Understanding Fijian health system challenges in the prevention of mother-to-child transmission of HIV services in the three tertiary hospitals in Fiji.

Mother-to-child transmission is the most common route of human immunodeficiency virus transmission in children, which could be prevented with proper treatment and access to care. Health system challenges can impede the effectiveness of prevention of mother-to-child transmission (PMTCT) programmes. We aim to understand the health system challenges to the provision of PMTCT services for pregnant women in three tertiary hospitals in Fiji. Data were collected using in-depth interviews in the three tertiary hospitals and associated health clinics in Fiji between April-May 2013 and February-March 2014. Ethical approvals were obtained. A total of 58 healthcare providers were interviewed including doctors (n = 12), midwives (n = 19), nurses (n = 14), laboratory technicians (n = 5) and counsellors (n = 8). The data were analysed using thematic analysis. We found that the healthcare workers faced a wide range of health system challenges including institutional and human resource challenges. Staff shortage, limited PMTCT training and shortage of supplies were barriers to the quality of PMTCT services. Our findings would be useful in developing strategies to overcome barriers as it would be imperative in improving the quality of PMTCT service provision in Fiji and other similar settings.

Knowledge, Attitude, and Practices Towards COVID-19 Among Pregnant and Postpartum Women in Rural Bangladesh: A Cross-Sectional Study.

OBJECTIVE: To identify knowledge, attitudes, and practices toward COVID-19 among pregnant and postpartum women in rural Bangladesh, and to assess any association with antenatal care attendance (ANC). METHODS: This cross-sectional study was conducted in Northern Bangladesh's Sherpur district with a sample of pregnant and post-partum women enrolled in 'Poriborton', a community-based cluster Randomised Controlled Trial. Knowledge, attitude, and practices toward COVID-19, and any association with antenatal care practices were assessed through face-to-face interviews using a structured questionnaire. Composite measures for knowledge, attitude, and practices of COVID-19 were generated. Specific knowledge on COVID-19 and the association of antenatal care were presented as descriptive statistics. An adjusted odds ratio was used to examine the association between categorical variables. RESULTS: Out of 4835 women, 34.0% correctly identified five or more COVID-19 symptoms, 31.8% knew three or more modes of coronavirus transmission, and 57.0% knew five or more preventive measures. Most (90.1%) had a "more positive attitude to testing" and 65.1% reported adequate practice of preventive measures. Women with adequate knowledge of COVID-19 were more likely to report both a positive attitude to testing (OR:2.96; 95% CI: 1.38-6.37) and adopt adequate practices of preventive measures (OR: 4.30;95% CI: 2.90-6.36). Education and being employed influenced KAP related to COVID-19. Only 14.9% were satisfied with their knowledge of COVID-19. Television was the main source of COVID-19-related specific information. CONCLUSIONS: We found that improved knowledge was associated with positive attitudes and behaviours that lead to the adoption of preventive measures. There was no association with ANC practices as attendance was very low in this region. The findings could be utilised to develop communication strategies for future public health emergencies in similar settings.

Risk factors for late preterm and term stillbirth: A secondary analysis of an individual participant data meta-analysis.

OBJECTIVE: Identify independent and novel risk factors for late-preterm (28-36 weeks) and term (≥37 weeks) stillbirth and explore development of a risk-prediction model. DESIGN: Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors. SETTING: An IPD database from five case-control studies in New Zealand, Australia, the UK and an international online study. POPULATION: Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257). METHODS: Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second-hand smoking, antenatal-care utilisation, and detailed fetal movement and sleep variables. MAIN OUTCOME MEASURES: Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth. RESULTS: After model building, 575 late-stillbirth cases and 1541 controls from three contributing case-control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hiccoughs, increasing strength, frequency or vigorous fetal movements) aOR of stillbirth. Poor antenatal-care utilisation increased risk while more-than-adequate care was protective. The area-under-the-curve was 0.84 (95% CI 0.82-0.86). CONCLUSIONS: Similarities in risk factors for late-preterm and term stillbirth suggest the same approach for risk-assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal-care utilisation could be valuable in late-stillbirth risk assessment.

Does fetal size affect maternal perception of fetal movements? Evidence from an individual participant data meta-analysis.

