on access to fertility care.

Impact of the COVID-19 pandemic on perinatal care and outcomes in the United States: An interrupted time series analysis.

BACKGROUND: Hospitals quickly adapted perinatal care to mitigate SARS-CoV-2 transmission at the onset of the COVID-19 pandemic. The objective of this study was to estimate the impact of pandemic-related hospital policy changes on perinatal care and outcomes in one region of the United States. METHODS: This interrupted time series analysis used retrospective data from consecutive singleton births at 15 hospitals in the Pacific Northwest from 2017 to 2020. The primary outcomes were those hypothesized to be affected by pandemic-related hospital policies and included labor induction, epidural use, oxytocin augmentation, mode of delivery, and early discharge (<48 hours after cesarean and <24 hours after vaginal births). Secondary outcomes included preterm birth, severe maternal morbidity, low 5-minute Apgar score, neonatal intensive care unit (NICU) admission, and 30-day readmission. Segmented Poisson regression models estimated the outcome level shift changes after the pandemic onset, controlling for underlying trends, seasonality, and stratifying by parity. RESULTS: No statistically significant changes were detected in intrapartum interventions or mode of delivery after onset of the pandemic. Early discharge increased for all births following cesarean and vaginal birth. Newborn readmission rates increased but only among nulliparas (aRR: 1.49, 95%CI: 1.17, 1.91). Among multiparas, decreases were observed in preterm birth (aRR: 0.90, 95%CI: 0.84, 0.96), low 5-minute Apgar score (aRR: 0.75, 95%CI: 0.68, 0.81), and term NICU admission rates (aRR: 0.85, 95%CI: 0.80, 0.91). CONCLUSIONS: Increases in early discharge and newborn readmission rates among nulliparas suggest a need for more postpartum support during the pandemic. Decreases in preterm birth and term NICU admission among multiparas may have implications beyond the pandemic and deserve further study.

Stressful life events, intimate partner violence, and perceived stress in the postpartum period: longitudinal findings in rural Pakistan.

PURPOSE: While the association between intimate partner violence (IPV) and stress is well documented, the directionality of this relationship is unclear. We use an adjusted longitudinal study design to better understand if stressful life events in the home precipitate or exacerbate intimate partner violence (IPV) and if experiences of IPV, in turn, increase levels of perceived stress. METHODS: Longitudinal data were collected among married women in rural Pakistan at 12 and 24 months postpartum (N = 815). Adjusted Poisson and linear regression models were used to examine stressful life events, past year IPV and severity (number and frequency of violent acts), and perceived stress (Cohen Perceived Stress Scale). RESULTS: At 12 months postpartum, the prevalence of past year physical, psychological, and sexual IPV was 8.5%, 25.7%, and 25.1%, respectively, with 42.6% experiencing any IPV. After adjustment, stressful life events were associated with a subsequent increased likelihood of all IPV types and increased severity of all but physical IPV. Any past year IPV (versus none) and greater IPV severity were associated with 3.43 (95% CI 2.33-4.52) and 2.57 (95% CI 1.87-3.27) point subsequent increases in perceived stress. Physical, psychological, and sexual IPV and their respective severities were all independently associated with increased perceived stress. CONCLUSIONS: Among postpartum women in Pakistan, stressful life events increase the likelihood of IPV and, in turn, experiences of IPV increase stress levels. Support to families undergoing stressful circumstances may be critical to reducing women's IPV exposure and resulting elevated stress.

Histopathologic upgrading of cutaneous squamous cell carcinomas during Mohs micrographic surgery: A retrospective cohort study.

BACKGROUND: Initial biopsies of cutaneous squamous cell carcinomas (cSCCs) may not reveal aggressive histologic features, which would otherwise inform appropriate surgical management and patient education. OBJECTIVE: To assess the incidence of, and risk factors for, histopathologic upgrading of cSCC during Mohs micrographic surgery (MMS). METHODS: This was a retrospective cohort study of invasive cSCCs treated with MMS between 2017 and 2019 at 1 academic institution. An "upgrade" was defined as a lesser degree of differentiation (poor or moderate) and/or bony or perineural invasion identified during MMS that was not reported in histopathologic evaluation of the initial biopsy. RESULTS: Of the 1558 tumors studied, 115 (7.4%) were upgraded during MMS. In multivariate logistic regression analysis, male sex, prior field treatment, location on the ear/lip, rapid growth of cSCC, and tumor diameter ≥2 cm were significant predictors of tumor upgrading. Upgraded tumors were more likely to require ≥3 MMS stages to clear, complicated closure (flap or graft), or outside (referral) repairs. LIMITATIONS: Single-center study, retrospective, and inter-rater variability. CONCLUSIONS: A significant proportion of cSCCs is histopathologically upgraded with more aggressive features during MMS. Routinely documented patient and tumor characteristics can predict tumor upgrading and assist clinicians in directing the management of potentially high-risk cSCC patients.