INTRODUCTION: Maternal perception of fetal movements during pregnancy are reassuring; however, the perception of a reduction in movements are concerning to women and known to be associated with increased odds of late stillbirth. Prior to full term, little evidence exists to provide guidelines on how to proceed unless there is an immediate risk to the fetus. Increased strength of movement is the most commonly reported perception of women through to full term, but perception of movement is also hypothesized to be influenced by fetal size. The study aimed to assess the pattern of maternal perception of strength and frequency of fetal movement by gestation and customized birthweight quartile in ongoing pregnancies. A further aim was to assess the association of stillbirth to perception of fetal movements stratified by customized birthweight quartile. MATERIAL AND METHODS: This analysis was an individual participant data meta-analyses of five case-control studies investigating factors associated with stillbirth. The dataset included 851 cases of women with late stillbirth (>28 weeks' gestation) and 2257 women with ongoing pregnancies who then had a liveborn infant. RESULTS: The frequency of prioritized fetal movement from 28 weeks' gestation showed a similar pattern for each quartile of birthweight with increased strength being the predominant perception of fetal movement through to full term. The odds of stillbirth associated with reduced fetal movements was increased in all quartiles of customized birthweight centiles but was notably greater in babies in the lowest two quartiles (Q1: adjusted OR: 9.34, 95% CI: 5.43, 16.06 and Q2: adjusted OR: 6.11, 95% CI: 3.11, 11.99). The decreased odds associated with increased strength of movement was present for all customized birthweight quartiles (adjusted OR range: 0.25-0.56). CONCLUSIONS: Increased strength of fetal movements in late pregnancy is a positive finding irrespective of fetal size. However, reduced fetal movements are associated with stillbirth, and more so when the fetus is small.

Perinatal depression screening: a systematic review of recommendations from member countries of the Organisation for Economic Co-operation and Development (OECD).

Perinatal depression (PND) screening recommendations are made by national, state-based and professional organisations; however, there is disagreement regarding screening timing, provider responsible, screening setting, screening tool as well as the follow-up and referral pathways required post-screening. This systematic review aimed to identify, describe and compare PND screening recommendations from member countries of the Organisation for Economic Co-operation and Development (OECD). Publications were identified through systematically searching PubMed, Google and the Guidelines International Network (GIN). Recommendations regarding PND screening endorsement, timing, frequency, responsible provider, tools/assessments and follow-up and referral were extracted. Twenty-one publications, including guidelines, from five countries were included. Most made recommendations in support of PND screening using the Edinburgh Postnatal Depression Scale. Details differed regarding terminology used, as well as frequency of screening, follow-up mechanisms and referral pathways. A broad range of health providers were considered to be responsible for screening. This is the first review to identify and compare PND screening recommendations from OECD member countries; however, only online publications published in English, from five countries were included. Heterogeneity of publication types and inconsistency in definitions rendered quality assessment inappropriate. While most publications generally endorsed PND screening, there are exceptions and the associated details pertaining to the actual conduct of screening vary between and within countries. Developing clear, standardised recommendations based on current evidence is necessary to ensure clarity amongst healthcare providers and a comprehensive approach for the early detection of PND.

Prevalence of, and factors associated with anaemia in children aged 1-3 years in Aceh, Indonesia: A cross-sectional study.

Background: Child anaemia continues to represent a major public health challenge in lower-and-middle income countries. It has serious long-term consequences for child growth and development. In Indonesia, there was a 10% increase in the national prevalence of child anaemia between 2013 and 2018. Aim: This study aims to assess the prevalence of, and factors associated with anaemia among children aged one to three years in eight districts in Aceh Province, Indonesia. Methods: A cross-sectional study was conducted on a sample of 1148 mother-child dyads aged one to three years between November and December 2018. The sampling process involved a three-stage cluster sampling design using the probability proportionate to size methodology. Anaemia status was determined using haemoglobin level (Hb < 11.0 g/dL). Data were analysed using multivariable logistic regression to estimate adjusted odds ratios (aOR) and their 95% confidence intervals (95% CI) for associated factors. Results: The overall prevalence of anaemia was 76.1% (869/1142). 44.7% (510/1142) and 28.6% (327/1142) had moderate and mild anaemia, respectively. Child aged 12-24 months (aOR: 2.00, 95% CI: 1.26-3.17), not receiving routine immunisation (aOR: 2.62, 95% CI: 1.34-5.10), and maternal anaemia (aOR: 2.15, 95% CI: 1.59-2.90) were significantly associated with anaemia. Conclusion: The prevalence of anaemia among the children in this study was high, and was associated with child age, immunisation status, and maternal anaemia. These findings provide further insight into anaemia as a public health issue at a sub-national level in Indonesia and for development of targeted programmes to address associated risk factors of child anaemia.

Risk factors of paternal postnatal depression in Pakistan: Findings from an urban sample.

Paternal postnatal depression is an emerging public health concern, with negative outcomes for men, their partners, and the newborn. There is a dearth of data on paternal postnatal depression in lower-middle-income countries like Pakistan. This study aimed to identify risk factors of postnatal depression in Pakistani men. Men who consented to this cross-sectional study completed a questionnaire that included sociodemographic information and Urdu translated versions of the Edinburgh Postnatal Depression Scale (EPDS) and the Pittsburgh Sleep Quality Index, 10-12 weeks postpartum. Descriptive analyses for the sociodemographic variables were calculated. Univariate analyses were conducted to calculate the relative risk and 95% confidence interval of the independent variables with an EPDS score of >10. Multivariate binary logistic regression models were performed for risk factors of paternal postnatal depression. Fifty-one questionnaires were analyzed and 23.5% of the participants scored more than 10 on the EPDS. Spouse's EPDS score > 12, and own sleep disturbance were risk factors of paternal postnatal depression in Pakistani men. There is an imminent need to incorporate fathers in the existing and future perinatal mental health programs in Pakistan.

The effect of electronic job aid assisted one-to-one counselling to support exclusive breastfeeding among 0-5-month-old infants in rural Bangladesh.

Exclusive breastfeeding (EBF) for the first 6 months has established benefits, yet had slow improvements globally. Little is known about electronic job aid-assisted counselling to support EBF. As a secondary outcome of a cluster randomized controlled trial in Bangladesh, we assessed the effect of electronic job aid-supported nutrition counselling and practical demonstration on EBF. We randomized pregnant women to one of five study arms in the trial and followed mother-child dyads until 2 years of age. Community health workers (CHWs) provided breastfeeding counselling with or without prenatal and complementary nutrient supplements in all four intervention arms. The comparison arm continued with the usual practice where mothers could receive nutrition counselling at routine antenatal and postnatal care, and during careseeking for childhood illnesses. We assessed breastfeeding indicators at birth and monthly until the child was 6 months old, in both intervention and comparison arms. To evaluate the effect of nutrition counselling on breastfeeding, we combined all four intervention arms and compared them with the comparison arm. Intervention newborns had half the risk (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.39, 0.76) of receiving prelacteal feeds than those in the comparison arm. EBF declined steeply in the comparison arm after 3 months of age. EBF was 16% higher in the intervention than the comparison arm at 4 months (RR: 1.16, 95% CI: 1.08, 1.23) and 22% higher at 5 months of age (RR: 1.22, 95% CI: 1.12, 1.33). Maternal background and household characteristics did not modify the intervention effect, and we observed no difference in EBF among caesarean versus vaginal births. Breastfeeding counselling and practical demonstration using an electronic job aid by CHWs are promising interventions to improve EBF and are scalable into existing community-based programmes.

Effect of nutrition counselling with a digital job aid on child dietary diversity: Analysis of secondary outcomes from a cluster randomised controlled trial in rural Bangladesh.

Adequate dietary diversity among infants is often suboptimal in developing countries. We assessed the impact of nutrition counselling using a digital job aid on dietary diversity of children aged 6-23 months using data from a cluster randomised controlled trial in Bangladesh. The trial had five arms, each with 25 clusters. The four intervention arms provided counselling using a digital job aid and different prenatal and post-natal combinations of lipid-based supplements and the comparison arm with usual practice. We enrolled 1500 pregnant women and followed them until the children reached their second birthday. We developed a tablet-based system for intervention delivery, data collection and project supervision. We combined the four intervention arms (n = 855), in which community health workers (CHWs) provided age-appropriate complementary feeding counselling, to compare against the comparison arm (n = 403). We calculated the outcome indicators from the children's 24-h dietary recalls. Overall, the intervention increased the mean dietary diversity score by 0.09 (95% confidence interval [CI]: 0.2-0.16) and odds of minimum dietary diversity by 18% (95% CI: 0.99-1.40). However, there was a significant interaction on the effect of the intervention on dietary diversity by age. The mean dietary diversity score was 0.24 (95% CI: 0.11-0.37) higher in the intervention than in the comparison arm at 9 months and 0.14 (95% CI: 0.01-27) at 12 months of age. The intervention effect was non-significant at an older age. Overall, consumption of flesh food was 1.32 times higher in the intervention arm (odds ratio [OR] 1.32, 95% CI: 1.11-1.57) in 6-23 months of age. The intervention significantly improved child dietary diversity score in households with mild and moderate food insecurity by 0.27 (95% CI: 0.06-0.49) and 0.16 (0.05-27), respectively, but not with food-secure and severely food-insecure households. Although the study did not evaluate the impact of digital job aid alone, the findings indicate the utility of nutrition counselling by CHWs using a digital job aid to improve child feeding practices in broader programmes.