Adverse childhood experiences and depression among women in rural Pakistan.

BACKGROUND: Adverse Childhood Experiences (ACEs) are a common pathway to adult depression. This pathway is particularly important during the perinatal period when women are at an elevated risk for depression. However, this relationship has not been explored in South Asia. This study estimates the association between ACEs and women's (N = 889) depression at 36 months postpartum in rural Pakistan. METHOD: Data come from the Bachpan Cohort study. To capture ACEs, an adapted version of the ACE-International Questionnaire was used. Women's depression was measured using both major depressive episodes (MDE) and depressive symptom severity. To assess the relationship between ACEs and depression, log-Poisson models were used for MDE and linear regression models for symptom severity. RESULTS: The majority (58%) of women experienced at least one ACE domain, most commonly home violence (38.3%), followed by neglect (20.1%). Women experiencing four or more ACEs had the most pronounced elevation of symptom severity (ß = 3.90; 95% CL = 2.13, 5.67) and MDE (PR = 2.43; 95% CL = 1.37, 4.32). Symptom severity (ß = 2.88; 95% CL = 1.46, 4.31), and MDE (PR = 2.01; 95% CL = 1.27, 3.18) were greater for those experiencing community violence or family distress (ß = 2.04; 95%; CL = 0.83, 3.25) (PR = 1.77; 95% CL = 1.12, 2.79). CONCLUSIONS: Findings suggest that ACEs are substantively distinct and have unique relationships to depression. They signal a need to address women's ACEs as part of perinatal mental health interventions and highlight women's lifelong experiences as important factors to understanding current mental health. TRIAL REGISTRATION: NCT02111915 . Registered 11 April 2014. NCT02658994 . Registered 22 January 2016. Both trials were prospectively registered.

Development of a fertility risk calculator to predict individualized chance of ovarian failure after chemotherapy.

PURPOSE: To develop an innovative machine learning (ML) model that predicts personalized risk of primary ovarian insufficiency (POI) after chemotherapy for reproductive-aged women. Currently, individualized prediction of a patient's risk of POI is challenging. METHODS: Authors of published studies examining POI after gonadotoxic therapy were contacted, and six authors shared their de-identified data (N = 435). A composite outcome for POI was determined for each patient and validated by 3 authors. The primary dataset was partitioned into training and test sets; random forest binary classifiers were trained, and mean prediction scores were computed. Institutional data collected from a cross-sectional survey of cancer survivors (N = 117) was used as another independent validation set. RESULTS: Our model predicted individualized risk of POI with an accuracy of 88% (area under the ROC 0.87, 95% CI: 0.77-0.96; p < 0.001). Mean prediction scores for patients who developed POI and who did not were 0.60 and 0.38 (t-test p < 0.001), respectively. Highly weighted variables included age, chemotherapy dose, prior treatment, smoking, and baseline diminished ovarian reserve. CONCLUSION: We developed an ML-based model to estimate personalized risk of POI after chemotherapy. Our web-based calculator will be a user-friendly decision aid for individualizing risk prediction in oncofertility consultations.

Oocyte cryopreservation versus ovarian tissue cryopreservation for adult female oncofertility patients: a cost-effectiveness study.

PURPOSE: In December 2019, the American Society for Reproductive Medicine designated ovarian tissue cryopreservation (OTC) as no longer experimental and an alternative to oocyte cryopreservation (OC) for women receiving gonadotoxic therapy. Anticipating increased use of OTC, we compare the cost-effectiveness of OC versus OTC for fertility preservation in oncofertility patients. METHODS: A cost-effectiveness model to compare OC versus OTC was built from a payer perspective. Costs and probabilities were derived from the literature. The primary outcome for effectiveness was the percentage of patients who achieved live birth. Strategies were compared using incremental cost-effectiveness ratios (ICER). All inputs were varied widely in sensitivity analyses. RESULTS: In the base case, the estimated cost for OC was $16,588 and for OTC $10,032, with 1.56% achieving live birth after OC, and 1.0% after OTC. OC was more costly but more effective than OTC, with an ICER of $1,163,954 per live birth. In sensitivity analyses, OC was less expensive than OTC if utilization was greater than 63%, cost of OC prior to chemotherapy was less than $8100, cost of laparoscopy was greater than $13,700, or standardized discounted costs were used. CONCLUSIONS: With current published prices and utilization, OC is more costly but more effective than OTC. OC becomes cost-saving with increased utilization, when cost of OC prior to chemotherapy is markedly low, cost of laparoscopy is high, or standardized discounted oncofertility pricing is assumed. We identify the critical thresholds of OC and OTC that should be met to deliver more cost-effective care for oncofertility patients.