A better understanding of the association between maternal perception of foetal movements and late stillbirth-findings from an individual participant data meta-analysis.

BACKGROUND: Late stillbirth continues to affect 3-4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings. Reduced foetal movements are frequently reported by women prior to foetal death, but there remains a poor understanding of the reasons and how to deal with this symptom clinically, particularly during the preterm phase of gestation. We aimed to determine which women are at the greatest odds of stillbirth in relation to the maternal report of foetal movements in late pregnancy (≥ 28 weeks' gestation). METHODS: This is an individual participant data meta-analysis of all identified case-control studies of late stillbirth. Studies included in the IPD were two from New Zealand, one from Australia, one from the UK and an internet-based study based out of the USA. There were a total of 851 late stillbirths, and 2257 controls with ongoing pregnancies. RESULTS: Increasing strength of foetal movements was the most commonly reported (> 60%) pattern by women in late pregnancy, which were associated with a decreased odds of late stillbirth (adjusted odds ratio (aOR) = 0.20, 95% CI 0.15 to 0.27). Compared to no change in strength or frequency women reporting decreased frequency of movements in the last 2 weeks had increased odds of late stillbirth (aOR = 2.33, 95% CI 1.73 to 3.14). Interaction analysis showed increased strength of movements had a greater protective effect and decreased frequency of movements greater odds of late stillbirth at preterm gestations (28-36 weeks' gestation). Foetal hiccups (aOR = 0.45, 95% CI 0.36 to 0.58) and regular episodes of vigorous movement (aOR = 0.67, 95% CI 0.52 to 0.87) were associated with decreased odds of late stillbirth. A single episode of unusually vigorous movement was associated with increased odds (aOR = 2.86, 95% CI 2.01 to 4.07), which was higher in women at term. CONCLUSIONS: Reduced foetal movements are associated with late stillbirth, with the association strongest at preterm gestations. Foetal hiccups and multiple episodes of vigorous movements are reassuring at all gestations after 28 weeks' gestation, whereas a single episode of vigorous movement is associated with stillbirth at term.

Perinatal depression in Pakistan: A systematic review and meta-analysis.

OBJECTIVE: To estimate the prevalence and associated risk factors of perinatal depression in Pakistan. METHODS: We conducted a systematic search of Medline, PsycINFO, CINAHL, EMBASE, and Global health, up through May 31, 2019. Studies reporting on the prevalence of perinatal depression in Pakistan with or without associated risks factors were included. RESULTS: Forty-three studies reporting data from 17 544 women met the eligibility criteria and were included. Overall, the pooled prevalence of antenatal depression was 37% (95% CI: 30-44), while that of postnatal depression was 30% (95% CI: 25-36). The prevalence of perinatal depression in women residing in urban areas and those living in rural settings was not significantly different. The most frequently reported risk factors for antenatal depression were intimate partner violence and poor relationship with spouse, and that reported for postnatal depression was low-income level. An unintended pregnancy was significantly associated with perinatal depression in Pakistan. CONCLUSIONS: We identified variability in prevalence rate of perinatal depression in Pakistan. It is difficult to gauge the true magnitude of this problem potentially due to differing risk factors between the antenatal and postnatal periods and the lack of uniformity of data collection protocols and procedures. The high prevalence rates of 30%-37% compared to global estimates suggest policy makers and stakeholders should direct additional resources toward improving perinatal mental health in Pakistan.

Saturation screening for neonatal hypoxaemia within 6 h of life: Not all about congenital cardiac disease.

AIMS: To assess the outcomes of an early oxygen saturation screening programme in apparently healthy newborns for the detection of cardiac and non-cardiac disease. To describe the aetiology and incidence of infants with oxygen saturations <95% in the first 6 h of life and describe the management to discharge. In addition, we sought to identify any risk factors for failed early saturations. METHODS: This is a retrospective hospital cohort assessing outcomes of an early saturation screening programme performed in apparently healthy newborns. Infants with oxygen saturations less than 95% were identified and their clinical notes were hand-searched. Descriptive statistics were used to present demographics, proportion of infants who passed or failed screening, subsequent diagnoses and short-term outcome. Multivariate logistic regression was used to identify independent associations of clinical factors (birthweight, gestation, elective caesarean section and gender) with failed screening. RESULTS: Between 2014 and 2019, 14 956 healthy newborns were assessed within the first 6 h, 94 (0.63%) failed the early saturation screen. The most common causes for saturation <95% were respiratory disease or delayed transition. There were 31 (33%) infants admitted to the NICU with an additional baby requiring emergency transfer to a cardiac centre. Infants were 28 times more likely to have saturations <95% if born by elective caesarean section (odds ratio 28, conflict of interest (18.54-42.82)). CONCLUSION: In apparently healthy newborns, early assessment of oxygen saturation, combined with clinical assessment and subsequent intervention can identify important conditions and should be considered as standard care.

One planet one health: What about the kids?

Humans in their increasing numbers and wealth are changing ecosystems through accelerated consumption of food, natural resources and energy which continue to cause significant damage to the planet. Using 'stunting in children' as a case study, we show how the traditional siloed (specialist) approaches have failed to reduce stunting world-wide. Despite significant effort, traditional approaches fail to appreciate the interconnectedness of the multiple factors that underpin stunting. We will not improve the lives of the millions of children living in poverty by doing the same things we have always done, rather we need to adopt approaches that recognise the interconnectedness of all the component parts and apply One Health methods designed to solve these intractable problems.

An analysis of the impact of newborn survival policies in Pakistan using a policy triangle framework.

INTRODUCTION: Pakistan has made slow progress towards reducing the newborn mortality burden; as a result, it has the highest burden of newborn mortality worldwide. This article presents an analysis of the current policies, plans, and strategies aimed at reducing the burden of newborn death in Pakistan for the purpose of identifying current policy gaps and contextual barriers towards proposing policy solutions for improved newborn health. METHODS: We begin with a content analysis of federal-level policies that address newborn mortality within the context of health system decentralization over the last 20 years. This is then followed by a case study analysis of policy and programme responses in a predominantly rural province of Pakistan, again within the context of broader health system decentralization. Finally, we review successful policies in comparable countries to identify feasible and effective policy choices that hold promise for implementation in Pakistan, considering the policy constraints we have identified. RESULTS: The major health policies aimed at reduction of newborn mortality, following Pakistan's endorsement of global newborn survival goals and targets, lacked time-bound targets. We found confusion around roles and responsibilities of institutions in the implementation process and accountability for the outcomes, which was exacerbated by an incomplete decentralization of healthcare policy-making and health service delivery, particularly for women around birth, and newborns. Such wide gaps in the areas of target-setting, implementation mechanism, and evaluation could be because the policy-making largely ignored international commitments and lessons of successful policy-making in comparable regional counties. CONCLUSIONS: Inclusion of clear goals and targets in newborn survival policies and plans, completion of the decentralization process of maternal and child healthcare service delivery, and policy-making and implementation by translating complex evidence and using regional but locally applicable case studies will be essential to any effective policy-making on newborn survival in Pakistan.

Barriers to uptaking HIV testing among pregnant women attending antenatal clinics in low- and middle-income countries: A systematic review of qualitative findings.