Maternal depression in rural Pakistan: the protective associations with cultural postpartum practices.

BACKGROUND: Traditional postpartum practices are intended to provide care to mothers, but there is mixed evidence concerning their impact on postpartum depression (PPD). It remains unknown if there is a unique impact of postpartum practices on PPD separately from other types of social support, or if practices differentially affect those with existing prenatal depression. In Pakistan, chilla (چله) is a traditional postpartum practice in which women receive relief from household work, additional familial support, and supplemental food for up to 40 days postpartum. This study aims to understand if chilla protects against PPD independent of other support and whether this relationship varies by prenatal depression status. METHODS: Data come from the Bachpan cohort study in rural Pakistan. Chilla participation and social support (Multidimensional Scale of Perceived Social Support) were assessed at 3 months postpartum. Women were assessed for major depressive episodes (MDE) with the Structured Clinical Interview, DSM-IV and for depression symptom severity with the Patient Health Questionnaire (PHQ-9) in their third trimester and at 6 months postpartum. Adjusted linear mixed models were used to assess the relationship between chilla participation and PPD. RESULTS: Eighty-nine percent of women (N = 786) participated in chilla and almost 70% of those that participated took part in all of chilla's aspects. In adjusted models, chilla participation was inversely related to MDE (OR = 0.56;95%CI = 0.31,1.03) and symptom severity (Mean Difference (MD) = - 1.54;95%CI: - 2.94,-0.14). Chilla participation was associated with lower odds of MDE (OR = 0.44;95%CI = 0.20,0.97) among those not prenatally depressed and with lower symptom severity among those prenatally depressed (MD = -2.05;95%CI:-3.81,-0.49). CONCLUSIONS: Chilla is inversely associated with both MDE and symptom severity at 6 months postpartum above and beyond social support. Specifically, chilla is inversely associated with MDE among those not prenatally depressed and with lower symptom severity among those prenatally depressed. This relationship signals an opportunity for interventions aimed at preventing and treating PPD in this region to draw upon chilla and similar traditional postpartum practices in creating community-based, low-cost, sustainable interventions for maternal mental health. TRIAL REGISTRATION: NCT02111915. Registered 18 September 2015. NCT02658994. Registered 22 January 2016. Both trials were prospectively registered.

Caregiver perceptions of child development in rural Madagascar: a cross-sectional study.

BACKGROUND: Human capital (the knowledge, skills, and health that accumulate over life) can be optimized by investments in early childhood to promote cognitive and language development. Parents and caregivers play a crucial role in the promotion and support of cognitive development in their children. Thus, understanding caregiver perceptions of a child's capabilities and attributes, including intelligence, may enhance investments early in life. To explore this question, we asked caregivers to rank their child's intelligence in comparison with other children in the community, and compared this ranking with children's scores on an assessment of developmental abilities across multiple domains. METHODS: Our study examined cross-sectional data of 3361 children aged 16-42 months in rural Madagascar. Child intelligence, as perceived by their caregiver, was captured using a ladder ranking scale based on the MacArthur Scale for Subjective Social Status. Children's developmental abilities were assessed using scores from the Ages and Stages Questionnaire: Inventory (ASQ-I), which measures cognitive, language, and socio-emotional development. Ranked percentiles of the ASQ-I were generated within communities and across the whole sample. We created categories of under-estimation, matched, and over-estimation by taking the differences in rankings between caregiver-perceived child intelligence and ASQ-I. Child nutritional status, caregiver belief of their influence on child intelligence, and sociodemographic factors were examined as potential correlates of discordance between the measures using multinomial logistic regressions. RESULTS: We found caregiver perceptions of intelligence in Madagascar did not align consistently with the ASQ-I, with approximately 8% of caregivers under-estimating and almost 50% over-estimating their children's developmental abilities. Child nutritional status, caregiver belief of their influence on child intelligence, caregiver education, and wealth were associated with under- or over-estimation of children's developmental abilities. CONCLUSIONS: Our findings suggest parents may not always have an accurate perception of their child's intelligence or abilities compared with other children. The results are consistent with the limited literature on parental perceptions of child nutrition, which documents a discordance between caregiver perceptions and objective measures. Further research is needed to understand the common cues caregivers that use to identify child development milestones and how these may differ from researcher-observed measures in low-income settings. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14393738 . Registered June 23, 2015.