BACKGROUND: Human immunodeficiency virus (HIV) testing is a gateway to HIV treatment, care and preventive services for pregnant women attending antenatal clinics. Despite this, uptake of HIV testing is not optimal among pregnant women in many low- and middle-income countries (LMICs) and it could negatively impact the effectiveness of prevention of mother-to-child transmission of HIV programs. AIM: To understand the factors that hinder the uptake of HIV testing among pregnant women attending antenatal clinics in LMICs. MATERIALS AND METHODS: A systematic search of the CINAHL, EMBASE, JSTOR, Medline, PubMed and Web of Science electronic databases was performed. We limited the search to peer-reviewed qualitative studies including mixed method studies. The titles and abstracts of the retrieved publications were screened for relevance then information was extracted. RESULTS: Our search yielded 2179 citations, out of which 312 full-text articles were reviewed and 22 studies that met the eligibility criteria were included in this review. We found that a lack of HIV testing kits, poor health infrastructure and shortage of healthcare workers were the main health system-related factors. Poor HIV knowledge, fear of HIV test results, HIV-related stigma and social exclusion negatively influenced pregnant women's decision to be tested for HIV. CONCLUSION: This review has identified that pregnant women faced a wide range of health system, individual, social and lack of women's empowerment related challenges that negatively influenced the uptake of HIV testing among pregnant women in LMICs. Our findings would be useful in developing strategies to overcome barriers that could enhance the uptake of HIV testing among pregnant women.

Impact of an informational flipchart on lifestyle advice for Nepali women with a pelvic organ prolapse: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle training (PFMT) and lifestyle advice are effective at improving the symptoms and severity of pelvic organ prolapse (POP) in a range of populations; however, the impact of these interventions in Nepali women is unknown. We aimed to evaluate the impact of an informational flipchart on PFMT and lifestyle advice on the quality of life (QOL) for Nepali women with a POP. METHODS: This prospective randomized controlled trial recruited 140 women with a stage I-III POP from Kathmandu Valley. The intervention group were instructed on PFMT and lifestyle advice through an informational flipchart and the control group were provided usual care. The primary outcome measure was the Prolapse Quality of Life questionnaire (P-QOL) and was completed at baseline, 6 weeks, 12 weeks and 6 months. The secondary outcome measure was the Pelvic Organ Prolapse Quantification (POP-Q) system and Modified Oxford Scale (MOS) assessed by clinical examination at baseline and 6 months. Differences in mean P-QOL scores for each domain were evaluated using analysis of covariance. RESULTS: Compared with usual care, the women in the informational flipchart group experienced significant improvement in six of the nine P-QOL domains and for the prolapse, bladder and bowel symptoms. Only a small percentage (20%) of women were able to attend the 6-month clinical assessment so we were unable to assess the secondary outcomes. CONCLUSIONS: A one-time intervention of an informational flipchart on PFMT and lifestyle advice is effective at improving QOL and symptoms for Nepali women with a stage I-III POP.

Influence of maternal and placental factors on newborn body composition.

AIM: The objective of this study was to assess whether maternal characteristics, placental size or histological chorioamnionitis was associated with newborn body composition. Furthermore, we sought to determine whether placental weight may mediate the association between maternal pre-pregnancy weight and age with newborn body composition. METHODS: A cross-sectional study was conducted at Royal Prince Alfred Hospital, Sydney, Australia. This study included 136 healthy, singleton, term-born newborns. Recruitment was stratified by newborn body fat percentiles (gender and gestational adjusted). Body fat was assessed by air displacement plethysmography. Placental examination was conducted by an anatomical pathologist. Maternal (chorioamnionitis) and fetal (chorionic and umbilical vasculitis, funisitis) inflammatory responses were classified according to Redline criteria. RESULTS: Maternal pre-pregnancy weight, parity, labour, placental weight and surface area were associated with newborn fat mass and fat-free mass. Gestational diabetes and maternal age were associated with newborn fat mass but not fat-free mass. There was no association between histological chorioamnionitis and newborn body composition; however, spontaneous onset of labour was strongly associated with the presence of histological chorioamnionitis. Only 25-31% of the association of maternal weight and age with newborn fat mass was mediated via the placenta. CONCLUSIONS: Maternal factors associated with newborn fat mass and fat-free mass differed, indicating that different mechanisms control fat mass and fat-free mass. Our mediation analysis suggests that placental weight partly mediates the association of maternal factors with newborn body composition. Histological chorioamnionitis was not associated with newborn body composition.

Understanding country-specific determinants of stillbirth using household surveys: The case of Afghanistan.

BACKGROUND: Stillbirth rates in Afghanistan have declined little in the past decade with no data available on key risk factors. Health care utilisation and maternal complications are important factors influencing pregnancy outcomes but rarely captured for stillbirth in national surveys from low- and middle-income countries. The 2010 Afghanistan Mortality Survey (AMS) is one of few surveys with this information. METHODS: We used data from the 2010 AMS that included a full pregnancy history and verbal autopsy. Our sample included the most recent live birth or stillbirth of 13 834 women aged 12-49 years in the three years preceding the survey. Multivariable Poisson regression was used to identify sociodemographic, maternal, and health care utilisation risk factors for stillbirth. RESULTS: The risk of stillbirth was increased among women in the Central Highlands (aRR: 3.01, 95% CI 1.35, 6.70) and of Nuristani ethnicity (aRR: 9.15, 95% CI 2.95, 28.74). Women who did not receive antenatal care had three times increased risk of stillbirth (aRR: 3.03, 95% CI 1.73, 5.30), while high-quality antenatal care was important for reducing the risk of intrapartum stillbirth. Bleeding, infection, headache, and reduced fetal movements were antenatal complications strongly associated with stillbirth. Reduced fetal movements in the delivery period increased stillbirth risk by almost seven (aRR: 6.82, 95% CI 4.20, 11.10). Facility births had a higher risk of stillbirths overall (aRR: 1.55, 95% CI 1.12, 2.16), but not for intrapartum stillbirths. CONCLUSIONS: Targeted interventions are needed to improve access and utilisation of services for high-risk groups. Early detection of complications through improved quality of antenatal and obstetric care is imperative. We demonstrate the potential of household surveys to provide country-specific evidence on stillbirth risk factors for LMICs where data are lacking.

Factors associated with perinatal mortality in Nepal: evidence from Nepal demographic and health survey 2001-2016.

BACKGROUND: Perinatal mortality is a devastating pregnancy outcome affecting millions of families in many low and middle-income countries including Nepal. This paper examined the more distant factors associated with perinatal mortality in Nepal. METHODS: A sample of 23,335 pregnancies > 28 weeks' gestation from the Nepal Demographic and Health Survey datasets for the period (2001-2016) was analysed. Perinatal Mortality (PM) is defined as the sum of stillbirth (fetal deaths in pregnancies > 28 weeks' gestation) and early neonatal mortality (deaths within the first week of life), while Extended Perinatal Mortality (EPM) is denoted as the sum of stillbirth and neonatal mortality (deaths within the first 28 days of life). Rates of PM and EPM were calculated. Logistic regression generalized linear latent and mixed models (GLLAMM) that adjusted for clustering and sampling weight was used to examine the factor associated with perinatal mortality. RESULTS: Over the study period, the PMR was 42 [95% Confidence Interval (CI): 39, 44] per 1000 births for the five-year before each survey; while corresponding EPMR was 49 (95% CI, 46, 51) per 1000 births. Multivariable analyses revealed that women residing in the mountains, who did not use contraceptives, women aged 15-18 years or 19-24 years, and women having no education were associated with increased PM and EPM. The study also identified households using biomass as cooking fuel, and households who reported unimproved sanitation or open defecation were significantly more likely to experience PM and EPM. CONCLUSIONS: Interventions aimed to improve use of contraceptives, and reduce biomass as a source of cooking fuel are needed to achieve the recommended target of < 12 perinatal deaths per 1000 births by 2030.

A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality: the Shonjibon trial.

BACKGROUND: Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes. METHODS/DESIGN: The effect of the early use of iron-folic acid supplements on neonatal mortality will be examined using a community based, cluster randomised controlled trial in five districts with 30,000 live births. In intervention clusters trained BRAC village volunteers will identify pregnant women & provide iron-folic acid supplements. Groundwater iron levels will be measured in all study households using a validated test kit. The analysis will follow the intention to treat principle. We will compare neonatal mortality rates & their 95% confidence intervals adjusted for clustering between treatment groups in each groundwater iron-level group. Cox proportional hazards mixed models will be used for mortality outcomes & will include groundwater iron level as an interaction term in the mortality model. DISCUSSION: This paper aims to describe the study protocol of a community based randomised controlled trial evaluating the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality. This study is critical because it will determine if antenatal IFA supplements commenced in the first trimester of pregnancy, rather than later, will significantly reduce neonatal deaths in the first month of life, and if this approach is cost-effective. TRIAL REGISTRATION: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on 31 May 2012. The registration ID is ACTRN12612000588897 .